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. They have not been edited or formatted and thus do not reflect the editorial standards to which the JOSPT holds its published material. 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.
DISCLAMER: Manuscripts published in JOSPT Express have not yet been edited or proofread and so may contain errors for which the Journal is not responsible.
Accepted Manuscripts Posted as of April 25, 2008
Clinical Commentary
Paul F. Beattie
SYNOPSIS: Degeneration of the lumbar intervertebral discs (IVDs) is highly prevalent in adults, and is nearly universal in the elderly population. Degenerative changes within, and adjacent to, the IVDs are likely to contribute to a variety of pain syndromes; however, the exact association between these findings and symptoms remains speculative. Recent research has provided new information regarding the etiology, pathophysiology, and clinical relevance of degeneration of the IVD. This information will assist clinicians and researchers in understanding the development and clinical course of lumbar disc degeneration as well as its potential impact upon patients seeking physical therapy care for back pain. The purposes of this clinical commentary are to review the structure and metabolic capacity of the normal and degenerative lumbar IVD, and to discuss factors that influence the onset and progression of disc degeneration. Lumbar magnetic resonance images will be used to illustrate the common findings associated with this condition.
J Orthop Sports Phys Ther., Epub 12 March 2008, doi:10.2519/jospt.2008.2768
KEY WORDS: back pain, lumbar disc, rehabilitation
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Case Report
Terry L. Grindstaff, Kate R. Jackson, J. Craig Garrison, David R. Diduch, Christopher D. Ingersoll, Joe H. Gieck
STUDY DESIGN: Case Report. BACKGROUND: Decreased quadriceps activation has been shown to be present following anterior cruciate ligament (ACL) injury, but its presence prior to ACL injury is unknown. The purpose of this case report was to describe the level of quadriceps activation measured hours before a non-contact ACL injury in an individual who previously demonstrated known biomechanical risk factors for ACL injury. CASE DESCRIPTION: A 23 year old female (height= 176.9 cm, mass= 72.4 kg), sustained a left non-contact ACL injury while landing from a jump-stop during a recreational basketball game. This case was unique because data regarding landing biomechanics and quadriceps force and activation were gathered in 2 separate, unrelated studies prior to injury. OUTCOMES: Peak external knee abduction moment (-65.3 Nm) during a drop jump landing, 8 months prior to injury, indicated elevated risk for ACL injury. Involved quadriceps central activation ratios (CAR) were obtained 1 week (CAR =0.81) and 4 hours (CAR =0.77) prior to injury. Strength and CAR (0.76) measurements changed very little within 36 hours of injury and both strength and activation (CAR =0.90) improved following surgical reconstruction and formal rehabilitation. DISCUSSION: An individual with known biomechanical risk factors for ACL injury may compound their risk for non-contact ACL injury if decreased quadriceps activation is also present.
J Orthop Sports Phys Ther., Epub 25 April 2008. doi:10.2519/jospt.2008.2761
KEY WORDS: ACL, biomechanics, knee, muscle inhibition
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Case Report
Akio Sakamoto, Kazuhiro Tanaka, Shuichi Matsuda, Tatsuya Yoshida, Yukihide Iwamoto
STUDY DESIGN: Resident's case problem BACKGROUND: Nonossifying fibroma (NOF) is the most common fibrous bone lesion in children. The lesion is usually asymptomatic, and rarely leads to pathological fractures. DIAGNOSIS: We present the case of a 12-year-old boy, who appeared to be normally developed, but who had a pathological insufficiency fracture associated with NOF in the distal femur. He was a member of a track athletics club and he ran more than 5 kilometers every day. Seven weeks prior to the initial evaluation, he felt discomfort in the left distal thigh when running, and felt pain upon knee flexion. The amount of discomfort increased gradually and he began to experience pain while running 4 weeks prior to his initial evaluation. At the time of the initial evaluation, he had tenderness over the distal thigh region and there was increased pain with weight-bearing. Plain radiographs showed an irregular well-defined cortical bone lesion, suggesting NOF, with vague increased density in the bone marrow across the femur and periosteal new bone, suggesting a fracture. Computed tomography confirmed a linear fracture with increased density across the femur leading to the cortical lesion. In the process of differential diagnosis, osteosarcoma or Ewing sarcoma, and bone/joint infection were ruled out using magnetic resonance imaging. The final diagnosis based upon the images and clinical course was pathological insufficiency fracture associated with NOF. The patient was treated with initial avoidance of weight bearing using 2 crutches for ambulation followed by progressive weight-bearing over a period of 5 weeks. Active range of motion of the knee joint was allowed. Three months after onset (5 weeks after the initial evaluation), the patient had normal gait without pain, whereupon the patient resumed his sport activities, beginning with jogging. DISCUSSION: Although pathological fractures secondary to NOF in the femur are rare, NOF can cause pathological insufficiency fractures in athletes, even if the lesion is confined and small. The current case is a reminder of such a possibility. This case also provides a time-course as a reference for the rehabilitation of patients in similar cases.
