The patient was a 79-year-old man with a chief complaint of neck pain after a fall. Three days following the fall, the patient was seen in the emergency department, where computed tomography imaging of the head and radiographs of the cervical spine were completed. The patient was subsequently referred to a physical therapist. Due to concern for a possible undetected cervical spine fracture, the patient was immediately referred to his physician. Magnetic resonance imaging demonstrated a type II fracture of the odontoid.

J Orthop Sports Phys Ther 2011;41(12):981. doi:10.2519/jospt.2011.0424

KEY WORDS: cervical spine, computed tomography, magnetic resonance imaging, radiography

SYNOPSIS: Musculoskeletal imaging of the spine can be an invaluable tool to inform clinical decision making in patients with spinal pain. An understanding of the technology involved in producing and interpreting high-resolution images produced from magnetic resonance imaging (MRI) of the human spine is necessary to better appreciate which sequences can be used for, or tailored to, individual patients and their conditions. However, there is substantial variability in the clinical meaningfulness of some MRI findings of spinal tissues. For example, normal variants can often mimic significant musculoskeletal pathology, which could increase the risk of misinformed clinical decisions and, even worse, poor or adverse outcomes. This clinical commentary will highlight some of the pearls and pitfalls of MRI for the cervical, thoracic, and lumbar regions, and include cases to illustrate some of the common imaging artifacts and normal variants for MRI of the spine.

J Orthop Sports Phys Ther 2011;41(11):848-860. doi:10.2519/jospt.2011.3636

KEY WORDS: MRI, medical imaging, radiology, spinal pain, whiplash

The ability to refer for diagnostic tests is particularly relevant to the topic of this special issue on magnetic resonance imaging (MRI). As a doctoring profession, one could argue that the ability to refer a patient for MRI (and other imaging applications) must be available to the direct-access physical therapist. Though the prescription for and use of MRI has not typically been considered within the scope of physical therapist practice, this may be the perfect time to challenge the obstacles precluding the obtainment of such diagnostic privileges and to specifically provide perspective on why and how such a specialized privilege could positively impact the provision of physical therapy services and patient outcomes. An expected obligation of such autonomy, however, is accountability. Is our entire profession adequately prepared to accept the role of, or the responsibilities associated with, referral for imaging privileges?

J Orthop Sports Phys Ther 2011;41(11):803-805. doi:10.2519/jospt.2011.0109

KEY WORDS: autonomy, direct access, MRI

SYNOPSIS: Muscle functional magnetic resonance imaging (mfMRI) is an innovative technique that offers a noninvasive method to quantify changes in muscle physiology following the performance of exercise. The mfMRI technique is based on signal intensity changes due to increases in the relaxation time of tissue water. In contemporary practice, mfMRI has proven to be an excellent tool for assessing the extent of muscle activation following the performance of a task and for the evaluation of neuromuscular adaptations as a result of therapeutic interventions. This article focuses on the underlying mechanisms and methods of mfMRI, discusses the validity and advantages of the method, and provides an overview of studies in which mfMRI is used to evaluate the effect of exercise and exercise training on muscle activity in both experimental and clinical studies.

J Orthop Sports Phys Ther 2011;41(11):896-903, Epub 4 September 2011. doi:10.2519/jospt.2011.3586

KEY WORDS: exercise, magnetic resonance imaging, muscle

The patient was a 22-year-old male physical therapy student whose tutor suspected the absence of the lower portion of the left trapezius muscle. During left lower trapezius manual muscle testing, it was noted that he was unable to achieve satisfactory control of the left scapula and the left lower trapezius was visibly and palpably absent compared to the right side. Because absence of the lower trapezius muscle was suspected, magnetic resonance imaging was completed to confirm its absence.

