STUDY DESIGN: Case series. OBJECTIVES: To use blood oxygenation level–dependent functional magnetic resonance imaging (fMRI) to determine if supraspinal activation in response to noxious mechanical stimuli varies pre– and post–thrust manipulation to the thoracic spine. BACKGROUND: Recent studies have demonstrated the effectiveness of thoracic thrust manipulation in reducing pain and improving function in some individuals with neck and shoulder pain. However, the mechanisms by which manipulation exerts such effects remain largely unexplained. The use of fMRI in the animal model has revealed a decrease in cortical activity in response to noxious stimuli following manual joint mobilization. Supraspinal mediation contributing to hypoalgesia in humans may be triggered following spinal manipulation. METHODS: Ten healthy volunteers (5 women, 5 men) between the ages of 23 and 48 years (mean, 31.2 years) were recruited. Subjects underwent fMRI scanning while receiving noxious stimuli applied to the cuticle of the index finger at a rate of 1 Hz for periods of 15 seconds, alternating with periods of 15 seconds without stimuli, for a total duration of 5 minutes. Subjects then received a supine thrust manipulation directed to the midthoracic spine and were immediately returned to the scanner for reimaging with a second delivery of noxious stimuli. An 11-point numeric pain rating scale was administered immediately after the application of noxious stimuli, premanipulation and postmanipulation. Blood oxygenation level–dependent fMRI recorded the cerebral hemodynamic response to the painful stimuli premanipulation and postmanipulation. RESULTS: The data indicated a significant reduction in subjects’ perception of pain (P<.01), as well as a reduction in cerebral blood flow as measured by the blood oxygenation level–dependent response following manipulation to areas associated with the pain matrix (P<.05). There was a significant relationship between reduced activation in the insular cortex and decreased subjective pain ratings on the numeric pain rating scale (r = 0.59, P<.05). CONCLUSION: This study provides preliminary evidence that suggests that supraspinal mechanisms may be associated with thoracic thrust manipulation and hypoalgesia. However, because the study lacked a control group, the results do not allow for the discernment of the causative effects of manipulation, which may also be related to changes in levels of subjects’ fear, anxiety, or expectation of successful outcomes with manipulation. Future investigations should strive to elicit more conclusive findings in the form of randomized clinical trials.
The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these clinical practice guidelines is to describe the peer-reviewed literature and make recommendations related to adhesive capsulitis.
Frozen shoulder, also known as adhesive capsulitis, refers to a condition where the shoulder becomes painful and stiff. It may occur following a relatively minor injury to the shoulder but most often develops without a clear reason, and the problem usually lasts 1 to 2 years. Recently, a panel of experts developed a set of treatment guidelines for improving the quality of care for people with frozen shoulder. These guidelines are published in the May 2013 issue of JOSPT.
In this issue of JOSPT, the Orthopaedic Section of the American Physical Therapy Association introduces the first of its shoulder clinical practice guidelines (CPGs), titled "Shoulder Pain and Mobility Deficits: Adhesive Capsulitis." This CPG, as well as the collection of Orthopaedic Section CPGs previously published in JOSPT, use long diagnostic labels to identify the underlying clinical conditions. Author Paula M. Ludewig discusses the merits of using these movement system diagnostic labels rather than shorter pathoanatomic labels, which create a disconnect between diagnostic and treatment processes.
STUDY DESIGN: Randomized, double-blind, parallel-group clinical trial. OBJECTIVES: To assess differences between a progressive agility and trunk stabilization rehabilitation program and a progressive running and eccentric strengthening rehabilitation program in recovery characteristics following an acute hamstring injury, as measured via physical examination and magnetic resonance imaging (MRI). BACKGROUND: Determining the type of rehabilitation program that most effectively promotes muscle and functional recovery is essential to minimize reinjury risk and to optimize athlete performance. METHODS: Individuals who sustained a recent hamstring strain injury were randomly assigned to 1 of 2 rehabilitation programs: (1) progressive agility and trunk stabilization or (2) progressive running and eccentric strengthening. MRI and physical examinations were conducted before and after completion of rehabilitation. RESULTS: Thirty-one subjects were enrolled, 29 began rehabilitation, and 25 completed rehabilitation. There were few differences in clinical or morphological outcome measures between rehabilitation groups across time, and reinjury rates were low for both rehabilitation groups after return to sport (4 of 29 subjects had reinjuries). Greater craniocaudal length of injury, as measured on MRI before the start of rehabilitation, was positively correlated with longer return-to-sport time. At the time of return to sport, although all subjects showed a near-complete resolution of pain and return of muscle strength, no subject showed complete resolution of injury as assessed on MRI. CONCLUSION: The 2 rehabilitation programs employed in this study yielded similar results with respect to hamstring muscle recovery and function at the time of return to sport. Evidence of continuing muscular healing is present after completion of rehabilitation, despite the appearance of normal physical strength and function on clinical examination. LEVEL OF EVIDENCE: Therapy, level 1b–.
STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To compare the effects of thrust and nonthrust manipulation and exercises with and without the addition of myofascial therapy for the treatment of acute inversion ankle sprain. BACKGROUND: Studies have reported that thrust and nonthrust manipulations of the ankle joint are effective for the management of patients post–ankle sprain. However, it is not known whether the inclusion of soft tissue myofascial therapy could further improve clinical and functional outcomes. METHODS: Fifty patients (37 men and 13 women; mean ± SD age, 33 ± 10 years) post–acute inversion ankle sprain were randomly assigned to 2 groups: a comparison group that received a thrust and nonthrust manipulation and exercise intervention, and an experimental group that received the same protocol and myofascial therapy. The primary outcomes were ankle pain at rest and functional ability. Additionally, ankle mobility and pressure pain threshold over the ankle were assessed by a clinician who was blinded to the treatment allocation. Outcomes of interest were captured at baseline, immediately after the treatment period, and at a 1-month follow-up. The primary analysis was the group-by-time interaction. RESULTS: The 2-by-3 mixed-model analyses of variance revealed a significant group-by-time interaction for ankle pain (P<.001) and functional score (P = .002), with the patients who received the combination of nonthrust and thrust manipulation and myofascial intervention experiencing a greater improvement in pain and function than those who received the nonthrust and thrust manipulation intervention alone. Significant group-by-time interactions were also observed for ankle mobility (P<.001) and pressure pain thresholds (all, P<.01), with those in the experimental group experiencing greater increases in ankle mobility and pressure pain thresholds. Between-group effect sizes were large (d>0.85) for all outcomes. CONCLUSION: This study provides evidence that, in the treatment of individuals post–inversion ankle sprain, the addition of myofascial therapy to a plan of care consisting of thrust and nonthrust manipulation and exercise may further improve outcomes compared to a plan of care solely consisting of thrust and nonthrust manipulation and exercise. However, though statistically significant, the difference in improvement in the primary outcome between groups was not greater than what would be considered a minimal clinically important difference. Future studies should examine the long-term effects of these interventions in this population. LEVEL OF EVIDENCE: Therapy, level 1b–.
STUDY DESIGN: Case series. OBJECTIVES: To evaluate the feasibility of an active rehabilitation program for patients with knee full-thickness articular cartilage lesions. BACKGROUND: No studies have yet evaluated the effect of active rehabilitation in patients with knee full-thickness articular cartilage lesions or compared the effects of active rehabilitation to those of surgical interventions. As an initial step, the feasibility of such a program needs to be described. METHODS: Forty-eight patients with a knee full-thickness articular cartilage lesion and a Lysholm score below 75 participated in a 3-month active rehabilitation program consisting of cardiovascular training, knee and hip progressive resistance training, and neuromuscular training. Feasibility was determined by monitoring adherence to the program, clinical changes in knee function, load progression, and adverse events. Patients were tested before and after completing the rehabilitation program by using patient-reported outcomes (Knee injury and Osteoarthritis Outcome Score, International Knee Documentation Committee Subjective Knee Evaluation Form 2000) and isokinetic muscle strength and hop tests. To monitor adherence, load progression, and adverse events, patients responded to an online survey and kept training diaries. RESULTS: The average adherence rate to the rehabilitation program was 83%. Four patients (9%) showed adverse events, as they could not perform the exercises due to pain and effusion. Significant and clinically meaningful improvement was found, based on changes on the International Knee Documentation Committee Subjective Knee Evaluation Form 2000, the Knee injury and Osteoarthritis Outcome Score quality of life subscale, isokinetic muscle strength, and hop performance (P<.05), with small to large effect sizes (standardized response mean, 0.3-1.22). CONCLUSION: The combination of a high adherence rate, clinically meaningful changes, and positive load progression and the occurrence of only a few adverse events support the potential usefulness of this program for patients with knee full-thickness cartilage lesions. This study was registered with the public trial registry ClinicalTrials.gov (NCT00885729). LEVEL OF EVIDENCE: Therapy, level 4.
