JOSPT Express
JOSPT Express provides immediate electronic publication of manuscripts that have been accepted for publication in the print edition of the Journal. These peer-reviewed manuscripts are posted in PDF format as submitted by their authors. JOSPT Express was created to give authors the opportunity to present their evidence to the musculoskeletal rehabilitation community many weeks or even months before it appears in print, and to give readers immediate access to the results of evidence-based research that can affect clinical practice and new research designs.
For more information, please see About JOSPT Express. To see the list of articles initially published in JOSPT Express and since finalized in a print issue of the Journal, please visit JOSPT Express Index.
Accepted Manuscripts Posted as of March 1, 2010
Case Report
Michael Beecher, J. Craig Garrison, Douglas Wyland
STUDY DESIGN: Case Report. BACKGROUND: The healing response procedure is a minimally invasive arthroscopic surgical technique used to stimulate healing in the treatment of partial cruciate ligament tears. The purpose of this report was to provide information on the surgical procedure, the post-operative rehabilitation, and the overall functional results in a patient who underwent such a procedure. CASE DESCRIPTION: A 15-year-old male who sustained a partial tear of both the anterior cruciate and posterior cruciate ligament while playing football underwent arthroscopic surgical management utilizing a healing response technique. Precautions concerning range of motion and resisted activities were followed post-operatively to protect the healing cruciate ligaments. The post-operative protocol consisted of 3 phases culminating in return to sport training. Treatment incorporated cardiovascular, proprioceptive, strength, power, plyometric, and sport specific activities. Treatment was progressed based on specific criteria emphasizing proper movement patterns and eccentric control during functional activities. OUTCOMES: The patient attended 31 physical therapy sessions over 17 weeks. Strength improved from 3/5 to 5/5, knee range of motion returned to normal, Lower Extremity Functional Scale (LEFS) scores improved from 21/80 to 80/80, and successful outcomes on functional return to sport testing allowed the patient to return to competitive athletics. DISCUSSION: Primary repair of cruciate ligament tears has yielded poor results and partial cruciate ligament tears may not require complete surgical reconstruction. The healing response technique offers a possible solution for the treatment of partial cruciate ligament tears. A criterion-based post-operative protocol was derived based on current evidence regarding rehabilitation following cruciate ligament reconstruction and evidence regarding lower extremity rehabilitation principles and injury prevention. LEVEL OF EVIDENCE: Therapy, Level 4.
J Orthop Sports Phys Ther, Epub 12 March 2010. doi:10.2519/jospt.2010.3162
KEY WORDS: ACL, anterior cruciate ligament, healing response, physical therapy, PCL, posterior cruciate ligament
View Abstract
View Full Article
Case Report
Emilio J. Puentedura, Candi L. Brooksby, Harvey W. Wallmann, Merrill R. Landers
STUDY DESIGN: Case report. BACKGROUND: Lumbar spine nucleoplasty is a new surgical option for patients with disc pathology. While early results of the surgery are promising, there are no reports in the literature describing the role of physical therapy in postoperative lumbar nucleoplasty management. The purpose of this case is to describe the postoperative physical therapy management of a patient who underwent this procedure. CASE DESCRIPTION: A 50-year-old male 7 weeks following a L5/S1 lumbar nucleus replacement completed 6 weeks of rehabilitation. The focus of the treatment was controlled reloading of the spine through a spinal stabilization progression in weight bearing and non-weight bearing activities. In addition, education, spinal manual therapy techniques, and a home exercise program were also incorporated. OUTCOMES: The patient's Oswestry Disability Index (ODI) decreased from 56% to 4% over 6 weeks of treatment. When contacted at 6, 12, 18 and 24 months post therapy, his ODI was 2%, 2%, 0% and 0%, respectively, and he had returned to all previous activities without recurrence of symptoms. DISCUSSION: This case report outlines the clinical decision making process during the postoperative management of an individual who had undergone a single-level lumbar nucleoplasty. A postoperative regimen of education, segmental spinal stabilization, and a home exercise program, may have contributed to the observed improvement in pain and disability levels in this patient. The role of these post-operative interventions warrants further research.
