STUDY DESIGN: Randomized, repeated-measures crossover design. OBJECTIVES: To determine the interrater reliability of directional-bias assessment and to investigate its validity for predicting immediate changes in dynamic postural stability and muscle performance following directionally biased exercises. BACKGROUND: Directional bias in dynamic postural stability deficits may be associated with outcome following intervention. METHODS: Two researchers independently assessed 33 participants, each with a history of more than 1 unilateral lower-limb injury, for directional bias. Interrater reliability was evaluated with the kappa coefficient and a prevalence-adjusted and bias-adjusted kappa coefficient. Participants were randomly allocated to perform matched-bias (MB) or unmatched-bias (UB) exercises first, in 2 crossover groups. Two outcome measures, time to stabilization and rebound hopping, were assessed before and following each exercise intervention, using a force plate. Crossover trial data were analyzed by t tests for period, interaction, and treatment effects, and repeated-measures analyses of variance were used to investigate differences between baseline, MB, and UB. RESULTS: Interrater reliability of directional-bias assessment was substantial (κ = 0.75; prevalence-adjusted and bias-adjusted κ = 0.76). Following MB exercises, medial/lateral time to stabilization and time on the ground during rebound hopping were significantly shorter (P = .01 and P = .05, respectively) compared with UB exercises. Compared with baseline, pairwise change in anterior/posterior time to stabilization (P = .008) improved following MB, whereas time in the air decreased following UB (P = .036). CONCLUSION: Directional-bias assessment demonstrates substantial reliability, and outcomes suggest validity for predicting immediate improvements following matched directionally biased exercises.

J Orthop Sports Phys Ther 2012;42(8):676-687. doi:10.2519/jospt.2012.3790

KEY WORDS: dance medicine, exercise therapy, rehabilitation

STUDY DESIGN: Clinical measurement, longitudinal; multicenter prospective cohort study. OBJECTIVES: To examine the validity, reliability, and responsiveness of the Patient-Specific Functional Scale (PSFS) in patients with musculoskeletal upper extremity problems being treated in physical therapy. BACKGROUND: The clinimetric properties of the PSFS have not been established nor compared with region-specific outcome measures in patients with upper extremity problems. METHODS: Patients completed the PSFS, Upper Extremity Functional Index (UEFI), and numeric pain rating scale (NPRS) at baseline and follow-up, and were categorized as improved, stable, or worsened, using the global rating of change. Construct validity was assessed by comparing the change scores of the stable and improved groups, using independent-samples t tests. Reliability was evaluated using intraclass correlation coefficient (ICC_2,1) with 95% confidence intervals. Bland-Altman plots determined limits of agreement. Responsiveness and minimal important difference (MID) were determined with receiver operator characteristic (ROC) curves. RESULTS: One hundred eighty patients met the inclusion criteria. Construct validity was supported for the PSFS and the UEFI (P<.001). Reliability was moderate to good for the PSFS (ICC_2,1 = 0.713) and UEFI (ICC_2,1 = 0.848). Reported estimates of reliability may be lower than true values because the group of “stable” patients from this cohort had, on average, a small positive change. Bland-Altman plots indicated good agreement. The area under the ROC curve (AUC) was significantly different from the null value of 0.5 for the PSFS (0.887) and the UEFI (0.877), indicating good accuracy in distinguishing improved patients from stable patients. MID was 1.2 for the PSFS (scale, 0-10) and 8.5 for the UEFI (scale, 0-80). CONCLUSION: The PSFS is a valid, reliable, and responsive outcome measure for patients with upper extremity problems.

J Orthop Sports Phys Ther 2012;42(2):56-65. doi:10.2519/jospt.2012.3953

KEY WORDS: clinical measurement, instrument validation, outcome measure, upper limb

STUDY DESIGN: Systematic review of the literature. OBJECTIVE: To summarize peer-reviewed literature on the reliability, validity, and responsiveness of the Patient-Specific Functional Scale (PSFS), and to identify its use as an outcome measure. METHODS: Searches were performed of several electronic databases from 1995 to May 2010. Studies included were published articles containing (1) primary research investigating the psychometric and clinimetrics of the PSFS or (2) the implementation of the PSFS as an outcome measure. We assessed the methodological quality of studies included in the first category. RESULTS: Two hundred forty-two articles published from 1994 to May 2010 were identified. Of these, 66 met the inclusion criteria for this review, with 13 reporting the measurement properties of the PSFS, 55 implementing the PSFS as an outcome measure, and 2 doing both of the above. The PSFS was reported to be valid, reliable, and responsive in populations with knee dysfunction, cervical radiculopathy, acute low back pain, mechanical low back pain, and neck dysfunction. The PSFS was found to be reliable and responsive in populations with chronic low back pain. The PSFS was also reported to be valid, reliable, or responsive in individuals with a limited number of acute, subacute, and chronic conditions. This review found that the PSFS is also being used as an outcome measure in many other conditions, despite a lack of published evidence supporting its validity in these conditions. CONCLUSION: Although the use of the PSFS as an outcome measure is increasing in physiotherapypractice, there are gaps in the research literature regarding its validity, reliability, and responsiveness in many health conditions.

