STUDY DESIGN: Resident’s case problem. BACKGROUND: The C8 nerve root is the least commonly encountered of cervical radiculopathies. The purpose of this resident’s case problem is to provide an unusual presentation of a C8 radiculopathy, without cervical or proximal upper quarter symptoms, diagnosed by a combination of physical examination, electromyography (EMG) and nerve conduction studies (NCSs), and imaging. DIAGNOSIS: A 49-year-old, right-hand–dominant male was referred to the EMG/NCS laboratory for a suspected left ulnar neuropathy at the elbow. A physical examination, NCS, and EMG were performed, and a C8 radiculopathy involving both the anterior and posterior primary rami was identified. Following the EMG and NCS evaluation, the patient had enhanced magnetic resonance imaging studies that confirmed a foraminal C7-T1 herniation and associated small central disc protrusion. The patient was then referred to neurosurgery for further consultation and subsequent surgical intervention. The patient underwent a C7-T1 laminectomy, mesial facetectomy, and foraminotomy, and excision of a herniated disk using an operating microscope. The neurosurgeon noted that there was a large disk herniation containing some disk material immediately anterior to the C8 motor root, that impinged directly on the motor root. One month postoperatively, the patient had decreased pain and numbness and tingling in his arm and his hand weakness had improved. DISCUSSION: The report illustrates the utility of a combination of physical examination, EMG and NCSs, and imaging in the diagnosis of a C8 radiculopathy in a patient presenting with forearm and hand symptoms but without cervical or upper quarter symptoms. LEVEL OF EVIDENCE: Diagnosis, level 4.

J Orthop Sports Phys Ther 2010;40(12):811-817, Epub 22 October 2010. doi:10.2519/jospt.2010.3187

KEY WORDS: electromyography, magnetic resonance imaging, neck nerve conduction studies, ulnar nerve

STUDY DESIGN: Descriptive. OBJECTIVES: To determine the presence of clinical and electrodiagnostic abnormalities of the median and ulnar nerves in both upper extremities of dental assistants. BACKGROUND: A high prevalence of median neuropathies at, or distal to, the wrist have been reported in dentists and dental hygienists. But there is a paucity of literature on the incidence of abnormalities of the median or ulnar nerves in dental assistants. METHODS: Thirty-five United States Army dental assistants (24 female, 11 male; age range, 18-41 years) volunteered for the study. Subjects completed a standardized history and physical examination. Nerve conduction status of the median and ulnar nerves of both upper extremities was obtained by performing motor, sensory, and F-wave (central) nerve conduction studies. RESULTS: All electrophysiological variables were normal for motor, sensory, and F-wave (central) values when compared to a chart of normal values. Based on comparison studies of median and ulnar motor latencies within the same hand, 9 subjects (26%) involving 14 hands (20%) were found to have electrodiagnostic abnormalities of the median nerve at, or distal to, the wrist. The other 26 dental assistants demonstrated normal comparison studies of the median and ulnar nerves in both upper extremities. CONCLUSIONS: In this descriptive study of 35 dental assistants, 9 subjects (26%) were found to have electrodiagnostic abnormalities of the median nerve at, or distal to, the wrist (when compared to the ulnar nerve of the same hand). Ulnar nerve electrophysiological function was within normal limits for all subjects examined. LEVEL OF EVIDENCE: Prognosis, level 4.

J Orthop Sports Phys Ther 2009;39(9):693-701, Epub 24 June 2009. doi:10.2519/jospt.2009.2995

KEY WORDS: carpal tunnel syndrome, hand, nerve conduction study, ulnar nerve

At the time this study was performed, LTs Ferguson, Blackley, Knight, and Sutlive were students in the US. Army-Baylor University Graduate Program in Physical Therapy. This research was performed in partial fulfillment of their requirements for the Master of Physical Therapy Degrees.

The purpose of this study was to evaluate the effects of varying electrode placement on the torque output of an electrically stimulated involuntary quadriceps femoris muscle contraction. Twenty-two volunteer subjects (18 men, 4 women) with a mean age of 21.7 years received electrical stimulation according to a randomized treatment order which included: Femoral nerve and 1) vastus medialis (VM), 2) rectus femoris (RF), 3) vastus lateralis (VL), 4) opposite quadriceps (OQ), and 5) the ipsilateral vastus medialis and vastus lateralis (VM/VL). The subject's knee was placed in 60° of flexion, and the isokinetic dynamometer set at 0°/sec. The peak torque produced by the involuntary quadriceps contraction was measured as a percentage of maximum voluntary isometric contraction (MVIC). An analysis of variance with repeated measures was used to examine the data. The results indicated the mean percentages of MVIC produced by stimulating the VM, VL, and RF sites were significantly greater (p ≤ 0.05) than the means of the OQ and VM/VL sites. Post hoc testing did not reveal a significant difference in the mean percent MVIC between the VM, VL, and RF sites. The VM, VL, or RF distal electrode site placement may be used clinically in conjunction with ipsilateral femoral nerve stimulation to produce a maximum involuntary isometric contraction of the quadriceps femoris muscle when stimulated electrically.

