The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these clinical practice guidelines is to describe the peer-reviewed literature and make recommendations related to adhesive capsulitis.

J Orthop Sports Phys Ther 2013;43(5):A1-A31. doi:10.2519/jospt.2013.0302

KEY WORDS: clinical practice guidelines, frozen shoulder, ICD, ICF, Orthopaedic Section

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF). The purpose of these low back pain clinical practice guidelines, in particular, is to describe the peer-reviewed literature and make recommendations related to (1) treatment matched to low back pain subgroup responder categories, (2) treatments that have evidence to prevent recurrence of low back pain, and (3) treatments that have evidence to influence the progression from acute to chronic low back pain and disability.

J Orthop Sports Phys Ther. 2012;42(4):A1-A57. doi:10.2519/jospt.2012.0301

KEY WORDS: clinical practice guidelines, ICD, ICF, LBP, Orthopaedic Section

The Orthopaedic Section of the American Physical Therapy Association presents this fourth set of clinical practice guidelines on knee ligament sprain, 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) interventions provided by physical therapists, (3) and assessment of outcome for common musculoskeletal disorders.

J Orthop Sports Phys Ther 2010;40(4):A1-A37. doi:10.2519/jospt.2010.0303

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

The Orthopaedic Section of the American Physical Therapy Association presents this third set of clinical practice guidelines on hip osteoarthritis, 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 2009;39(4):A1-A25. doi:10.2519/jospt.2009.0301

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

The purpose of this study was to 1) compare two commonly practiced stretching techniques to determine which is most effective for improving hip range of motion, and 2) evaluate the effect of these techniques on gait economy. Seven asymptomatic males, 18-22 years of age, served as subjects. Goniometric measurements of hip range of motion (ROM) and gait economy, as measured by submaximal oxygen consumption of walking and running on a treadmill, were taken before and after each of the two stretching procedures, (a) static stretching, and (b) soft tissue mobilization with proprioceptive neuromuscular facilitation (STM/PNF). Static stretching procedures resulted in significant improvements in ROM for hip extension (p < 0.01) and hip flexion (p < 0.01). The STM/PNF also resulted in significant improvements in hip extension ROM (p < 0.01) and hip flexion ROM (p < 0.05). There was a significant improvement in gait economy at 40% VO₂max (p < 0.05), at 60% VO₂max (p < 0.05), and at 80% VO₂max (p < 0.01) following the static stretching procedure. The STM/PNF procedure improved gait economy only at one workload, 60% of VO₂max (p < 0.05). These results suggest that a single bout of static stretching or STM/PNF was effective for improving hip ROM but static stretching was more effective for improving gait economy in young, asymptomatic males.

J Orthop Sports Phys Ther 1989;10(9):350-357.

J Orthop Sports Phys Ther 1990;12(6):243-247.

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

The Heel Pain-Plantar Fasciitis Guidelines link the International Classification of Functioning, Disability, and Health (ICF) body structures (Ligaments and fascia of ankle and foot, and Neural structures of lower leg) and the ICF body functions (Pain in lower limb, and Radiating pain in a segment or region) with the World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD) health condition (Plantar fascia fibromatosis/Plantar fasciitis). 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(4):A1-A18. doi:10.2519/jospt.2008.0302

The original article was corrected in October 2008, and the amended article PDF is provided here. Please see: October 2008 Errata

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

This is the first of a series of evidence-based practice guidelines that are being developed using the International Classification of Functioning, Disability, and Health (ICF) as the basis for describing and classifying care provided by physical therapists to patients with a variety of musculoskeletal conditions. The practice guidelines being developed by the Orthopaedic Section of the American Physical Therapy Association will focus primarily on the structures related to movement and the neuromusculoskeletal and movement-related functions and sensory functions and pain categories within the ICF. These body structures and body functions will be linked with their associated health conditions from the World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD).

J Orthop Sports Phys Ther. 2008;38(4):167-168. doi:10.2519/jospt.2008.0105

KEY WORDS: heel pain, ICF, Orthopaedic Section, plantar fasciitis, practice guidelines

Letters to the Editor-in-Chief of the JOSPT as follows:

• Letter regarding the article, Does Evidence Support the Existence of Lumbar Spine Coupled Motion? A Critical Review of the Literature. J Orthop Sports Phys Ther. 2007:37(7):412. doi:10.2519/jospt.2007.0205.
• Authors' Response. J Orthop Sports Phys Ther. 2007:37(7):412-413. doi:10.2519/jospt.2007.0206.
• Letter regarding the article, The Effect of Anterior Versus Posterior Glide Joint Mobilization on External Rotation Range of Motion in Patients With Shoulder Adhesive Capsulitis. J Orthop Sports Phys Ther. 2007:37(7):413. doi:10.2519/jospt.2007.0207.
• Authors' Response. J Orthop Sports Phys Ther. 2007:37(7):414-415. doi:10.2519/jospt.2007.0208.

STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To compare the effectiveness of an­terior versus posterior glide mobilization techniques for improving shoulder external rotation range of motion (ROM) in patients with adhesive capsulitis. BACKGROUND: Physical therapists use joint mobilization techniques to treat motion impair­ments in patients with adhesive capsulitis. However, opinions of the value of anterior versus posterior mobilization procedures to improve external rotation ROM differ. METHODS AND MEASURES: Twenty consecu­tive subjects with a primary diagnosis of shoulder adhesive capsulitis and exhibiting a specific external rotation ROM deficit were randomly assigned to 1 of 2 treatment groups. All subjects received 6 therapy sessions consisting of application of therapeutic ultrasound, joint mobilization, and upper-body ergometer exercise. Treatment differed between groups in the direction of the mobilization technique performed. Shoulder external rotation ROM mea­sured initially and after each treatment session was compared within and between groups and analyzed using a 2-way ANOVA, followed by paired and independent t tests. RESULTS: There was no significant differ­ence in shoulder external rotation ROM between groups prior to initiating the treatment program. A significant difference between groups (P = .001) was present by the third treatment. The individu­als in the anterior mobilization group had a mean improvement in external rotation ROM of 3.0° (SD, 10.8°; P = .40), whereas the individuals in the poste­rior mobilization group had a mean improvement of 31.3° (SD, 7.4°; P<.001). CONCLUSIONS: A posteriorly directed joint mobilization technique was more effective than an anteriorly directed mobilization technique for improving external rotation ROM in subjects with adhesive capsulitis. Both groups had a significant decrease in pain.  

J Orthop Sports Phys Ther. 2007;37(3):88-99. doi:10.2519/jospt.2007.2307 

Study Design: Randomized controlled 2-group, pretest-posttest, multivariate study of patients with shoulder musculoskeletal disorders. Objective: The purpose of this study was to evaluate the immediate effect of soft tissue mobilization (STM) with proprioceptive neuromuscular facilitation (PNF) to increase glenohumeral external rotation at 45° of shoulder abduction and overhead reach. Background: It is postulated that limitation in glenohumeral external rotation, when measured at 45° of shoulder abduction, represents subscapularis muscle flexibility deficits and is associated with the inability to fully reach overhead. No research, however, is available to demonstrate whether intervention strategies intended to improve subscapularis flexibility and glenohumeral external rotation range of motion at 45° of shoulder abduction will improve a patient’s ability to reach overhead. Methods and Measures: Twenty patients (10 males, 10 females; age range, 21-83 years) with limited glenohumeral external rotation and overhead reach of 1 year duration or less served as subjects. The subjects were randomly assigned to a treatment group, which consisted of soft tissue mobilization to the subscapularis and proprioceptive neuromuscular facilitation to the shoulder rotators, or a control group. Goniometric measurements of glenohumeral external rotation at 45° abduction and overhead reach were taken preintervention and immediately postintervention for the treatment group or at prerest and postrest periods for the control group. Results: The treatment group improved by a mean of 16.4° (95% confidence interval [CI], 12.5°-20.3°) of glenohumeral external rotation, as compared to less than a 1° gain (95% CI, -0.2°-2.0°) in the control group (P<.0005). Overhead reach in the treatment group improved by a mean of 9.6 cm (95% CI, 5.2-14.0 cm) in comparison to a mean gain of 2.4 cm (95% CI, -0.8-5.6 cm) for the control group (P = .009). Conclusion: These findings suggest that a single intervention session of STM and PNF was effective for producing immediate improvements in glenohumeral external rotation and overhead reach in patients with shoulder disorders.

J Orthop Sports Phys Ther. 2003;33(12):713-718.
 

Key Words: manual therapy, proprioceptive neuromuscular facilitation, range of motion, shoulder, subscapularis

Recent years have brought about an expansion of physical therapy residency and fellowship programs, providing physical therapists the opportunity to accelerate the development of their clinical skills through a structured mentoring process. Along with the expansion of residency and fellowship programs, a process has been created to formally evaluate and credential programs that meet specific standards. Standardized, structured mentoring helps newly graduated physical therapists accelerate their professional growth and their ability to provide optimal patient care.

J Orthop Sports Phys Ther. 2004; 34(1):1-3. doi:10.2519/jospt.2004.0101.

