STUDY DESIGN: Planned secondary analysis of a randomized controlled trial comparing neural tissue management (NTM) to advice to remain active (ARA). OBJECTIVE: To develop a model that predicts the likelihood of patient-reported improvement following NTM. BACKGROUND: Matching patients to an intervention they are likely to benefit from potentially improves outcomes. However, baseline characteristics that predict patients' responses to NTM are unknown. METHODS: Data came from 60 consecutive adults who had non-traumatic, nerve-related neck and unilateral arm pain for at least 4 weeks. NTM (n = 40) involved brief education, manual therapy, and nerve gliding exercises for 4 treatments over 2 weeks. ARA (n = 20) involved instruction to continue usual activities. Participants' Global Rating of Change at a 3 to 4 week follow-up defined improvement. Penalized regression of NTM data identified the best prediction model. A medical nomogram was created for prediction model scoring. Post hoc analysis determined whether the model predicted a specific response to NTM. RESULTS: Absence of neuropathic pain qualities, higher age, and smaller deficits in median nerve neurodynamic test range of motion predicted improvement. Prediction model cut-offs increased the likelihood of improvement from 53% to 90% (95% CI: 56%, 98%) or decreased the likelihood of improvement to 9% (95% CI: 1%, 42%). The model did not predict ARA group outcomes. CONCLUSIONS: Baseline characteristics of patients with nerve-related neck and arm pain predicted the likelihood of improvement with NTM. Model performance needs to be validated in a new sample using different comparison interventions and longer follow-up.

J Orthop Sports Phys Ther, Epub 30 April 2013. doi:10.2519/jospt.2013.4490

KEY WORDS: cervical radicular pain, clinical prediction rule, medical nomogram, neurodynamic treatment, penalized regression

STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To compare the effectiveness of a manual therapy and exercise approach (MTEX) to a home exercise program (HEP) in the management of individuals with an inversion ankle sprain. BACKGROUND: An in clinic exercise program has been found to yield similar outcomes as an HEP for individuals with an inversion ankle sprain. However, no studies have compared a MTEX approach to an HEP.  METHODS: Patients with an inversion ankle sprain completed the Foot and Ankle Ability Index Activities of Daily Living subscale (FAAM-ADL), the Foot and Ankle Ability Index Sport subscale (FAAM-SPORT), the Lower Extremity Functional Scale (LEFS), and the Numeric Pain Rating Scale (NPRS). Patients were randomly assigned to either an MTEX or an HEP approach. Outcomes were collected at baseline, 4-weeks, and 6-months.  The primary aim (effects of treatment on pain and disability) was examined with a mixed model ANOVA. The hypothesis of interest was the 2-way interaction (group*time). RESULTS: Seventy-four patients, mean age 35.1 (SD= 11.0) years, (48.6% female), were randomized into the MTEX group (n=37) or HEP group (n=37). The overall group*time interaction for the mixed model ANOVA was statistically significant for the FAAM-ADL (P<.001), FAAM-SPORT (P< .001), LEFS (P<.001), and pain (P=<.001).  Improvements in all functional outcome measures and pain were significantly greater at both the 4-week and 6-month follow-up periods in favor of the MTEX group. CONCLUSION: The results suggest that a MTEX approach is superior to an HEP in the treatment of inversion ankle sprains. Trial Registration: NCT00797368. LEVEL OF EVIDENCE: Therapy, level 1b.