J Orthop Sports Phys Ther., Epub 12 March 2008, doi:10.2519/jospt.2008.2655
KEY WORDS: athletes, bone lesion, femur, fibroxanthoma
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Case Report
Shaw Bronner, Sheyi Ojofeitimi, Donald Rose
STUDY DESIGN: Case report. BACKGROUND: Tendon lacerations of the hallux are potentially devastating to a dancer. Strength of the hallux musculature is necessary to attain and maintain balance, push off in multiple turns, and decelerate in jumps and hops. The purpose of this paper is to report on the repair and rehabilitation of extensor hallux longus (EHL) and brevis (EHB) tendon lacerations in a professional dancer. CASE DESCRIPTION: A 30 year-old dancer sustained complete laceration of her EHL and EHB tendons and partial laceration of the dorsal aspect of the hallux metatarsophalangeal (MTP) joint capsule. Following primary repair, at 9-weeks post-surgery, hallux MTP joint active dorsiflexion was limited to 5º and passive dorsiflexion to 70º. First toe dorsiflexion and plantar flexion strength was 4/5 at the MTP and 3+/5 at the interphalangeal (IP) joint. Rehabilitation included functional electric stimulation to address considerable calf atrophy, strengthening, functional retraining, and progressive return to dance. OUTCOME: The dancer returned to her previous level of dancing in 18 weeks, with 73º and 85º of hallux MTP joint active and passive dorsiflexion and 30º / 35º of active / passive plantar flexion. Hallux MTP and IP joint muscle strength were 5/5 and 4+/5 respectively. Improvement, manifested in her SF-36 and Dance Functional Outcome System scores, accompanied her full functional recovery. DISCUSSION: Hallux stability provided by co-activation of the great toe extensors and flexors is crucial to accomplish the demands of bi- and unipedal balances and activities in dance. This report demonstrates the success of primary surgical repair and rehabilitation in a dancer-athlete experiencing this injury.
J Orthop Sports Phys Ther., Epub 22 January 2008, doi:10.2519/jospt.2008.2749
KEY WORDS: dance injury, foot, hallux, metatarsophalangeal joint
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Literature Review
Wayne A. Dessaur, Mary E. Magarey
STUDY DESIGN: Systematic literature review. OBJECTIVES: To conduct a systematic review of case series and clinical trials investigating the diagnostic accuracy of clinical tests for superior labral anterior posterior (SLAP) lesions. BACKGROUND: Primary contact practitioners are often presented with shoulder problems and use a battery of clinical tests to reach a diagnosis. Early detection of SLAP pathology may lead to more optimal interventions and better outcomes for patients. METHODS AND MEASURES: The OVID search interface was utilized with MEDLINE, AHMED, CINAHL, and SPORTDiscus databases searched from 1996-2006. Studies were retrieved that included patients with shoulder pain who underwent at least 1 clinical shoulder test for SLAP lesions. For an article to be included in this review, the results of the clinical tests needed to be compared with findings on arthroscopy. Quality of the manuscripts included in this review were rated using the QUADAS appraisal tool so comparisons could be made across studies. RESULTS: Seventeen published manuscripts fit the inclusion/exclusion criteria and were used for this review. Eight studies were found to be of high quality. Within these 8 studies, Lui et al27 reported high diagnostic accuracy values for the Crank test (sensitivity 91% (95% confidence intervals 76-97), specificity 93% (95% confidence intervals 79-88), + likelihood ratio 13.6 (95% confidence intervals 3.6-52.1), and - likelihood ratio 0.1 (95% confidence intervals 0.0-0.3). The study by Myers et al35 on the Resisted Supination External Rotation Test also scored high on the QUADAS and reported diagnostic accuracy values of 83% (66-92), 82% (52-95), 4.6 (1.3-16.1) and 0.20 (0.1-0.5) respectively. Of significance is the fact that the majority of papers reporting highly accurate clinical diagnostic tests, were of low quality with the results not supported by other authors. CONCLUSION: It appears no single test is sensitive or specific enough to determine the presence of a SLAP lesion accurately. Further research is required to determine whether sub-grouping of patients by mechanism of injury or the type of SLAP lesion, may improve diagnostic accuracy. Determining the diagnostic accuracy of a combination of 2 or more tests is also needed.