J Orthop Sports Phys Ther 2011;41(8):614. doi:10.2519/jospt.2011.0416

KEY WORDS: magnetic resonance imaging, neck pain, scapula

STUDY DESIGN: Cross-sectional. OBJECTIVE: To develop a new magnetic resonance imaging (MRI) measure for the diffusive properties of the healthy cervical multifidus and to determine the interrater and intrarater reliability of the measurement. BACKGROUND: Diffusion-weighted MRI, via calculation of the apparent diffusion coefficient (ADC), provides a representation of microscopic movements of water molecules in human tissues and may be useful to assess structural changes in neck muscle, as has been observed following whiplash. The optimal imaging parameters, however, have not been established. METHODS: A diffusion-weighted MRI measure was developed, and, for the basic examination, the right cervical multifidus muscle at the C5 level was studied. A total of 6 asymptomatic volunteer individuals (3 females and 3 males) underwent a single diffusion-weighted MRI scan. Interrater and intrarater agreement was evaluated using Bland-Altman plots and intraclass correlation coefficients. RESULTS: Mean ADC^b0-b50 and ADC^b50-250 were significantly different from one another (P = .03). The plots confirmed the agreement of raters for ADC of the right cervical multifidus at C5. CONCLUSIONS: A quantitative and reliable diffusion-weighted MRI measure of cervical multifidus ADC has been described. There appears to be a fast and slow component ADC for the healthy multifidus, suggesting changes in extracellular and intracellular volume. Further comparative study is needed to quantify ADCs in the neck muscles in patients with traumatic whiplash.

J Orthop Sports Phys Ther 2010;40(11):722-728, Epub 1 September 2010. doi:10.2519/jospt.2010.3423

KEY WORDS: cervical spine, magnetic resonance imaging, radiology

The patient was a 32-year-old woman diagnosed with grade III spondylolisthesis at the age of 18. While the patient had not experienced back pain in recent years, she anticipated a recurrence of symptoms during her final trimester of pregnancy. Lumbar magnetic resonance imaging was used to confirm the presence of grade IV spondylolisthesis.

J Orthop Sports Phys Ther 2010;40(5):324. doi:10.2519/jospt.2010.0407

KEY WORDS: lumbar spine, magnetic resonance imaging

A 28-year-old female was referred for enrollment in an acute whiplash research study that involved magnetic resonance imaging. A conventional magnetic resonance imaging scan of her cervical spine was performed by the lead researcher. Upon retrieval of the images by the physical therapist, a bright signal was noted on both sequences within the C6 vertebral body. The images were referred to a neuroradiologist, who noted that the area of concern was an incidental finding consistent with a vertebral hemangioma, which is a benign vascular tumor of the vertebral body. This case highlights the fact that many opportunities exist whereby physical therapists can, and should, correspond with physicians on a level that resembles collegial consultation, whether in the clinical or research setting.

J Orthop Sports Phys Ther. 2009;39(2):149. doi:10.2519/jospt.2009.0402

KEY WORDS: cervical spine, differential diagnosis

SYNOPSIS: There is irrefutable evidence of an association between mechanical neck pain (MNP) and dysfunction of the muscles of the cervical spine. A myriad of impairments have been demonstrated that include changes in the physical structure (cross-sectional area, fatty infiltration, fiber type), as well as changes in behavior (timing and activation level), of the cervical muscles. Such changes suggest an impaired capacity of the cervical muscles to generate, sustain, and maintain precision of the required levels of torque needed for optimal function. In the context of physical support, these changes potentially have deleterious consequences for the cervical region, which relies heavily on its muscles for mechanical stability. While interventions focused on the retraining of cervical muscle function have shown favorable responses in alleviating MNP, the development of best practice strategies for the assessment and management of cervical muscle dysfunction is still a work in progress. One obstacle in researching the efficacy of cervical muscle training is that, as yet, we do not possess the capacity to optimally measure and classify those patients most likely to respond to different methods of training that would enrich clinical practice. While gains in this area are emerging, the ability of a clinician to best identify the need and implement the most appropriate method of training cervical muscle function is still largely dependent on a comprehensive examination of the patient that considers all aspects of the patient's disorder and functional requirements. LEVEL OF EVIDENCE: Level 5.

J Orthop Sports Phys Ther 2009;39(5):324-333, Epub 15 December 2008. doi:10.2519/jospt.2009.2872

KEY WORDS: mechanical neck pain, rehabilitation, therapeutic exercise

The Orthopaedic Section of the American Physical Therapy Association presents this second set of clinical practice guidelines on neck pain, linked to the International Classification of Functioning, Disability, and Health (ICF). The purpose of these practice guidelines is to describe evidence-based orthopaedic physical therapy clinical practice and provide recommendations for (1) examination and diagnostic classification based on body functions and body structures, activity limitations, and participation restrictions, (2) prognosis, (3) interventions provided by physical therapists, and (4) assessment of outcome for common musculoskeletal disorders.

