STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To compare the short-term effects of upper cervical and upper thoracic high-velocity low-amplitude (HVLA) thrust manipulation to nonthrust mobilization in patients with neck pain. BACKGROUND: Although upper cervical and upper thoracic HVLA thrust manipulation and nonthrust mobilization are common interventions for the management of neck pain, no studies have directly compared the effects of both upper cervical and upper thoracic HVLA thrust manipulation to nonthrust mobilization in patients with neck pain. METHODS: Patients completed the Neck Disability Index, the numeric pain rating scale, the flexion-rotation test for measurement of C1-2 passive rotation range of motion, and the craniocervical flexion test for measurement of deep cervical flexor motor performance. Following the baseline evaluation, patients were randomized to receive either HVLA thrust manipulation or nonthrust mobilization to the upper cervical (C1-2) and upper thoracic (T1-2) spines. Patients were reexamined 48-hours after the initial examination and again completed the outcome measures. The effects of treatment on disability, pain, C1-2 passive rotation range of motion, and motor performance of the deep cervical flexors were examined with a 2-by-2 mixed-model analysis of variance (ANOVA). RESULTS: One hundred seven patients satisfied the eligibility criteria, agreed to participate, and were randomized into the HVLA thrust manipulation (n = 56) and nonthrust mobilization (n = 51) groups. The 2-by-2 ANOVA demonstrated that patients with mechanical neck pain who received the combination of upper cervical and upper thoracic HVLA thrust manipulation experienced significantly (P<.001) greater reductions in disability (50.5%) and pain (58.5%) than those of the nonthrust mobilization group (12.8% and 12.6%, respectively) following treatment. In addition, the HVLA thrust manipulation group had significantly (P<.001) greater improvement in both passive C1-2 rotation range of motion and motor performance of the deep cervical flexor muscles as compared to the group that received nonthrust mobilization. The number needed to treat to avoid an unsuccessful outcome was 1.8 and 2.3 at 48-hour follow-up, using the global rating of change and Neck Disability Index cut scores, respectively. CONCLUSION: The combination of upper cervical and upper thoracic HVLA thrust manipulation is appreciably more effective in the short term than nonthrust mobilization in patients with mechanical neck pain. LEVEL OF EVIDENCE: Therapy, level 1b.

J Orthop Sports Phys Ther 2012;42(1):5-18, Epub 30 September 2011. doi:10.2519/jospt.2012.3894

KEY WORDS: high-velocity low-amplitude thrust, mobilization, neck pain, spinal manipulation

STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To determine if patients who met the clinical prediction rule (CPR) criteria for the success of thoracic spine thrust joint manipulation (TJM) for the treatment of neck pain would have a different outcome if they were treated with a cervical spine TJM. BACKGROUND: A CPR had been proposed to identify patients with neck pain who would likely respond favorably to thoracic spine TJM. Research on validation of that CPR had not been completed when this trial was initiated. In our clinical experience, though many patients with neck pain responded favorably to thoracic spine TJM, they often reported that their symptomatic cervical spine area had not been adequately addressed. METHODS: Twenty-four consecutive patients, who presented to physical therapy with a primary complaint of neck pain and met 4 out of 6 of the CPR criteria for thoracic TJM, were randomly assigned to 1 of 2 treatment groups. The thoracic group received thoracic TJM and a cervical range-of-motion (ROM) exercise for the first 2 sessions, followed by a standardized exercise program for an additional 3 sessions. The cervical group received cervical TJM and the same cervical ROM exercise for the first 2 sessions, and the same exercise program given to the thoracic group for the next 3 sessions. Outcome measures collected at 1 week, 4 weeks, and 6 months from start of treatment included the Neck Disability Index, numeric pain rating scale, and Fear-Avoidance Beliefs Questionnaire. RESULTS: Patients who received cervical TJM demonstrated greater improvements in Neck Disability Index (P≤.001) and numeric pain rating scale (P≤.003) scores at all follow-up times. There was also a statistically significant improvement in the Fear-Avoidance Beliefs Questionnaire physical activity subscale score at all follow-up times for the cervical group (P≤.004). The number needed to treat to avoid an unsuccessful overall outcome was 1.8 at 1 week, 1.6 at 4 weeks, and 1.6 at 6 months. CONCLUSION: Patients with neck pain who met 4 of 6 of the CPR criteria for successful treatment of neck pain with a thoracic spine TJM demonstrated a more favorable response when the TJM was directed to the cervical spine rather than the thoracic spine. Patients receiving cervical TJM also demonstrated fewer transient side-effects. LEVEL OF EVIDENCE: Therapy, level 1b.