STUDY DESIGN: Within-subject, repeated-measures design. OBJECTIVES: To determine the influence of pelvis position and hip angle on activation of the hip abductors while performing the clam exercise. BACKGROUND: Therapeutic exercises are regularly employed to strengthen the hip abductors to improve lower-limb and pelvis stability. While previous studies primarily have compared the activity of hip abductor muscles between various exercises, few studies have examined the influence of varying the techniques of particular exercises on the relative activation of hip abductor muscles. Such information could be used to facilitate appropriate exercise instruction. METHODS: Muscle activation in 17 healthy, asymptomatic volunteers during 6 variations of the clam exercise was analyzed with surface electromyography. Electromyographic signals were recorded from the gluteus maximus, gluteus medius, and tensor fasciae latae. Normalized data were examined using 2-way, repeated-measures analyses of variance. RESULTS: The magnitude of gluteus maximus and gluteus medius activation was significantly greater when the pelvis was in neutral rather than reclined. Furthermore, gluteus medius activation was greatest when the hip was flexed to 60°. Activation of the tensor fasciae latae was not influenced by pelvis position or hip angle. CONCLUSION: A neutral pelvis position is advocated to optimize recruitment of the gluteus maximus and gluteus medius during the clam exercise. Increasing the hip flexion angle increases activation of the gluteus medius. Tensor fasciae latae activity was relatively low and generally unaffected by variations of the clam exercise.
STUDY DESIGN: Clinical measurement study. OBJECTIVES: To cross-culturally adapt the Anterior Knee Pain Scale (AKPS), the Functional Index Questionnaire (FIQ), and the Pain Severity Scale (PSS) for patellofemoral pain syndrome (PFPS) into Brazilian Portuguese. This study also aimed to test the measurement properties of the AKPS, the FIQ, and the PSS, and the existing Brazilian Portuguese versions of the numeric pain rating scale (NPRS) and the Global Perceived Effect scale in a group with PFPS. BACKGROUND: PFPS is a common condition. Therefore, translated, culturally adapted, and clinimetrically tested instruments for measuring PFPS are needed. METHODS: The AKPS, FIQ, and PSS instruments were cross-culturally adapted into Brazilian Portuguese. The measurement properties of the AKPS, FIQ, PSS, NPRS, and Global Perceived Effect scale (internal consistency, ceiling and floor effects, and construct validity) were tested in 83 patients with PFPS. The reproducibility and responsiveness were tested in 52 patients with PFPS in a test-retest design, with follow-up testing at 48 to 72 hours and at 4 weeks after baseline. RESULTS: The AKPS, the FIQ, and the PSS yielded adequate internal consistency (Cronbach alpha ranging from .75 to .87) and excellent reliability (intraclass correlation coefficients [model 2,1] ranging from 0.90 to 0.97). The AKPS and the PSS yielded very good agreement (standard error of measurement, 2.9% and 3.5%, respectively). The highest correlations were observed among the AKPS, the FIQ, and the PSS (Pearson r>0.60, P<.05). No floor or ceiling effects were observed for any of the instruments. Effect sizes used for measuring internal responsiveness ranged from moderate to high for all measures. The NPRS and the AKPS were the measures with the highest external responsiveness. CONCLUSION: The Brazilian Portuguese versions of the AKPS, FIQ, PSS, NPRS, and Global Perceived Effect scale have acceptable measurement properties.
The patient was an 8-year-old girl who was referred to a physical therapist by her pediatrician for a chief complaint of worsening proximal right calf pain and progressive right-sided toe walking for the past 6 weeks. Due to concern that the patient's symptoms were nonmusculoskeletal in nature, the physical therapist discussed the history and physical examination findings with the patient's pediatrician and an orthopaedic surgeon. Subsequent magnetic resonance imaging and percutaneous biopsy led to a diagnosis of a low-flow venolymphatic malformation of the proximal gastrocnemius muscle.
The patient was a 48-year-old man serving in a deployed combat setting, who was referred to a physical therapist for evaluation of progressively worsening left hip and left wrist pain. Due to concern for hip and wrist fractures, the physical therapist ordered radiographs of the left hip and left wrist. The radiographs revealed comminuted fractures of the midneck to distal neck of the left femur and left scaphoid.