J Orthop Sports Phys Ther, Epub 29 April 2013. doi:10.2519/jospt.2013.4792

KEY WORDS: manipulation, mobilization

STUDY DESIGN: Retrospective cohort. OBJECTIVES: The objectives of this study were to 1) examine patients' general expectations for treatment by physical therapists and specific expectations for common interventions in patients with neck pain; and 2) assess the extent to which the patients' general and specific expectations for treatment affect clinical outcomes. BACKGROUND: Patient expectations can have a profound influence on the magnitude of treatment outcome across a broad variety of patient conditions. METHODS: We performed a secondary analysis of data from a clinical trial of interventions for neck pain. Prior to beginning treatment for neck pain, 140 patients were asked their general expectations of benefit as well as their specific expectations for individual interventions. Next we examined how these expectations related to the patients' ratings of the success of treatment at one and six months after treatment. RESULTS: Patients had positive expectations for treatment by a physical therapist with more than 80% of patients expecting to have moderate relief of symptoms, prevention of disability, the ability to do more activity, and to sleep better. The manual therapy interventions of massage (87%) and manipulation (75%) had the highest proportion of patients who expected these interventions to significantly improve neck pain. These were followed by strengthening (70%) and range of motion (54%) exercises. Very few patients thought surgery would improve their neck pain (<1%). At 1-month, patients who were unsure of experiencing complete pain relief had lower odds than patients expecting complete relief (OR 0.33, 95%CI 0.11, 0.99). Believing that manipulation would help and not receiving manipulation lowered the odds of success (OR 0.16, 95%CI 0.04, 0.72) compared to believing manipulation would help and receiving manipulation. Six months after treatment, having unsure expectations for complete pain relief lowered the odds of success 0.19 (95%CI 0.05, 0.7) times while definitely expecting to do more exercise increased odds of success (OR 11.4, 95%CI 1.7, 74.7) times. When considering self-reported disability, patients who believed manipulation would help and received manipulation reported less disability than those who didn't believe manipulation would help and both received manipulation (difference of -3.8, 95%CI -5.9, -1.5; p=0.006) and did not receive manipulation (difference of -5.7, 95%CI -9.3, -2.1; p=0.014).  There was also an interaction between time and the expectation for complete relief. Here, participants who expected complete relief had greater changes in disability at 1-month (20.3% 95%CI 18.1, 22.6) compared to those participants who did not expect complete relief (14.1%, 95%CI 11.1, 17.0; p=0.014). CONCLUSION: General expectations of benefit have a strong influence on clinical outcomes for patients with neck pain. LEVEL OF EVIDENCE: Prognosis, level 2b.

J Orthop Sports Phys Ther, Epub 18 March 2013. doi:10.2519/jospt.2013.4492

KEY WORDS: exercise, manual therapy, neck pain, outcomes

STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To compare the effects of thrust and nonthrust manipulation and exercises with and without the addition of myofascial therapy for the treatment of acute inversion ankle sprain. BACKGROUND: Studies have reported that thrust and nonthrust manipulations of the ankle joint are effective for the management of patients post–ankle sprain. However, it is not known whether the inclusion of soft tissue myofascial therapy could further improve clinical and functional outcomes. METHODS: Fifty patients (37 men and 13 women; mean ± SD age, 33 ± 10 years) post–acute inversion ankle sprain were randomly assigned to 2 groups: a comparison group that received a thrust and nonthrust manipulation and exercise intervention, and an experimental group that received the same protocol and myofascial therapy. The primary outcomes were ankle pain at rest and functional ability. Additionally, ankle mobility and pressure pain threshold over the ankle were assessed by a clinician who was blinded to the treatment allocation. Outcomes of interest were captured at baseline, immediately after the treatment period, and at a 1-month follow-up. The primary analysis was the group-by-time interaction. RESULTS: The 2-by-3 mixed-model analyses of variance revealed a significant group-by-time interaction for ankle pain (P<.001) and functional score (P = .002), with the patients who received the combination of nonthrust and thrust manipulation and myofascial intervention experiencing a greater improvement in pain and function than those who received the nonthrust and thrust manipulation intervention alone. Significant group-by-time interactions were also observed for ankle mobility (P<.001) and pressure pain thresholds (all, P<.01), with those in the experimental group experiencing greater increases in ankle mobility and pressure pain thresholds. Between-group effect sizes were large (d>0.85) for all outcomes. CONCLUSION: This study provides evidence that, in the treatment of individuals post–inversion ankle sprain, the addition of myofascial therapy to a plan of care consisting of thrust and nonthrust manipulation and exercise may further improve outcomes compared to a plan of care solely consisting of thrust and nonthrust manipulation and exercise. However, though statistically significant, the difference in improvement in the primary outcome between groups was not greater than what would be considered a minimal clinically important difference. Future studies should examine the long-term effects of these interventions in this population. LEVEL OF EVIDENCE: Therapy, level 1b–.

J Orthop Sports Phys Ther 2013;43(5):300-309. Epub 13 March 2013. doi:10.2519/jospt.2013.4467