J Orthop Sports Phys Ther., Epub 22 February 2008, doi:10.2519/jospt.2008.2676
KEY WORDS: labral lesion, labrum, shoulder, SLAP
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Research Report
Susumu Ota, Takeshi Nakashima, Ayako Morisaka, Kunio Ida, Morio Kawamura
STUDY DESIGN: Case control study and repeated measurements. OBJECTIVE: To compare the patellar mobility of female adult subjects with and without patellofemoral pain (PFP). BACKGROUND: Although abnormal patellar mobility is believed to be one of the causes of PFP, there is currently no published evidence to support this contention. In part this lack of evidence is because a reliable clinical measurement method to measure patellar mobility and objective criteria to define abnormal patellar mobility have not been established. METHODS AND MEASURES: The study comprised 22 females with PFP (PFP group) and 22 females who had no knee pain (control group) who were matched to the subjects with PFP based on age, height, and body mass index. Patellar mobility was measured objectively using a specially designed apparatus. Measurements of lateral and medial patellar displacement, patellar mobility balance (lateral minus medial patellar displacement), lateral patellar mobility index (LPMI: lateral patellar displacement/ patellar width), and medial patellar mobility index (MPMI: medial patellar displacement/ patellar width) were used. RESULTS: Lateral and medial patellar mobility values were not significantly different between the individuals in the PFP and control groups. When normal patellar mobility was arbitrarily defined as the average ± 2SD based on the data from the control group, normal lateral patellar displacement was within a range of 7.2 to 17.6 mm and normal medial patellar displacement was within a range of 6.8 to 14.0 mm. The intraclass correlation coefficient for intratester and intertester reliability of lateral and medial patellar displacement measurements varied from 0.80 to 0.97. CONCLUSION: Although these were no significant differences in patellar mobility between females with and without PFP, these measurements give reference information about normal patellar mobility for this group.
J Orthop Sports Phys Ther., Epub 12 March 2008, doi:10.2519/jospt.2008.2585
KEY WORDS: knee, patella, patellofemoral joint, reliability
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Research Report
Elaine Trudelle-Jackson, Shweta A. Sarvaiya-Shah, Sharon S. Wang
STUDY DESIGN: A prospective methodological study of interrater reliability. OBJECTIVES: To examine the interrater reliability of a movement impairment-based classification system for patients with chronic low back pain (LBP). BACKGROUND: Movement impairment-based classification for the lumbar spine categorizes LBP based on the findings derived from a patient history and standardized examination. Though many presume this classification to be useful for directing treatment of individuals with LBP, agreement between examiners for assigning a lumbar spine category to a patient has not been studied thoroughly. METHODS AND MEASURES: Two physical therapists independently examined 24 patients (8 men, 16 women) with chronic LBP (pain duration > 12 weeks). All patients enrolled in the study had been diagnosed with LBP believed to be due to mechanical causes and the duration of their symptoms ranged from 20 to 1,040 weeks. The examiners used a standardized examination to assess patients and then classify them into 1 of 5 lumbar spine categories. Percent agreement and kappa coefficients were calculated between the examiners for the lumbar movement impairment-based classifications. RESULTS: Percent agreement between examiners was 75% and the kappa coefficient was 0.61. The most prevalent lumbar spine categories identified by both examiners were lumbar extension rotation syndrome (41.7% of patients by examiner 1, 37.5% of patients by examiner 2) and lumbar rotation syndrome (41.7% of patients by both examiners). CONCLUSIONS: Interrater reliability between 2 physical therapists classifying patients with chronic LBP patients into 1 of 5 lumbar spine movement impairment categories substantial agreement.
J Orthop Sports Phys Ther., Epub 22 January 2008, doi:10.2519/jospt.2008.2760
KEY WORDS: agreement, diagnostic categories, kappa statistic
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Research Report
Stephanie J. Woodley, Helen D. Nicholson, Vicki Livingstone, Terence C. Doyle, Grant R. Meikle, Janet E. Macintosh, Susan R. Mercer
STUDY DESIGN: Prospective cross-sectional study. OBJECTIVES: To examine the radiological and physical therapy diagnoses of lateral hip pain (LHP), and determine the validity of selected clinical variables for predicting gluteal tendon pathology. BACKGROUND: LHP is frequently encountered by clinicians. Further investigation is required to establish the specific pathologies implicated in the cause of LHP, and which clinical tests are useful in the assessment of this problem. METHODS AND MEASURES: Forty patients with unilateral LHP underwent a physical therapy examination followed by magnetic resonance (MR) imaging studies. Three radiologists analyzed the images of both hips for signs of pathology. Interobserver reliability of the image analyses, the agreement between the physical therapy and radiological diagnoses, and the validity of the clinical tests were examined. RESULTS: Gluteus medius tendon pathology, bursitis, osteoarthritis and gluteal muscle atrophy (predominantly affecting gluteus minimus) were all implicated in the imaging report of LHP. While prevalent in symptomatic hips, abnormalities were also identified in asymptomatic hips, particularly relating to the diagnosis of bursitis. The strength of agreement between radiologists was variable and little agreement existed between the physical therapy and radiological diagnoses of pathology. Nine of the 26 clinical variables examined in relation to gluteal tendon pathology had likelihood ratios above 2.0 or below 0.5, but the associated 95% confidence intervals were large. CONCLUSIONS: The diagnosis of LHP is challenging and our results highlight some problems associated with the use of MR imaging as a diagnostic reference standard. This factor, together with the inexact point estimates of the likelihood ratios, means no firm conclusions can be made regarding the diagnostic utility of the clinical tests used in the assessment of gluteal tendon pathology.