J Orthop Sports Phys Ther 1989;11(1):24-29.

The purpose of this study was to evaluate the effects of low-amplitude electrical stimulation (ES) on maximal tolerable ES and involuntary torque production of the quadriceps femoris muscle. Seventeen healthy volunteers (11 male, 6 female) aged 19-35 years (mean, 25.1 years) completed the study. Both quadriceps femoris muscle groups received maximal tolerated ES in all subjects. One limb was treated with 10 minutes of low-amplitude ES prior to application of the maximal tolerated ES, while the opposite limb did not receive the low-amplitude ES. Analysis of the data revealed significantly (p < 0.01) greater torque generation and current tolerated when the maximal tolerated ES was delivered following the low-amplitude ES. The clinical implication is that if ES is to be used to increase muscular strength, a low-amplitude current delivered prior to maximal tolerable current delivery allows greater involuntary torque production.

J Orthop Sports Phys Ther 1990;12(3):101-104.

Study Design: Nonexperimental descriptive research design. Objective: To describe the frequency of use and perceived level of importance of professional responsibilities, procedures, and knowledge areas by physical therapists practicing in primary contact care settings and to compare these data to similar data from physical therapists practicing in nonprimary contact care settings. Background: Physical therapy services have moved toward a primary contact model of practice in response to changes in the health care delivery system. Several studies have reported the effectiveness of primary contact physical therapy. However, a practice analysis has not been performed to define the clinical practice of primary contact physical therapy. Methods and Measures: A sample of 212 physical therapists practicing as primary contact providers in the military and civilian sectors, and a comparison group of 250 physical therapists not practicing as primary contact providers were surveyed. A Delphi technique was used to develop the survey instrument, which was pretested by a pilot group. The final survey instrument consisted of 171 items. Chi-square and Kruskal-Wallis tests were conducted to examine significant differences among the 3 groups (P<.001). Results: Of the 212 surveys mailed to the primary contact group, 119 (56.1%) responses were received (82 military physical therapists and 37 civilian physical therapists). Of the 250 surveys mailed to the comparison group, 103 (41.2%) responses were received. There were numerous significant differences among the 3 groups in professional responsibilities, procedures, and knowledge areas, most notably in the areas of selecting and ordering of imaging procedures, identifying signs and symptoms of nonmusculoskeletal conditions, establishing physical therapy diagnoses, and prescribing over-the-counter medications. Conclusion: The study describes the clinical practice of physical therapists functioning in the role of primary contact providers or as members of a diverse team of health care professionals in primary care, which may provide curricular direction to professional, postprofessional, and clinical residency or fellowship-based educational settings.

J Orthop Sports Phys Ther. 2004;34(6):284-304. doi:10.2519/jospt.2004.1298

Key Words: clinical competencies, physical therapists, primary care

The purposes of this editorial are to acquaint the physical therapy profession and readers of the JOSPT with an abridged and focused summary of the new anatomical terminology currently being used in health education, scholarly publication, research, and practice, and to provide a rationale for the implemented changes. The current anatomical terms are being utilized in the education and training of students of physical therapy, medicine, and other allied health programs, and are being integrated into clinical practice. Acceptance and adherence to the new standard will enable clear understanding and increase the accuracy of documentation, and improve communication among health care professionals who will all be speaking the same language.

J Orthop Phys Ther. 2004; 34(7):363-367. doi:10.2519/jospt.2004.0107

Key Words: anatomical terminology

Study Design: Cross-sectional study. Objectives: The purpose of this study was to examine the effects of the superficial heating modality, Fluidotherapy, on skin temperature and on sensory nerve action potential (SNAP) conduction latency and amplitude of the superficial radial nerve in healthy individuals. Background: Fluidotherapy is a dry, superficial heating modality, which also provides tactile stimulation through the bombardment of air-fluidized cellulose particles. Previous literature has documented a direct relationship between skin temperature and neural conduction velocity; however, there is an absence of published research examining the effects of Fluidotherapy, and of tactile stimulation specifically, on neural conduction. Methods and Measures: Twenty-one subjects between the ages of 22 and 31 years (mean ± SD, 25.5 ± 0.7 years) and without prior history of diabetes, alcoholism, renal or metabolic dysfunction, current pregnancy, or heat sensitivity were invited to participate. Subjects completed an upper quarter screening exam and medical history form prior to participation. One group underwent heat (46.7°C-48.9°C) and tactile stimulation, a second group underwent tactile stimulation alone, while a third served as controls. Dependent variables were assessed at 3 intervals: before the intervention, immediately after the intervention, and 20 minutes after the intervention. All interventions were 20 minutes in length. Results: A mixed 2-way analysis of variance indicated a significant interaction between time of neural conduction velocity assessment and treatment group for the dependent variables of sensory nerve action potential latency (P<.001) and skin temperature (P<.001). Appropriate post hoc tests were performed for simple effect comparisons. An inverse linear relationship existed between skin temperature and latency (r² = .65; Pearson product coefficient, –.81). Conclusions: Fluidotherapy treatment, which combines the effects of heat and tactile stimulation, significantly elevated superficial skin temperature, while tactile stimulation alone and no treatment (control group) did not bring about a temperature change. As the superficial skin temperature increased, there was a concomitant decrease in the distal sensory latency of the superficial radial sensory nerve action potential. These results should be an important consideration for the clinician using superficial heating modalities.