J Orthop Sports Phys Ther, Epub 12 March 2010. doi:10.2519/jospt.2010.3115
KEY WORDS: manual therapy, nucleus replacement, postoperative rehabilitation, pain science education, physical therapy, spinal segmental stabilization
View Abstract
View Full Article
Research Report
Steven Z. George, Carolina Valencia, Jason M. Beneciuk
STUDY DESIGN: Validity and test-retest reliability of questionnaires related to the Fear-Avoidance Model (FAM). OBJECTIVE: To investigate test-retest reliability, construct redundancy, and criterion validity for 4 commonly used FAM measures. BACKGROUND: Few studies have reported psychometric properties for more than 2 FAM measures within the same cohort making it difficult to determine which specific measures should be implemented in outpatient physical therapy settings. METHODS: 53 consecutive patients (mean age = 44.3 years ± 18.5) with chronic low back pain (LBP) participated in this study. Data collected included validated measures for FAM constructs including the Fear-Avoidance Beliefs Questionnaire (FABQ), Fear of Pain Questionnaire (FPQ-9), Tampa Scale for Kinesiophobia (TSK-11), and Pain Catastrophizing Scale (PCS). Validated measures were used to investigate criterion validity of the FAM measures including the Patient Health Questionnaire (PHQ) for depression, Numerical Rating Scale (NRS) for pain intensity, Physical Impairment Scale (PIS) for physical impairment, and the Oswestry Disability Questionnaire (ODQ) for self-report of disability. Test-retest reliability of the FAM measures was determined with intraclass correlation coefficients (ICC [2,1]) for total questionnaire scores at baseline and 48 hours later. Construct redundancy was determined with Pearson correlation coefficients for FAM measures. Criterion validity was assessed by 4 separate multiple regression models that included age, sex, and employment status as covariates. Depression, pain intensity, physical impairment, and disability were the dependent variables for these analyses. RESULTS: Test-retest ICC coefficients ranged from 0.90 to 0.97 for all FAM questionnaires. The FAM measures were significantly correlated with each other, with the only exception being that the FPQ was not correlated with the FABQ - work scale. In the multiple regression models the PCS contributed additional variance to depression. The FABQ - physical activity scale contributed additional variance to pain intensity and disability. The FABQ - work scale contributed additional variance to physical impairment and disability. No other FAM measures contributed to these regression models. CONCLUSION: These data suggest 4 commonly used FAM measures have similar test-retest with varying amounts of construct redundancy. The criterion validity analyses suggest that measurement of fear-avoidance constructs for patients seeking outpatient physical therapy with chronic LBP should include the PCS and the FABQ.
J Orthop Sports Phys Ther, Epub 12 March 2010. doi:10.2519/jospt.2010.3298
KEY WORDS: chronic pain, lumbar spine, pain catastrophizing
View Abstract
View Full Article
Research Report
Joy L. Long, Ramon A. Ruberte Thiele, Jack G. Skendzel, Jongeun Jeon, Richard E. Hughes, Bruce S. Miller, James E. Carpenter
STUDY DESIGN: Prospective, single-group, repeated measures design. OBJECTIVES: To evaluate electromyographic (EMG) signal amplitude in the supraspinatus, infraspinatus, and deltoid muscles during pendulum exercises and light activities in a group of healthy subjects. BACKGROUND: There are numerous rehabilitation protocols used after rotator cuff repair. One of the most commonly used exercises in these protocols is the pendulum. Patients can easily perform these exercises incorrectly, and may also perform light activities of daily living without knowing that they may be putting excessive stress on the repair. The effect of improperly performed pendulum exercises and light activities after rotator cuff repair is unknown. METHODS: Muscle activity was recorded in 13 subjects performing pendulum exercises incorrectly and correctly in both large (51 cm) and small (20 cm) diameters, and while typing, drinking, and brushing their teeth. RESULTS: Incorrect and correct large pendulums and drinking elicited more than 15% maximum isometric voluntary contraction in the supraspinatus and infraspinatus. TheSuprapraspinatus EMG signal amplitude was greater during large, incorrectly performed pendulums than those performed correctly. Both correct and incorrect large pendulums resulted in statistically higher muscle activity in the supraspinatus than the small pendulums. CONCLUSION: Larger pendulums may require more force than desirable early in rehabilitation after rotator cuff repair.