J Orthop Sports Phys Ther 2012;42(1):30-42, Epub 25 October 2011. doi:10.2519/jospt.2012.3727

KEY WORDS: disability evaluation, instrument validation, PSFS, questionnaires, treatment outcomes

STUDY DESIGN: Prospective cohort study. OBJECTIVES: To establish the major clinically important improvement (MCII) of the timed up-and-go test (TUG), 40-meter self-paced walk test (40-m SPWT), 30-second chair stand (30 CST), and a 20-cm step test in patients with hip osteoarthritis (OA) undergoing physiotherapy treatment. As a secondary aim, a comparison of methods was employed to evaluate the effect of method on the reported MCII. BACKGROUND: Minimal clinically important difference scores are commonly used by rehabilitation professionals to determine patient response following treatment. A gold standard for calculating MCII has yet to be determined, which has resulted in problems of interpretation due to varied results. METHODS: As part of a randomized controlled trial, 65 patients were randomized into a physiotherapy treatment group for hip OA, in which they completed 4 physical performance measures at baseline and 9 weeks. Upon completion of physiotherapy, patients assessed their response to treatment on a 15-point global rating of change scale (GRCS). MCII was estimated using 3 variations of an anchor-based method, based on the patient’s opinion. RESULTS: A comparison of 3 methods resulted in the following change scores being best associated with our definition of MCII: a reduction equal to or greater than 0.8, 1.4, and 1.2 seconds for the TUG; an increase equal to or greater than 0.2, 0.3, and 0.2 m/s for the 40-m SPWT; an increase equal to or greater than 2.0, 2.6, and 2.1 repetitions for the 30 CST; an increase equal to or greater than 5.0, 12.8, and 16.4 steps for the 20-cm step test. CONCLUSION: The variation in methods provided very different results. This illustrates the importance of comparing methodologies and reporting a range of values associated with the MCII, as such values vary, depending upon the methodology chosen.

J Orthop Sports Phys Ther 2011;41(5):319-327, Epub 18 February 2011. doi:10.2519/jospt.2011.3515

KEY WORDS: outcome assessment, rehabilitation, task performance and analysis, timed up and go

STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To compare the effectiveness of 2 different conservative management approaches in the treatment of plantar heel pain. BACKGROUND: There is insufficient evidence
to establish the optimal physical therapy management strategies for patients with heel pain, and little evidence of long-term effects. METHODS: Patients with a primary report of plantar heel pain underwent a standard evaluation and completed a number of patient self-report questionnaires, including the Lower Extremity Functional Scale (LEFS), the Foot and Ankle Ability Measure (FAAM), and the Numeric Pain Rating Scale (NPRS). Patients were randomly assigned to be treated with either an electrophysical agents and exercise (EPAX) or a manual physical therapy and exercise (MTEX) approach. Outcomes ofinterest were captured at baseline and at 4-week and 6-month follow-ups. The primary aim (effects of treatment on pain and disability) was examined with a mixed-model analysis of variance (ANOVA). The hypothesis of interest was the 2-way interaction (group by time). RESULTS: Sixty subjects (mean [SD] age, 48.4 [8.7] years) satisfied the eligibility criteria, agreed to participate, and were randomized into the EPAX (n = 30) or MTEX group (n = 30). The overall group-by-time interaction for the ANOVA was statistically significant for the LEFS (P = .002), FAAM (P = .005), and pain (P = .043). Between-group differences favored the MTEX group at both 4-week (difference in LEFS, 13.5; 95% CI: 6.3, 20.8) and 6-month (9.9; 95% CI: 1.2, 18.6) follow-ups. CONCLUSION: The results of this study provide evidence that MTEX is a superior management approach over an EPAX approach in the management of individuals with plantar heel pain at both the short- and long-term follow-ups. Future studies should examine the contribution of the different components of the exercise and manual physical therapy programs. LEVEL OF EVIDENCE: Therapy, level 1b.

J Orthop Sports Phys Ther 2009;39(8):573-585, Epub 24 June 2009. doi:10.2519/jospt.2009.3036

KEY WORDS: iontophoresis, manipulation, mobilization, plantar fasciitis, plantar fasciosis

Study Design: We report 2 cases in which a novel tibialis posterior muscle stretch is used to treat heel pain and lower extremity impairment. Objectives: To explore dysfunction of the tibialis posterior as a source of heel pain. Background: Heel pain is a common symptom of orthopaedic dysfunction of the lower extremity. Tibialis posterior tendon dysfunction is well documented in the medical and surgical literature, but its identification in its early or precursive stages has received little attention. Methods and Measures: An examination and treatment outline, incorporating a novel assessment and stretching technique, is presented. Results: We identified a stage of dysfunction of the tibialis posterior ("Pre-Stage 1") without clinically identifiable tendon pathology. We refer to this as tibialis posterior myofascial tightness (TPMT). Conclusion: Tibialis posterior myofascial tightness is a clinical entity that may be differentially diagnosed in cases of heel pain and specifically treated.

J Orthop Sports Phys Ther. 2000;30(10):624-632.

Key Words: calcaneus, exercise therapy, muscle, physical examination, physical therapy, skeletal