J Orthop Sports Phys Ther 2011;41(4):208-220, Epub 18 February 2011. doi:10.2519/jospt.2011.3640

KEY WORDS: clinical prediction rule, manual therapy, mobilization, prognosis

STUDY DESIGN: A randomized controlled clinical trial. OBJECTIVE: To investigate the effects of trigger point (TrP) manual therapy combined with a self-stretching program for the management of patients with plantar heel pain. BACKGROUND: Previous studies have reported that stretching of the calf musculature and the plantar fascia are effective management strategies for plantar heel pain. However, it is not known if the inclusion of soft tissue therapy can further improve the outcomes in this population. METHODS: Sixty patients, 15 men and 45 women (mean ± SD age, 44 ± 10 years) with a clinical diagnosis of plantar heel pain were randomly divided into 2 groups: a self-stretching (Str) group who received a stretching protocol, and a self-stretching and soft tissue TrP manual therapy (Str-ST) group who received TrP manual interventions (TrP pressure release and neuromuscular approach) in addition to the same self-stretching protocol. The primary outcomes were physical function and bodily pain domains of the quality of life SF-36 questionnaire. Additionally, pressure pain thresholds (PPT) were assessed over the affected gastrocnemii and soleus muscles, and over the calcaneus, by an assessor blinded to the treatment allocation. Outcomes of interest were captured at baseline and at a 1-month follow-up (end of treatment period). Mixed-model ANOVAs were used to examine the effects of the interventions on each outcome, with group as the between-subjects variable and time as the within-subjects variable. The primary analysis was the group-by-time interaction. RESULTS: The 2 × 2 mixed-model analysis of variance (ANOVA) revealed a significant group-by-time interaction for the main outcomes of the study: physical function (P = .001) and bodily pain (P = .005); patients receiving a combination of self-stretching and TrP tissue intervention experienced a greater improvement in physical function and a greater reduction in pain, as compared to those receiving the self-stretching protocol. The mixed ANOVA also revealed significant group-by-time interactions for changes in PPT over the gastrocnemii and soleus muscles, and the calcaneus (all P<.001). Patients receiving a combination of self-stretching and TrP tissue intervention showed a greater improvement in PPT, as compared to those who received only the self-stretching protocol. CONCLUSIONS: This study provides evidence that the addition of TrP manual therapies to a self-stretching protocol resulted in superior short-term outcomes as compared to a self-stretching program alone in the treatment of patients with plantar heel pain. LEVEL OF EVIDENCE: Therapy, level 1b.

J Orthop Sports Phys Ther 2011;41(2):43-50. doi:10.2519/jospt.2011.3504

KEY WORDS: ankle plantar flexors, plantar fasciitis, triceps surae

STUDY DESIGN: Case-control study with blinded examiner. OBJECTIVE: To investigate if pressure pain sensitivity is related to specific nerve trunks in the upper extremity of patients with either unilateral lateral epicondylalgia (LE) or carpal tunnel syndrome (CTS). BACKGROUND: In the clinical setting, patients with LE tend to exhibit radial nerve trunk tenderness, whereas patients with CTS exhibit median nerve tenderness. No studies have investigated if specific nerve pressure pain hypersensitivity exists in patients with either LE or CTS. METHODS: Sixteen women with unilateral LE (mean ± SD age, 43 ± 7 years), 17 women with unilateral CTS (43 ± 6 years), and 17 healthy women (43 ± 6 years) were included in this study. Pressure pain thresholds (PPT) were bilaterally assessed over the median, ulnar, and radial nerve trunks, as well as over the C5-6 zygapophyseal joints, by an examiner blinded to the subjectsí condition. A mixed-model analysis of variance was used to evaluate differences in PPT among groups (LE, CTS, or controls) and between sides (affected/nonaffected or dominant/nondominant). RESULTS: The individuals in both the LE and CTS groups demonstrated lower PPT bilaterally over the median (group, P<.001; side, P = .437), radial (group, P<.001; side, P = .556), and ulnar (group, P<.001; side, P = .938) nerve trunks as compared to controls. Additionally, radial (P<.001) and ulnar (P = .005) nerves were more sensitive bilaterally in patients with LE than in patients with CTS. The median nerve was more sensitive bilaterally in patients with CTS than patients with LE (P = .002). Lower PPT over the cervical spine (group, P<.001; side, P = .233) were found bilaterally in both the LE and CTS groups. Further, patients with CTS exhibited lower cervical PPT than patients with LE (P<.001). PPT was negatively correlated with both pain intensity and duration of symptoms in both the LE and CTS groups (P<.001). CONCLUSIONS: Bilateral mechanical nerve pain hypersensitivity is related to specific and particular nerve trunks in women with either unilateral LE or CTS. Our results suggest the presence of central and peripheral sensitization mechanisms in individuals with either LE or CTS.

J Orthop Sports Phys Ther 2010;40(11):751-760, Epub 22 October 2010. doi:10.2519/jospt.2010.3331

KEY WORDS: elbow, median nerve, neck, pressure pain threshold, radial nerve, ulnar nerve