J Orthop Sports Phys Ther, Epub 1 March 2010. doi:10.2519/jospt.2010.3095
KEY WORDS: activities of daily living, muscle activation, rehabilitation, rotator cuff
View Abstract
View Full Article
Research Report
Richard B. Souza, Christie E. Draper, Michael Fredericson, Christopher M. Powers
STUDY DESIGN: Controlled laboratory study using a cross-sectional design. OBJECTIVE: To compare patellofemoral joint kinematics, femoral rotation, and patella rotation between females with patellofemoral pain (PFP) and pain-free controls using weight-bearing kinematic magnetic resonance imaging (MRI). BACKGROUND: Recently, it has been recognized that patellofemoral malalignment may be the result of femoral motion as opposed to patella motion. METHODS: Fifteen females with PFP and 15 pain-free females between the ages of 18 and 45 years participated in this study. Kinematic imaging of the patellofemoral joint was performed using a vertically open MRI system. Axial-oblique images were obtained using a fast gradient-echo (Fast-GRE) pulse sequence. Images were acquired at a rate of 1 image per second while subjects performed a single limb squat. Measures of femur and patella rotation (relative to the image field of view), lateral patella tilt, and lateral patella displacement were made from images obtained at 45°, 30°, 15°, and 0° of knee flexion. Group differences were assessed using a mixed-model analysis of variance (ANOVA) with repeated measures. RESULTS: When compared to the control group, females with PFP demonstrated significantly greater lateral patella displacement at all angles evaluated and significantly greater lateral patella tilt at 30°, 15° and 0° of knee flexion. Similarly, greater medial femoral rotation was observed in the PFP group at 45°, 15° and 0° of knee flexion when compared to the control group. No group differences in patella rotation were found. CONCLUSION: Altered patellofemoral joint kinematics in females with PFP appears to be related to excessive medial femoral rotation as opposed to lateral patella rotation. Our results suggest that the control of femur rotation may be important in restoring normal patellofemoral joint kinematics.
J Orthop Sports Phys Ther, Epub 12 March 2010. doi:10.2519/jospt.2010.3215
KEY WORDS: biomechanics (lower extremity), hip, knee, medical imaging, MRI
View Abstract
View Full Article
Research Report
Toby Hall, Kathy Briffa, Diana Hopper, Kim Robinson
STUDY DESIGN: Reliability of clinical measurements over time. OBJECTIVES: To determine the long-term stability and minimal detectable change (MDC) of the flexion-rotation test (FRT) measurements over days in subjects with cervicogenic headache (CGH). BACKGROUND: The FRT is used by physical therapists to assist in identifying upper cervical movement impairment as well as gauge treatment effectiveness. Test-retest reliability for the FRT has been reported but the stability of range of motion (ROM) measures taken during the FRT over time and the MDC have not been investigated. METHODS: Fifteen subjects with CGH were evaluated on headache-free days using the FRT by a blinded examiner at baseline, two, four and 14 days later. An additional 10 asymptomatic subjects were included for blinding purposes. On each occasion the examiner measured ROM and determined whether the FRT was positive or negative. RESULTS: For subjects with CGH there was no significant change in FRT ROM over days (p>0.05). Intraclass correlation coefficients for intratester reliability were 0.95 (95% CI: 0.90-0.98) and 0.97 (95% CI: 0.94-0.99) for right and left rotation. MDC90 was 4.7˚ for right rotation and 7˚ for left rotation. Examiner interpretation of the FRT was consistent over time with Kappa of 0.92. CONCLUSIONS: This study provides evidence that FRT measurements are stable over time and the MDC indicates that a change in FRT ROM of at least 7˚ is required to be confident that a change has occurred due to an intervention rather than measurement error.
J Orthop Sports Phys Ther, Epub 12 March 2010. doi:10.2519/jospt.2010.3100
KEY WORDS: cervicogenic headache, neck, psychometrics, ROM, spine
View Abstract
View Full Article
Research Report
Harrison Philip Crowell, Clare E. Milner, Joseph Hamill, Irene S. Davis
STUDY DESIGN: Single-subject with repeated measures. OBJECTIVES: To determine if runners can use real-time visual feedback from an accelerometer to achieve immediate reductions in tibial acceleration and vertical force loading rates. BACKGROUND: Stress fractures are a common injury among runners. Previous studies suggest that runners with higher than normal tibial acceleration and vertical force loading rates are at increased risk for tibial stress fractures. If these runners can be trained to reduce the loading on their lower extremities, it may reduce their risk of stress fractures. METHODS: Five subjects participated in this study. All subjects ran on a treadmill, instrumented with force transducers, during a single 30-minute session that was divided into warm-up, feedback, no-feedback, and cool-down periods. During running, the subjects also wore an accelerometer taped to their distal right tibia. Peak positive acceleration of the tibia, vertical force impact peak, and average and instantaneous vertical force loading rates were assessed at the end of the warm-up, feedback, and no-feedback periods. RESULTS: Single-subject analysis revealed that 4 of the 5 subjects had significant reductions in their peak positive acceleration at the end of the no-feedback period compared to the warm-up. In addition, all of the subjects had significant decreases in impact peak and vertical ground reaction force loading rates at the end of the no-feedback period. CONCLUSION: In a single session of training with real-time visual feedback, it appears that most runners can reduce the types of lower extremity loading associated with stress fractures. This may lead to training programs that reduce the risk of stress fractures for runners.