J Orthop Sports Phys Ther., Epub 22 February 2008, doi:10.2519/jospt.2008.2685
KEY WORDS: bursitis, gluteal, muscle atrophy, reliability, tendon pathology, validity
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Research Report
Christine A. Iverson, Thomas G. Sutlive, Michael S. Crowell, Rebecca L. Morrell, Matthew W. Perkins, Matthew B. Garber, Josef H. Moore, Robert S. Wainner
STUDY DESIGN: Prospective cohort/predictive validity study. OBJECTIVE: To determine the predictive validity of selected clinical exam items and to develop a clinical prediction rule (CPR) to determine which patients with patellofemoral pain syndrome (PFPS) have a positive immediate response to lumbopelvic manipulation. BACKGROUND: Quadriceps muscle function in patients with PFPS was recently shown to improve following treatment with lumbopelvic manipulation. No previous study has determined if individuals with PFPS experience symptomatic relief of pain immediately following this manipulation technique. METHODS AND MEASURES: Fifty subjects (26 male, 24 female; age range: 18 to 45 years) with PFPS underwent a standardized history and physical examination. After the evaluation, each subject performed 3 typically pain-producing functional activities (squatting, stepping up a 20 cm step and stepping down a 20 cm step). The pain level perceived during each activity was rated on a numerical pain scale (0=no pain, 10=worst possible pain). Following the assessment, all subjects were treated with a lumbopelvic manipulation, which was immediately followed by re-testing the 3 functional activities to determine if there was any change in pain ratings. An immediate overall 50% reduction in pain or moderate improvement on a Global Rating of Change questionnaire was considered a treatment success. Likelihood ratios (LRs) were calculated to determine which examination items were most predictive of treatment outcome. RESULTS: Data for 49 subjects were included in the data analysis, of which 22 (45%) had a successful outcome. Five predictor variables were identified. The most powerful predictor of treatment success was a side-to-side difference in hip internal rotation range of motion greater than 14º (+LR = 4.9). If this variable was present, the chance of experiencing a successful outcome improved from 45% to 80%. CONCLUSION: A CPR was developed to predict an immediate successful response to lumbopelvic manipulation in patients with PFPS. However, future studies are necessary to validate the CPR rule and in light of a limited sample size and omission of potentially meaningful predictor variables.
J Orthop Sports Phys Ther., Epub 22 January 2008, doi:10.2519/jospt.2008.2669
KEY WORDS: anterior knee pain, physical examination, rehabilitation, spinal manipulation
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Research Report
Ryan L. Mizner, Jeffrey K. Kawaguchi, Terese L. Chmielewski
STUDY DESIGN: Pre- and post-instruction testing in a laboratory setting. OBJECTIVES: To examine the predictive relationship between lower extremity muscle strength and the immediate post-instruction changes in landing patterns of female athletes. We hypothesized that greater strength would be associated with larger post-instruction improvements in landing patterns. BACKGROUND: Female athletes in high-demand sports may be predisposed to anterior cruciate ligament injury because of poor landing patterns. Instruction has been shown to improve landing patterns. Lower extremity muscular strength may determine the potential for instruction to alter landing patterns. METHODS AND MEASURES: Thirty-seven female collegiate athletes in high-demand sports participated. Strength was assessed in the following muscle groups: trunk extensors and flexors, hip abductors and extensors, knee flexors and extensors, and ankle plantar flexors. Strength testing was followed by kinetic and kinematic analysis of a drop vertical jump task. Athletes then received verbal instruction on how to improve their landing technique and were retested. Landing variables of interest were force absorption time, peak vertical ground reaction force (vGRF), peak knee flexion and abduction angle, and peak external knee abduction moment. Pre- and post-instruction landing variables data were compared. Linear regression models were created with strength values as independent variables and landing variables as dependent variables. RESULTS: After instruction, athletes significantly increased their force absorption time and peak knee flexion angle while decreasing their peak vGRF, peak knee abduction angle, and peak external knee abduction moment (p<0.001). None of the regression models were statistically significant (p>0.05). CONCLUSIONS: A brief instructional session promotes short-term improvements in the landing patterns of collegiate female athletes, but muscular strength was a poor predictor of the improvements.
J Orthop Sports Phys Ther., Epub 10 April 2008. doi:10.2519/jospt.2008.2726
KEY WORDS: ACL, biomechanics, hip, knee, motion analysis
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