STUDY DESIGN: Case report. BACKGROUND: Differential diagnosis for patients with radial wrist pain requires consideration of systemic disease, referred pain to the radial aspect of the wrist, and local dysfunction. The list of possible local dysfunctions should include De Quervain syndrome, as well as entrapment neuropathy of the superficial radial nerve. CASE DESCRIPTION: The patient was a 57-year-old man with right radial wrist pain of 6 months’ duration. The referral diagnosis was De Quervain syndrome, but a previous course of electrophysical agents-based physical therapy management had been unsuccessful. The physical examination ruled out the cervical, shoulder, elbow, and wrist joints as possible sources of pain. In this case, the diagnosis of entrapment neuropathy of the superficial radial nerve, rather than De Quervain syndrome, was primarily based on the symptom provocation resulting from a modified radial bias upper limb nerve tension test. Based on this diagnosis, treatment consisted of active and passive exercises using neurodynamic techniques. OUTCOMES: After 1 treatment session, the patient noted changes with regard to current pain intensity and function that exceeded the minimal clinically important difference and the minimal detectable change, respectively. After only 2 treatment sessions, the patient reported a complete resolution of symptoms and a full return to work. DISCUSSION: This case report critically evaluates the diagnostic process for patients with radial wrist pain and suggests neuropathy of the superficial sensory branch of the radial nerve as a differential diagnostic option. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2010;40(6):361-368, Epub 22 April 2010. doi:10.2519/jospt.2010.3210

KEY WORDS: De Quervain syndrome, neuropathy, superficial sensory branch radial nerve, thumb

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To describe the clinical outcomes following outpatient physical therapy for postoperative rehabilitation in 4 categories of shoulder surgery. Furthermore, we sought to determine if differences in outcomes between genders existed. BACKGROUND: Improving the quality of care for patients following shoulder surgery requires an understanding of the clinical outcomes resulting from current clinical practice. METHODS: This study included 856 patients (43.7% female; mean ± SD age, 51.8 ± 14.2 years) who received outpatient physical therapy following shoulder surgery. Standardized methods for classification of patients to type of shoulder surgery and collection of outcome variables were used. Data were gathered from 57 therapists working in 12 clinics. Patients included had been classified into 1 of 4 surgical categories: repair of a unidirectional instability, rotator cuff repair, rotator cuff repair with a subacromial decompression, or subacromial decompression alone. Descriptive statistics were calculated for baseline characteristics of patients in each surgical category. For all patients, scores on the Disability of the Arm Shoulder and Hand (DASH) questionnaire and a numeric pain rating scale (NPRS) were obtained at the initial and final physical therapy visits, and the change between visits was calculated. Data on number of physical therapy sessions and length of stay (LOS) were collected. For each surgical category, independent-samples t tests were used to determine differences between genders for each initial and final clinical outcome of pain and disability, change scores, utilization of visits, and LOS. The percentage of patients who achieved a minimal clinically important difference (MCID) on the DASH was also determined for each surgical group. For each gender in each surgical category, paired t tests were used to determine if patients achieved significant change in pain and disability. RESULTS: Means for each clinical outcome for the initial and final pain and disability scores, change scores, and the percentage of patients that achieved an MCID are provided. Significant differences were observed between genders for clinical outcomes. In the group treated with unilateral instability repair, women reported significantly greater initial disability than men, and their DASH change scores were significantly greater. In the group that had rotator cuff repairs, women reported significantly greater disability initially and at the final follow-up. In the group that had rotator cuff repairs combined with subacrominal decompression, women reported significantly greater disability initially and greater change in DASH scores. Females also reported greater change in their pain scores than males (P<.05). There were no significant differences between men and women in the subacromial decompression group (P<.05). There were no significant differences between genders for number of physical therapy visits or LOS. Men and women in each surgical category achieved clinically meaningful and statistically significant improvement for pain and disability during treatments (P<.01). Greater than 75% of patients achieved an MCID (15 points) on the DASH score in each surgical category (range, 75.6%-94.5%). CONCLUSIONS: Differences were observed between men and women in 4 postoperative surgical categories in each of the clinical outcomes but not for number of physical therapy visits or LOS. Statistically significant and clinically meaningful pain and disability improvements were reported for each gender within each shoulder category. Results from this study may help therapists estimate the prognosis of males and females receiving nonstandardized postoperative physical therapy in 4 different shoulder surgical categories. LEVEL OF EVIDENCE: Therapy, level 2b.

J Orthop Sports Phys Ther 2010;40(1):20-29, Epub 7 December 2009. doi:10.2519/jospt.2010.3043

KEY WORDS: DASH, instability, rotator cuff

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: Case control study. OBJECTIVES: To compare the amount of forward head posture (FHP) and cervical range of motion between patients with moderate carpal tunnel syndrome (CTS) and healthy controls. We also sought to assess the relationships among FHP, cervical range of motion, and clinical variables related to the intensity and temporal profile of pain due to CTS. BACKGROUND: It is plausible that the cervical spine may be involved in patients with CTS. No studies have investigated the possible associations among FHP, cervical range of motion, and symptoms related to CTS. METHODS: FHP and cervical range of motion were assessed in 25 women with CTS and 25 matched healthy women. Side-view pictures were taken in both relaxed-sitting and standing positions to measure the craniovertebral angle. A CROM device was used to assess cervical range of motion. Posture and mobility measurements were performed by an experienced therapist blinded to the subjects’ condition. Differences in cervical range of motion were examined using the nonparametric Mann-Whitney U test. A 2-way mixed-model analysis of variance (ANOVA) was used to evaluate differences in FHP between groups and positions. RESULTS: The ANOVA revealed significant differences between groups (F = 30.4; P<.001) and between positions (F = 6.5; P<.01) for FHP assessment. Patients with CTS had a smaller craniovertebral angle (greater FHP) than controls (P<.001) in both standing and sitting. Additionally, patients with CTS showed decreased cervical range of motion in all directions when compared to controls (P<.001). Only cervical flexion (r_s = –0.43; P = .02) and lateral flexion contralateral to the side of the CTS (r_s = –0.51; P = .01) were associated with the reported lowest pain experienced in the preceding week. A positive association between FHP and cervical range of motion was identified in both groups: the smaller the craniovertebral angle (reflective of a greater FHP), the smaller the range of motion (r values between 0.27 and 0.45; P<.05). Finally, cervical range of motion and FHP were negatively associated with age in the control group but not in the group with CTS. CONCLUSIONS: Patients with mild/moderate CTS exhibited a greater FHP and less cervical range of motion, as compared to healthy controls. Additionally, a greater FHP was associated with a reduction in cervical range of motion. However, a cause-and-effect relationship cannot be inferred from this study. Future research should investigate if FHP and restricted cervical range of motion is a consequence or a causative factor of CTS and related symptoms (eg, pain).