J Orthop Sports Phys Ther, Epub 12 March 2010. doi:10.2519/jospt.2010.3166
KEY WORDS: accelerometer, gait retraining, ground reaction forces, stress fracture, tibia
View Abstract
View Full Article
Research Report
Paul F. Beattie, Cathy F. Arnot, Jonathan W. Donley, Harmony Noda, Lane Bailey
STUDY DESIGN: Single group, prospective, repeated measures design. OBJECTIVES: To determine differences in the changes of diffusion of water in the L5-S1 intervertebral disc between those subjects with non-specific low back pain (LBP) who reported an immediate reduction in pain intensity of > 2 on an 11-point (0-10) numeric rating scale after a 10-minute session of lumbar joint mobilization followed by prone press-up exercises compared to those who did not report an immediate reduction in pain intensity of 2 or greater on the pain scale. BACKGROUND: Combining lumbar joint mobilization and prone press-up exercises is a common intervention for patients with LBP; however there is conflicting evidence regarding the effectiveness and efficacy of this approach. Increased knowledge of the physiologic effects of the combined use of these treatments, and the relationship to pain reports, can lead to refinement of their clinical application. METHODS: Twenty adults aged 22-54 participated in this study. All subjects reported LBP of at least 2 on an 11-point (0-10) verbally administered numeric rating scale at the time of enrollment in the study, and were classified as being candidates for the combination of joint mobilization and prone press-ups. Subjects underwent T2 and diffusion-weighted lumbar magnetic resonance imaging scans before, and immediately after, receiving a 10-minute session of lumbar posterior to anteriorly (P-A) directed pressures and prone press-up exercises. Subjects who reported a decrease in current pain intensity of > 2 immediately following treatment were classified as "immediate responders," while the remainder were classified as "not-immediate responders." The apparent diffusion coefficient (ADC), representing the diffusion of water in the nucleus pulposis, was calculated from the mid-sagittal diffusion-weighted images. RESULTS: Following treatment, immediate responders (n=10) had a mean increase in the ADC in the middle portion of the L5-S1 intervertebral disc (IVD) of 4.2% compared to a mean decrease of 1.6% for the not-immediate responders (p <.005). CONCLUSION: In a group of subjects with LBP who were classified as being candidates for extension-based treatment the report of an immediate reduction in pain intensity of >2/10 after a treatment of PA pressures followed by prone press-up exercises was associated with an increase in diffusion of water in the nuclear region of the L5-S1 IVD. Subjects who did not report a pain reduction of >2/10 did not have a change in diffusion.
J Orthop Sports Phys Ther, Epub 12 March 2010. doi:10.2519/jospt.2010.3284
KEY WORDS: low back pain, manual therapy, magnetic resonance imaging
View Abstract
View Full Article
Research Report
Isabel Audette, Jean-Pierre Dumas, Julie N. Côté, Sophie J. De Serres
STUDY DESIGN: Clinical Measurement, validity and intra-rater reliability study. OBJECTIVES: (1) To confirm the validity and assess between-day test-retest reliability of cervical spine motion measurements made with the cervical range of motion (CROM) device in flexion, extension, bilateral rotation, and bilateral side flexion; (2) To provide meaningful information to clinicians about the standard error of measurement (SEM) and the minimal detectable change (MDC) for the CROM device. BACKGROUND: Range of motion (ROM) is a common outcome measure used in the assessment of the cervical spine. The CROM device is one of the tools used to measure cervical ROM in the clinical setting. However, its psychometric properties are not well established, especially for measurements taken on separate days. METHODS: Quasi-experimental design with 1 group comparison. Twenty healthy adults (9 men and 11 women) participated in this study. Cervical ROM was simultaneously recorded with the CROM device and the Fastrak® motion analysis system for all 6 cervical movements mentioned above. The CROM device was placed on the participant's head consistent with standard clinical procedures. Two Fastrak® sensors were positioned, 1 on the forehead and 1 over the spinous process of the T6 vertebra. Test-retest reliability of measurements made with the CROM device was assessed, as well as its SEM and MDC, with measures taken on 2 separate days spaced 48 hours. RESULTS: Values obtained by the 2 measuring devices yielded Pearson correlation coefficients ranging between 0.93 and 0.98. Test-retest reliability of measurements of cervical ROM using the CROM was found to be good, with ICCs ranging between 0.89 and 0.98. The SEMs across the 6 movements ranged from 1.6° to 2.8° and the MDCs across the 6 movements ranged from 3.6° to 6.5°. CONCLUSIONS: The measurements made with the CROM were shown to be reliable in all movement directions.
J Orthop Sports Phys Ther, Epub 12 March 2010. doi:10.2519/jospt.2010.3180
KEY WORDS: cervical ROM measurement, clinical tool, psychometrics, SEM, MDC
View Abstract
View Full Article