J Orthop Sport Phys Ther. 2005;35(1)16-23. doi: 10.2519/jospt.2005.1138

Key Words: heat, latency, neural conduction, physical agents

The purpose of this paper is to provide a brief background on the concept of primary care physical therapy, describe 3 existing models of primary care physical therapy, explore their similarities and differences, and discuss the potential implications and opportunities for the profession. The programs at US Army medical facilities, Kaiser Permanente Northern California and the Department of Veterans Affairs Salt Lake City Health Care System, are presented by the author affiliated with each respective program.

J Orthop Sports Phys Ther. 2005;35(11):699-707. doi:10.2519/jospt.2005.2167

Key Words: differential diagnosis, direct access, health policy

Study Design: Descriptive study. Objectives: To determine the presence of median and ulnar neuropathies in both upper extremities of university guitarists. Background: Peripheral nerve entrapment syndromes of the upper extremities are well documented in musicians. Guitarists and plucked-string musicians are at risk for entrapment neuropathies in the upper extremities and are prone to mild neurologic deficits. Methods and Measures: Twenty-four volunteer male and female guitarists (age range, 18-26 years) were recruited from the Belmont University School of Music and the Vanderbilt University Blair School of Music. Individuals were excluded if they were pregnant or had a history of recent upper extremity or neck injury. Subjects completed a history form, were interviewed, and underwent a physical examination. Nerve conduction status of the median and ulnar nerves of both upper extremities was obtained by performing motor, sensory, and F-wave (central) nerve conduction studies. Descriptive statistics of the nerve conduction study variables were computed using Microsoft Excel. Results: Six subjects had positive findings on provocative testing of the median and ulnar nerves. Otherwise, these guitarists had normal upper extremity neural and musculoskeletal function based on the history and physical examinations. When comparing the subjects’ nerve conduction study values with a chart of normal nerve conduction studies values, 2 subjects had prolonged distal motor latencies (DMLs) of the left median nerve of 4.3 and 4.7 milliseconds (normal, <4.2 milliseconds). Prolonged DMLs are compatible with median neuropathy at or distal to the wrist. Otherwise, all electrophysiological variables were within normal limits for motor, sensory, and F-wave (central) values. However, comparison studies of median and ulnar motor latencies in the same hand demonstrated prolonged differences of greater than 1.0 milliseconds that affected the median nerve in 2 additional subjects, and identified contralateral limb involvement in a subject with a prolonged distal latency. The other 20 subjects demonstrated normal comparison studies of the median and ulnar nerves in both upper extremities. Conclusions: In this descriptive study of a population of 24 university guitarists, 4 musicians (17%) were found to have electrophysiologic evidence of median neuropathy at or distal to the wrist or carpal tunnel syndrome. Ulnar nerve electrophysiological function was within normal limits for all subjects examined.

J Orthop Sports Phys Ther. 2006;36(2):101-111. doi:10.2519/jospt.2006.2155

Key Words: median nerve, nerve conduction study, ulnar nerve

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department bf the Army or the Department of Defense. Army physical therapists have had unique experiences relevant to orthopaedic physical therapy. The educational process, expanded clinical privileges, and physician supervisor role as developed to prepare and support physical therapists working as primary neuromusculoskeletal screeners are summarized. After-action reports demonstrate that Army physical therapists can evaluate and treat one-third of all sick-call patients generated in field training missions and significantly improve return-to-duty rates without requiring physician intervention. The historic events that led to the physician-extender role in the evaluation and treatment of patients with neuromusculoskeletal conditions are presented. These events support the current battlefield assignment of physical therapists as far forward as the inflatable Combat Support Hospitals. The scope of Army physical therapy practice continues to evolve and expand to meet the new challenge of nation assistance, peacekeeping, and humanitarian missions.

J Orthop Sports Phys Ther. 1994;19(5):261-266.

Key Words: physical therapy, orthopaedics, neuromusculoskeletal