J Orthop Sports Phys Ther 2009;39(9):658-664, Epub 19 March 2009. doi:10.2519/jospt.2009.3058

KEY WORDS: CROM, CTS, neck

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

• Clinical Prediction Rules in Physical Therapy: Coming of Age? J Orthop Sports Phys Ther 2009;39(3):231-232. doi:10.2519/jospt.2009.0201
• Frontal Plane Measurements During a Single-Leg Squat Test in Individuals With Patellofemoral Pain Syndrome and Authors' Response, J Orthop Sports Phys Ther 2009;39(3):233-234. doi:10.2519/jospt.2009.0202
• Management of Patients With Patellofemoral Pain Syndrome Using a Multimodal Approach: A Case Series and Authors' Response, J Orthop Sports Phys Ther 2009;39(3):234-237. doi:10.2519/jospt.2009.0203

DESIGN: Randomized clinical trial. OBJECTIVES: To determine the short-term effects of Kinesio Taping, applied to the cervical spine, on neck pain and cervical range of motion in individuals with acute whiplash-associated disorders (WADs). BACKGROUND: Researchers have begun to investigate the effects of Kinesio Taping on different musculoskeletal conditions (eg, shoulder and trunk pain). Considering the demonstrated short-term effectiveness of Kinesio Tape for the management of shoulder pain, it is suggested that Kinesio Tape may also be beneficial in reducing pain associated with WAD. METHODS AND MEASURES: Forty-one patients (21 females) were randomly assigned to 1 of 2 groups: the experimental group received Kinesio Taping to the cervical spine (applied with tension) and the placebo group received a sham Kinesio Taping application (applied without tension). Both neck pain (11-point numerical pain rating scale) and cervical range-of-motion data were collected at baseline, immediately after the Kinesio Tape application, and at a 24-hour follow-up by an assessor blinded to the treatment allocation of the patients. Mixed-model analyses of variance (ANOVAs) were used to examine the effects of the treatment on each outcome variable, with group as the between-subjects variable and time as the within-subjects variable. The primary analysis was the group-by-time interaction. RESULTS: The group-by-time interaction for the 2-by-3 mixed-model ANOVA was statistically significant for pain as the dependent variable (F = 64.8; P<.001), indicating that patients receiving Kinesio Taping experienced a greater decrease in pain immediately postapplication and at the 24-hour follow-up (both, P<.001). The group-by-time interaction was also significant for all directions of cervical range of motion: flexion (F = 50.8; P<.001), extension (F = 50.7; P<.001), right (F = 39.5; P<.001) and left (F = 3.8, P<.05) lateral flexion, and right (F = 33.9, P<.001) and left (F = 39.5, P<.001) rotation. Patients in the experimental group obtained a greater improvement in range of motion than thosein the control group (all, P<.001). CONCLUSIONS: Patients with acute WAD receiving an application of Kinesio Taping, applied with proper tension, exhibited statistically significant improvements immediately following application of the Kinesio Tape and at a 24-hour follow-up. However, the improvements in pain and cervical range of motion were small and may not be clinically meaningful. Future studies should investigate if Kinesio Taping provides enhanced outcomes when added to physical therapy interventions with proven efficacy or when applied over a longer period. LEVEL OF EVIDENCE: Therapy, level 1b.

J Orthop Sports Phys Ther 2009;39(7):515-521, Epub 24 February 2009. doi:10.2519/jospt.2009.3072

KEY WORDS: cervical spine, neck, taping, WAD

J Orthop Sports Phys Ther 2009;39(3):188-200, Epub 24 October 2008. doi:10.2519/jospt.2009.2940