J Orthop Sports Phys Ther. 2008;38(9):A1-A34. doi:10.2519/jospt.2008.0303

The original article was corrected in April 2009, and the amended article PDF is provided here. Please see: April 2009 Errata

KEY WORDS: APTA, cervical spine, clinical practice guidelines, ICD, ICF, Orthopaedic Section

SYNOPSIS: The development of chronic pain and disability following whiplash injury is common and contributes substantially to personal and economic costs related with this condition. Emerging evidence demonstrates the clinical presence of alterations in the sensory and motor systems, including psychological distress in all individuals with a whiplash injury, regardless of recovery. However, individuals who transition to the chronic state present with a more complex clinical picture characterized by the presence of widespread sensory hypersensitivity, as well as significant posttraumatic stress reactions. Based on the diversity of the signs and symptoms experienced by individuals with a whiplash condition, clinicians must take into account the more readily observable/measurable differences in motor, sensory, and psychological dysfunction. The implications for the assessment and management of this condition are discussed. Further review into the pathomechanical, pathoanatomical, and pathophysiological features of the condition also will be discussed. LEVEL OF EVIDENCE: Level 5.

J Orthop Sports Phys Ther 2009;39(5):312-323, Epub 3 June 2008. doi:10.2519/jospt.2009.2826

KEY WORDS: cervical spine, neck, WAD

The patient was a 51-year-old female with persistent pain resulting from 2 rear-end vector motor vehicle accidents 7 years ago (head turned at impact during the second motor vehicle accident). She self-referred to our physical therapy practice with symptoms that included constant neck pain, dizziness/unsteadiness, fatigue, and self-reported anxiety. Active cervical range of movement was also notably reduced and reproduced "clunking" in the upper cervical region. Based on the patient's history and examination findings, the physical therapist was concerned about the possibility of upper cervical ligament damage. It was suggested to her physician that proton-density weighted magnetic resonance imaging be performed. The radiologist's findings led to the commencement of physical therapy aimed at addressing range-of-motion deficits, pain, and motor control of the cervical region. After 4 months, the patient reported feeling less anxious and more stable, with less mechanical clunking, and is now able to engage in daily activities with less pain and fatigue.

J Orthop Sports Phys Ther. 2008;38(6):377. doi:10.2519/jospt.2008.0406

KEY WORDS: magnetic resonance imaging, neck pain

SYNOPSIS: Interest in rehabilitative ultrasound imaging (RUSI) of the posterior paraspinal muscles is growing, along with the body of literature to support integration of this technique into routine physical therapy practice. This clinical commentary reviews how RUSI can be used as an evaluative and treatment tool, and proposes guidelines for its use for the posterior muscles of the lumbar and cervical regions. Both quantitative and qualitative applications are described, as well as measurement reliability and validity. Measurement of morphological characteristics of the muscles (morphometry) in healthy populations and people with spinal pathology are described. Preliminary normal reference data exist for measurements of cross-sectional area (CSA), linear dimensions (muscle depth/thickness and width), and shape ratios. Compared to individuals without low back pain, changes in muscles' size at rest and during the contracted state have been observed using RUSI in people with spinal pathology. Visual observation of the image during contraction indicates that RUSI may be a valuable biofeedback tool. Further investigation of many of these observations is required using controlled studies to provide conclusive evidence that RUSI enhances clinical practice.

J Orthop Sports Phys Ther. 2007;37(10):581-595, published online 29 August 2007. doi: 10.2519/jospt.2007.2599

KEY WORDS: cervical muscles, lumbar muscles, lumbar spine, neck, morphometry, sonography

The use of ultrasound imaging by physical therapists is growing in popularity. This commentary has 2 aims. The first is to introduce the concept of rehabilitative ultrasound imaging (RUSI), provide a definition of the scope of this emerging tool in regard to the physical therapy profession, and describe how this relates to the larger field of medical ultrasound imaging. The second aim is to provide an overview of basic ultrasound imaging and instrumentation principles, including an understanding of the various modes and applications of the technology with respect to neuromusculoskeletal rehabilitation and in relation to other common imaging modalities.

J Orthop Sports Phys Ther. 2007:37(8):434-449; published online 30 May 2007. doi:10.2519/jospt.2007.2530

KEY WORDS: elastography, magnetic resonance imaging, rehabilitation, sonography