Key Words: education, mentorship, profession

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

Study Design: Clinical case report. Objectives: To describe a physical therapy program addressing impairments of the upper thoracic and cervical spine region for an individual with a whiplash-associated disorder. Background: A 32-year-old female with complaint of diffuse posterior cervical and upper thoracic region pain was evaluated 2 weeks following a motor vehicle accident. The patient reported that she was unable to sit for longer than 10 minutes or perform household duties for longer than 1 hour. In addition, she was unable to perform her tasks as a postal worker or participate in her customary running and aerobic exercise activities because of pain in the cervical and upper thoracic region. Methods and Measures: An examination for physical impairments was performed, including the measurement of cervical range of motion using the CROM device, and the assessment of soft tissue and segmental mobility of the upper thoracic and cervical spine regions. The Northwick Park Neck Pain Questionnaire was used to assess functional limitations and disability. Manual therapy and therapeutic exercises were applied to address the identified impairments. Manual therapy techniques included soft tissue mobilization, joint mobilization, and joint manipulation. Results: The patient’s cervical range of motion was improved and the disability score improved from 25% to 19.5% 3 days after the initial session addressing the thoracic spine. Following a second session also addressing thoracic spine impairments and the use of therapeutic exercises for 7 days, the disability score improved to 11.1%. At the final visit 17 days following the third visit, which focused on addressing the cervical spine impairments, there was complete resolution of signs and symptoms and disability. Conclusions: Interventions addressing the impairments of the upper thoracic and cervical spine region were associated with reducing pain, increasing cervical range of motion, and facilitating return to work and physical activities in a patient with a whiplash-associated disorder. There is a need for continued research investigating the efficacy of providing interventions to the thoracic spine for patients with whiplash-related injuries.

Invited Commentary by Kathryn Refshauge 

J Orthop Sports Phys Ther. 2004;34(9):511-523. doi:10.2519/jospt.2004.1393

Key Words: manipulation, manual therapy, mobilization, neck, thoracic spine

Clinical specialization is part of physical therapy's continued development as a profession. Clinical specialization in physical therapy has evolved with little discussion of how specialization is related to the development of professional expertise. The purposes of this paper were to compare the identified clinical competencies in orthopaedic physical therapy to selected clinical reasoning models and expertise development models in physical therapy and interpret these comparisons in light of current theoretical work in expertise. Descriptive content analysis using results from the 1993 Practice Analysis for Orthopaedic Physical Therapy Certified Specialists was done to link attributes identified in 3 selected theoretical models of clinical decision making and practice. Survey materials were linked to theories by use of a binary index (yes/no) of whether theoretical concepts were present or absent in the survey results. The attributes that characterize an expert physical therapy practitioner involve clinical reasoning, and the ability to teach patients. The skills of a master clinician were based not just on the application of knowledge, but also on thinking and reasoning that occurs with experience. We propose that knowledge is gained through the clinician's thinking and reasoning during practice which results in a transformation or change in the clinician's knowledge base. Describing the clinical specialization process in the context of expert theory provides a strong foundation for the specialization process in physical therapy.

J Orthop Sports Phys Ther. 1999;29(4):240-247.

Key Words: clinical specialization, expertise, professional competence

The first orthopaedic physical therapy practice analysis survey was completed in 1983. Another practice analysis survey was conducted in 1993 to identify the advance practice of clinicians who practice in orthopaedic physical therapy settings. Since 10 years elapsed, a new practice analysis study was conducted to identify the practice of orthopaedic clinical specialists. The purpose of this report is to describe the results of this survey. Orthopaedic physical therapists, both specialists and nonspecialists, participated in group interviews, subject matter expert meetings, and a national practice survey to delineate important knowledges and responsibilities. The survey was sent to a stratified convenience sample of 1,000 orthopaedic physical therapists, of which 325 were orthopaedic clinical specialists. The three-part survey contained 180 items. A total of 420 respondents, of which 241 were orthopaedic clinical specialists, rated the importance and application level for the items. The results of this study provide evidence for a core body of knowledge required by clinicians practicing with advanced skills in orthopaedic physical therapy and create the framework for the Orthopaedic Physical Therapy Specialty Exam.

J Orthop Sports Phys Ther. 1997;25(3):163-170.

Key Words: orthopaedic physical therapy, specialization, clinical competence, decision making

Study Design: Resident’s case problem. Background: Vertigo and visual disturbances are common symptoms associated with vertebrobasilar insufficiency (VBI), but the physical examination procedures to verify the existence of VBI have not been validated in the literature. The objective of this resident’s case problem is to demonstrate how a patient’s complaint of vertigo and visual disturbances, combined with positive clinical examination findings, can be a potential medical screening tool for VBI. Diagnosis: The patient in this report was initially referred to physical therapy for neck pain. However, the patient’s chief concerns identified during the history were (1) vertigo, (2) visual disturbances, (3) headache, and (4) right shoulder region pain. Clinical VBI tests were performed, whereby the patient’s vertigo and visual disturbances were reproduced with cervical spine extension. The patient was sent back to the referring physician to be evaluated for possible VBI.
Diagnostic imaging tests were ordered. Carotid ultrasound revealed 80% to 90% stenosis in the proximal left internal carotid artery, and magnetic resonance angiography of the extracerebral vessels showed greater than 90% stenosis of the left internal carotid artery. Discussion: VBI may be present in patients with subjective reports of vertigo and visual disturbances that are reproduced with VBI physical examination procedures.

J Orthop Sports Phys Ther. 2005;35(10):645-650. doi:10.2519/jospt.2005.1732

Key Words: cervical spine, direct access, neck, primary care, vertebral artery