STUDY DESIGN: Randomized clinical trial. OBJECTIVES: To investigate if patients with mechanical neck pain receiving thoracic spine thrust manipulation would experience superior outcomes compared to a group not receiving thrust manipulation. BACKGROUND: Evidence has begun to emerge in support of thoracic thrust manipulation as an intervention in the management of mechanical neck pain. However, to make a strong recommendation for a clinical technique it is necessary to have multiple studies with convergent findings. METHODS AND MEASURES: Forty-five patients (21 females) were randomly assigned to 1 of 2 groups: a control group, which received electro/thermal therapy for 5 treatment sessions, and the experimental group, which received the same electro/thermal therapy program in addition to a thoracic spine thrust manipulation once a week for 3 consecutive weeks. Mixed-model analyses of variance (ANOVAs) were used to examine the effects of treatment on pain (100-mm visual analogue scale), disability (100-point disability scale), and cervical range of motion, with group as the between-subjects variable and time as the within-subjects variable. The primary analysis was the group-by-time interaction for pain. RESULTS: The group-by-time interaction effects for the ANOVA models were statistically significant for pain, mobility, and disability (P<.05), indicating greater improvements in the manipulation group for all the outcome measures. Patients receiving thoracic manipulation experienced greater improvements in pain at the fifth (final) treatment session and at the 2-week and 4-week follow-up periods (P<.001), with pain improvement scores in the manipulation group of 16.8 mm and 26.5 mm greater than those in the comparison group at the 2- and 4-week follow-up periods, respectively. The experimental group also experienced significantly greater improvements in disability with a between-group difference of 8.8 points (95% confidence interval [CI]: 7.5, 10.1; P<.001) at the fifth visit and 8.0 points (95% CI: 5.8, 10.2; P<.001) at the 2-week follow-up. CONCLUSIONS: The results of our study suggest that thoracic spine thrust manipulation results in superior clinical benefits that persist beyond the 1-month follow-up period for patients with acute neck pain. Future studies should continue to investigate the effects of thoracic spine thrust manipulation, as compared to other physical therapy interventions, in a population with mechanical neck pain. LEVEL OF EVIDENCE: Therapy, level 1b.

J Orthop Sports Phys Ther 2009;39(1):20-27, Epub 19 September 2008. doi:10.2519/jospt.2009.2914

KEY WORDS: cervical spine, clinical trial, manual therapy, mobilization, thrust manipulation

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

STUDY DESIGN: A case series of consecutive patients referred to physical therapy with patellofemoral pain syndrome (PFPS). BACKGROUND: Physical therapists often treat patients with PFPS, yet there is currently no consensus as to the most effective management strategies. The purpose of this case series is to describe the outcomes of patients referred to physical therapy with PFPS who were treated with a multimodal approach. CASE DESCRIPTION: Five patients were treated with a combination of thrust and nonthrust manipulation directed at the joints of the lower quarter, trunk and hip stabilization exercises, patellar taping, and foot orthotics. Outcome measures used to capture change in patient status included the Numeric Pain Rating Scale, the Kujala Anterior Knee Pain Scale, the Lower Extremity Functional Scale, and the Global Rating of Change. OUTCOMES: Five patients (median age, 15 years; range, 14-50 years) with a median duration of knee pain for 8 months (range, 3-24 months) were included in this prospective case series. Four (80%) of the 5 patients demonstrated decreased pain and a clinically significant improvement in function. These gains in function were maintained at a 6-month follow-up. DISCUSSION: Although a cause-and-effect relationship cannot be inferred from a case series, the outcomes achieved by the patients are consistent with studies incorporating manual physical therapy, exercise, patellar taping, and orthotic prescription to the management of conditions of the lower extremity. Further randomized controlled trials should be performed to determine the effectiveness of this multimodal approach for the management of individuals with PFPS. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther. 2008; 38(11):691-702, Epub 11 August 2008. doi:10.2519/jospt.2008.2690

KEY WORDS: knee, manual therapy, spine, orthotics, taping, pain, patellofemoral joint

SYNOPSIS: The process of evidence-based practice (EBP) guides clinicians in the integration of individual clinical expertise, patient values and expectations, and the best available evidence. Becoming proficient with this process takes time and consistent practice, but should ultimately lead to improved patient outcomes. The EBP process entails 5 steps: (1) formulating an appropriate question, (2) performing an efficient literature search, (3) critically appraising the best available evidence, (4) applying the best evidence to clinical practice, and (5) assessing outcomes of care. This second commentary in a 2-part series will review principles relating to steps 3 through 5 of this 5-step model. The purpose of this commentary is to provide a perspective to assist clinicians in interpreting results, applying the evidence to patient care, and evaluating proficiency with EBP skills in studies of interventions for orthopaedic and sports physical therapy. 

J Orthop Sports Phys Ther. 2008;38(8):485-501, published online 27 June 2008. doi:10.2519/jospt.2008.2725

SYNOPSIS: The process of evidence-based practice (EBP) guides clinicians in the integration of individual clinical expertise, patient values and expectations, and the best available evidence. Becoming proficient with this process takes time and consistent practice, but should ultimately lead to improved patient outcomes. The EBP process entails 5 steps: (1) formulating an appropriate question, (2) performing an efficient literature search, (3) critically appraising the best available evidence, (4) applying the best evidence to clinical practice, and (5) assessing outcomes of care. This first commentary in a 2-part series will review principles relating to steps 1, 2, and 3 of this 5-step model. The purpose of this commentary is to provide a perspective to assist clinicians in formulating foreground questions, searching for the best available evidence, and determining validity of results in studies of interventions for orthopaedic and sports physical therapy.

J Orthop Sports Phys Ther. 2008;38(8):476-484, published online 27 June 2008. doi:10.2519/jospt.2008.2722

KEY WORDS: critical appraisal, physical therapy, treatment effectiveness

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

• Regional Interdependence: A Musculoskeletal Examination Model Whose Time Has Come. J Orthop Sports Phys Ther. 2008;38(3):159-161. doi:10.2519/jospt.2008.0201
• Authors' response. J Orthop Sports Phys Ther. 2008;38(3):159-161. doi:10.2519/jospt.2008.0202
• Slipped Capital Femoral Epiphysis in a Patient Referred to Physical Therapy for Knee Pain. J Orthop Sports Phys Ther. 2008;38(3):159-161. doi:10.2519/jospt.2008.0203
• Authors' response. J Orthop Sports Phys Ther. 2008;38(3):159-161. doi:10.2519/jospt.2008.0204

For physical therapists to justify our services for patients with musculoskeletal problems, we need to achieve clinical outcomes superior to those associated with natural history or due to the passage of time. If a patient's presentation is unclear or if the response to intervention is less favorable than expected, practical application of the regional-interdependence model may add clarity to the patient's clinical picture and guide subsequent interventions. Likewise, further investigation of the regional-interdependence concept in a systematic fashion may add clarity to the nature of many musculoskeletal problems and guide subsequent decision making in clinical care.

J Orthop Sports Phys Ther 2007;37(11):658-660. doi:10.2519/jospt.2007.0110

KEY WORDS: regional interdependence

J Orthop Sports Phys Ther. 2007;37(6):290-302, Epub 15 March 2007. doi:10.2519/jospt.2007.2498

The original article was corrected in December 2007, and the amended article PDF is provided here. Please see Erratum December 2007. J Orthop Sports Phys Ther. 2007;37(12):769.

KEY WORDS: clinical decision-making, lumbar spine, manipulation, stabilization, traction

As the physical therapy profession continues the paradigm shift toward evidencebased practice, it becomes increasingly important for therapists to base clinical decisions on the best available evidence. Defining the best available evidence, however, may not be as straightforward as we assume, and will inevitably depend in part upon the perspective and values of the individual making the judgment. To some, the best evidence may be viewed as research that minimizes bias to the greatest extent possible, while others may prioritize research that is deemed most pertinent to clinical practice. The evidence most highly valued and ultimately judged to be the best may differbased on which perspective predominates. One issue that highlights the importance of perspective in judging the evidence is the difference between efficacy and effectiveness approaches to research. These terms are frequently assumed to be synonyms and are often used incorrectly in the literature. There is actually a meaningful distinction between efficacy and effectiveness approaches to research. The distinction is not merely a pedantic concern within the lexicon of researchers, but impacts the nature of the results disseminated by a study, how the results may be applied to clinical practice, and finally how the results are judged by those who seek to evaluate the evidence. Understanding the contrast between effectiveness and efficacy has important and very practical implications for those who seek to evaluate and apply research evidence to clinical practice.

J Orthop Sports Phys Ther. 2003; 33(4):163-165.

Key Words: effectiveness, efficacy, evidence, research

Study Design: Single-case A1-B-A2 design. Objective: To determine if manual physical therapy, therapeutic exercise, and patient education would be an effective management strategy for a patient with a disc displacement without reduction of both temporomandibular joints. Background: A number of conservative management strategies have been proposed for the treatment of temporomandibular disorders. However, little evidence exists to indicate the effectiveness of physical therapy interventions in patients with bilateral disc displacement without reduction. Methods and Measures: Phase A1 of the study consisted of a baseline condition in which no intervention was initiated. Phase B included manual physical therapy, therapeutic exercise, and patient education focusing on the temporomandibular joint and cervical spine. Phase A2 consisted of withdrawal of the intervention. The Steigerwald/Maher disability questionnaire was used to collect data relative to function. A visual analog scale was used to collect pain data and maximal mouth opening measurements were obtained as an indicator of range of motion. Visual analysis and the 2 standard deviation band method of statistical analysis were used to compare data. Results: Following the implementation of the intervention phase, the patient demonstrated significant reductions in pain and improvements in maximal mouth opening and function as measured by the Steigerwald/Maher disability questionnaire. These observed improvements were maintained at the time of a 3-month follow-up. Conclusions: The results of our study suggest that manual physical therapy, therapeutic exercise, and patient education may have been an effective management strategy for a patient with bilateral disc displacement without reduction of the temporomandibular joints. Further outcome studies in the form of randomized controlled trials are needed to determine the clinical utility of this treatment approach in a larger population.

J Orthop Sport Phys Ther. 2004;34(9):535-548. doi:10.2519/jospt.2004.1508

Key Words: jaw, maximal mouth opening, orofacial pain, temporomandibular disorder

Design: Retrospective ex-post facto design. Objectives: To retrospectively review the management of patients with lateral epicondylalgia, and to compare self-reported outcomes to assess the potential benefit of manual physical therapy to the cervical spine. Background: It has been postulated that dysfunction of the cervical spine may contribute to the symptoms associated with lateral epicondylalgia; however, the literature assessing the effectiveness of manual physical therapy to the cervicothoracic region in this patient population has been inconclusive. Documentation and analysis of outcomes of management strategies focusing on the cervical spine may lead to determining the most effective and efficient clinical practices. Methods and Measures: Of the 213 charts reviewed, 112 satisfied inclusion-exclusion criteria and were divided into 2 groups: those who received treatment solely directed at the elbow (local management [LM]), or those who received treatment directed at the elbow and cervical manual therapy (LM+C). Telephone follow-up interviews were used to determine the number of successful outcomes. Percentages of successful outcomes in each group were compared using chi-square analysis. An independent samples t test was used to compare the total number of visits per group. Results: Sixty-one of the 112 patients were in the LM group, while 51 received LM+C. Seventy-five percent of the patients available for follow-up in the LM group and 80% in the LM+C group reported a successful outcome. Patients in the LM group received a greater number of visits (mean, 9.7; SD, 2.4) than patients in the LM+C group (mean, 5.6; SD, 1.7; P<.01). Conclusions: The results of this retrospective review suggest that most patients had successful outcomes regardless of the inclusion of manual therapy interventions to the cervical spine. The LM+C group achieved the successful long-term outcome in significantly fewer visits.

Invited Commentary by Bill Vicenzino

J Orthop Sports Phys Ther. 2004;34(11):713-724. doi:10.2519/jospt.2004.1433

Key Words: extensor carpi radialis brevis, joint mobilization, lateral epicondylitis, tennis elbow

Study Design: Systematic literature review. Objective: Investigate the literature regarding the most effective positions, techniques, and durations of stretching to improve hamstring muscle flexibility. Background: Hamstring stretching is popular among physical therapists, athletic trainers, and fitness/coaching professionals; however, numerous stretching methodologies have been proposed in the literature. This fact establishes a need to systematically summarize available evidence in an attempt to determine the most effective stretching approach. Methods: A list of 28 pertinent manuscripts that included randomized and clinical trials was created according to specific inclusion/exclusion criteria. These manuscripts were critically reviewed for quality according to the Physiotherapy Evidence Database (PEDro) (10-point) scale and descriptive information about the stretching parameters employed in the research. Results: Cumulatively, 1338 healthy subjects were included in the reviewed studies. Methodological quality scores ranged from 2 to 8 (mean ± SD, 4.3 ± 1.6). Several methodological flaws were frequently recognized, including failure to conceal group allocation or perform blinded assessment. All studies reported improvements in range of motion after stretching. Conclusions: Overall, methodological quality was poor, with only 21.4% (6/28) of studies achieving a score between 6 and 8. Thus it was difficult to confidently identify 1 most effective hamstring stretching method. Instead, the evidence appears to indicate that hamstring stretching increases range of motion with a variety of stretching techniques, positions, and durations.

J Orthop Sports Phys Ther. 2005;35(6):377-387. doi:10.2519/jospt.2005.2012

Key Words: flexibility, hip, knee, PEDro

Study Design: Resident's case problem. Background: Acute back pain most often presents as musculoskeletal in nature; however, less frequently it may be the result of an underlying, or coexisting, systemic pathology. When present, the signs and symptoms of systemic pathology can mimic, or be masked by, musculoskeletal back pain, which may pose a diagnostic challenge during the clinical evaluation. The purpose of this resident's case problem is to describe the clinical reasoning process leading to a medical referral for a patient who presented to physical therapy with debilitating low back pain. Diagnosis: The patient in this resident's case problem was a 67-year-old male referred to physical therapy with a 2-week history of severe low back pain and muscle spasms. The patient history and physical examination were suggestive of musculoskeletal back pain and physical therapy treatment was initiated. Abdominal pain was elicited during an introductory therapeutic exercise, which was recognized by the therapist as a potential sign of abdominal pathology. The therapist performed an additional review of systems and an abdominal screening examination, which established the necessity of an immediate medical referral. At the emergency department, ominous abdominal pathology was safely ruled out through diagnostic imaging and the patient was treated for secondary gastrointestinal effects of opioid analgesic medications. Discussion: This resident's case problem provides an opportunity to discuss the clinical reasoning process leading to the suspicion of abdominal pathology. Specifically, this case reinforces the importance of recognizing potential signs of systemic pathology, executing an appropriate physical examination, including screening of the involved anatomical region, and providing an appropriate medical referral when indicated.

J Orthop Sports Phys Ther. 2005;35(11):755-764. doi:10.2519/jospt.2005.2052

Key Words: differential diagnosis, low back, lumbar spine evaluation, pharmacology, primary care

Study Design: A case series of consecutive patients with cervical radiculopathy. Background: A multitude of physical therapy interventions have been proposed to be effective in the management of cervical radiculopathy. However, outcome studies using consistent treatment approaches on a well-defined sample of patients are lacking. The purpose of this case series is to describe the outcomes of a consecutive series of patients presenting to physical therapy with cervical radiculopathy and managed with the use of manual physical therapy, cervical traction, and strengthening exercises. Case Description: Eleven consecutive patients (mean age, 51.7 years; SD, 8.2) who presented with cervical radiculopathy on the initial examination were treated with a standardized approach, including manual physical therapy, cervical traction, and strengthening exercises of the deep neck flexors and scapulothoracic muscles. At the initial evaluation all patients completed self-report measures of pain and function, including a numeric pain rating scale (NPRS), the Neck Disability Index (NDI), and the Patient-Specific Functional Scale (PSFS). All patients again completed the outcome measures, in addition to the global rating of change (GROC), at the time of discharge from therapy and at a 6-month follow-up session. Outcomes: Ten of the 11 patients (91%) demonstrated a clinically meaningful improvement in pain and function following a mean of 7.1 (SD, 1.5) physical therapy visits and at the 6-month follow-up. Discussion: Ninety-one percent (10 of 11) of patients with cervical radiculopathy in this case series improved, as defined by the patients classifying their level of improvement as at least ‘‘quite a bit better’’ on the GROC. However, because a cause-and-effect relationship cannot be inferred from a case series, follow-up randomized clinical trials should be performed to further investigate the effectiveness of manual physical therapy, cervical traction, and strengthening exercises in a homogeneous group of patients with cervical radiculopathy.

J Orthop Sports Phys Ther. 2005;35(12):802-811. doi:10.2519/jospt.2005.2077

Key Words: cervical spine, manipulation, mobilization, thoracic spine

Study Design: A case series of patients with low back pain (LBP) who satisfy a clinical prediction rule (CPR).

Background: A CPR that identifies patients with LBP who are likely to respond with rapid and prolonged reductions in pain and disability following spinal manipulation was developed and recently validated. The CPR developed to predict favorable response to manipulation investigated the effects of only 1 manipulation technique. The accuracy of the CPR for predicting outcomes using other manipulation techniques is not known. The purpose of the case series was to describe the outcomes of patients presenting to physical therapy with LBP who met the CPR and were treated with an alternative lumbar manipulation technique.

Case Description: Consecutive patients referred to physical therapy who satisfied the eligibility criteria, including the presence of at least 4 of the 5 criteria on the CPR, were invited to participate in the case series. Patients were treated for 2 visits with a side-lying lumbar manipulation technique, followed by a basic range of motion exercise. Patients who exhibited a 50% reduction or greater in disability, as measured by the Oswestry Disability Index (ODI), were considered to have experienced a successful outcome.

Outcomes: A total of 12 patients participated in the case series. The mean age of the group was 39 years (SD, 8.9 years) and the median duration of symptoms was 19 days (range, 8-148 days). Of the 12 patients who participated in this case series, the mean reduction in disability as measured with the ODI was 57% (SD, 9%). Only 1 patient did not surpass the 50% reduction in ODI scores.Discussion: Eleven of the 12 patients (92%) in this case series who satisfied the CPR and were treated with an alternative lumbar manipulation technique demonstrated a successful outcome in 2 visits. It is plausible that patients with LBP who satisfy the CPR may obtain a successful outcome with either manipulation technique directed at the lumbopelvic region.

J Orthop Sports Phys Ther. 2006;36(4):209-214, doi:10.2519/jospt.2006.2163.

Key Words: low back pain, manual therapy, physical therapy

Three contributors discuss the divide that seems to exist between physical therapy research and clinical practice.

J Orthop Sports Phys Ther. 2006; 36(7):451-461. doi:10.2519/jospt.2006.0108

Study Design: Case series describing the outcomes of individual patients with hip osteoarthritis treated with manual physical therapy and exercise.
Case Description: Seven patients referred to physical therapy with hip osteoarthritis and/or hip pain were included in this case series. All patients were treated with manual physical therapy followed by exercises to maximize strength and range of motion. Six of 7 patients completed a Harris Hip Score at initial examination and discharge from physical therapy, and 1 patient completed a Global Rating of Change Scale at discharge.
Outcomes: Three males and 4 females with a median age of 62 years (range, 52-80 years) and median duration of symptoms of 9 months (range, 2-60 months) participated in this case series. The median number of physical therapy sessions attended was 5 (range, 4-12). The median increase in total passive range of motion of the hip was 82° (range, 70°-86°). The median improvement on the Harris Hip Score was 25 points (range, 15-38 points). The single patient who completed the Global Rating of Change Scale at discharge reported being ‘‘a great deal better.’’ Numeric pain rating scores decreased by a mean of 5 points (range, 2-7 points) on 0-to-10-point scale.
Discussion: All patients exhibited reductions in pain and increases in passive range of motion, as well as a clinically meaningful improvement in function. Although we cannot infer a cause and effect relationship from a case series, the outcomes with these patients are similar to others reported in the literature that have demonstrated superior clinical outcomes associated with manual physical therapy and exercise for hip osteoarthritis compared to exercise alone.

J Orthop Sports Phys Ther. 2006;36(8):588-599. doi:10.2519/jospt.2006.2233. The original article was corrected in September 2007, and the amended article PDF is provided here. Please see Correction: Altman's criteria for osteoarthritis of the hip and knee. J Orthop Sports Phys Ther. 2007; 37(9):573.

Key Words: arthritis, Harris Hip Score, manipulation, mobilization, passive range of motion

As a professional responsibility, we must provide procedures, such as manual therapy techniques and exercise interventions that are supported by evidence, to our patients who experience headaches as well as spinal and extremity disorders.

J Orthop Sports Phys Ther. 2006:36(11):834-836. doi:10.2519/jospt.2006.0112