KEY WORDS: manual therapy, pressure pain threshold, triceps surae

STUDY DESIGN: Case series. OBJECTIVES: To use blood oxygenation level–dependent functional magnetic resonance imaging (fMRI) to determine if supraspinal activation in response to noxious mechanical stimuli varies pre– and post–thrust manipulation to the thoracic spine. BACKGROUND: Recent studies have demonstrated the effectiveness of thoracic thrust manipulation in reducing pain and improving function in some individuals with neck and shoulder pain. However, the mechanisms by which manipulation exerts such effects remain largely unexplained. The use of fMRI in the animal model has revealed a decrease in cortical activity in response to noxious stimuli following manual joint mobilization. Supraspinal mediation contributing to hypoalgesia in humans may be triggered following spinal manipulation. METHODS: Ten healthy volunteers (5 women, 5 men) between the ages of 23 and 48 years (mean, 31.2 years) were recruited. Subjects underwent fMRI scanning while receiving noxious stimuli applied to the cuticle of the index finger at a rate of 1 Hz for periods of 15 seconds, alternating with periods of 15 seconds without stimuli, for a total duration of 5 minutes. Subjects then received a supine thrust manipulation directed to the midthoracic spine and were immediately returned to the scanner for reimaging with a second delivery of noxious stimuli. An 11-point numeric pain rating scale was administered immediately after the application of noxious stimuli, premanipulation and postmanipulation. Blood oxygenation level–dependent fMRI recorded the cerebral hemodynamic response to the painful stimuli premanipulation and postmanipulation. RESULTS: The data indicated a significant reduction in subjects’ perception of pain (P<.01), as well as a reduction in cerebral blood flow as measured by the blood oxygenation level–dependent response following manipulation to areas associated with the pain matrix (P<.05). There was a significant relationship between reduced activation in the insular cortex and decreased subjective pain ratings on the numeric pain rating scale (r = 0.59, P<.05). CONCLUSION: This study provides preliminary evidence that suggests that supraspinal mechanisms may be associated with thoracic thrust manipulation and hypoalgesia. However, because the study lacked a control group, the results do not allow for the discernment of the causative effects of manipulation, which may also be related to changes in levels of subjects’ fear, anxiety, or expectation of successful outcomes with manipulation. Future investigations should strive to elicit more conclusive findings in the form of randomized clinical trials.

J Orthop Sports Phys Ther 2013;43(5):340-348. Epub 13 March 2013. doi:10.2519/jospt.2013.4631

KEY WORDS: fMRI, manipulation, neuroscience, pain

STUDY DESIGN: Double-blind, randomized controlled trial. OBJECTIVE: To examine the effectiveness of a manual therapy and exercise approach relative to a placebo intervention in individuals with carpometacarpal (CMC) joint osteoarthritis (OA). BACKGROUND: Recent studies have reported the outcomes of exercise, joint mobilization, and neural mobilization interventions used in isolation in patients with CMC joint OA. However, it is not known if using a combination of these interventions as a multimodal approach to treatment would further improve outcomes in this patient population. METHODS: Sixty patients, 90% female (mean ± SD age, 82 ± 6 years), with CMC joint OA were randomly assigned to receive a multimodal manual treatment approach that included joint mobilization, neural mobilization, and exercise, or a sham intervention, for 12 sessions over 4 weeks. The primary outcome measure was pain. Secondary outcome measures included pressure pain threshold over the first CMC joint, scaphoid, and hamate, as well as pinch and strength measurements. All outcome measures were collected at baseline, immediately following the intervention, and at 1 and 2 months following the end of the intervention. Mixed-model analyses of variance were used to examine the effects of the interventions on each outcome, with group as the between-subject variable and time as the within-subject variable. RESULTS: The mixed-model analysis of variance revealed a group-by-time interaction (F = 47.58, P<.001) for pain intensity, with the patients receiving the multimodal intervention experiencing a greater reduction in pain compared to those receiving the placebo intervention at the end of the intervention, as well as at 1 and 2 months after the intervention (P<.001; all group differences greater than 3.0 cm, which is greater than the minimal clinically important difference of 2.0 cm). A significant group-by-time interaction (F = 3.19, P = .025) was found for pressure pain threshold over the hamate bone immediately after the intervention; however, the interaction was no longer significant at 1 and 2 months postintervention. CONCLUSION: This clinical trial provides evidence that a combination of joint mobilization, neural mobilization, and exercise is more beneficial in treating pain than a sham intervention in patients with CMC joint OA. However, the treatment approach has limited value in improving pressure pain thresholds, as well as pinch and grip strength. Future studies should include several therapists, a measure of function, and long-term outcomes. Trial registration: Current Controlled Trials ISRCTN37143779. LEVEL OF EVIDENCE: Therapy, level 1b.

J Orthop Sports Phys Ther 2013;43(4):204-213. Epub 13 March 2013. doi:10.2519/jospt.2013.4524

KEY WORDS: arthritis, CMC, joint mobilization, neural mobilization

STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To investigate the short-term effects of thoracic spine thrust manipulation combined with cervical spine nonthrust manipulation (experimental group) versus cervical spine nonthrust manipulation alone (comparison group) in individuals with mechanical neck pain. BACKGROUND: Research has demonstrated improved outcomes with both nonthrust manipulation directed at the cervical spine and thrust manipulation directed at the thoracic spine in patients with neck pain. Previous studies have not determined if thoracic spine thrust manipulation may increase benefits beyond those provided by cervical nonthrust manipulation alone. METHODS: Sixty-four participants with mechanical neck pain were randomized into 1 of 2 groups, an experimental or comparison group. Both groups received 2 treatment sessions of cervical spine nonthrust manipulation and a home exercise program consisting of active range-of-motion exercises, and the experimental group received additional thoracic spine thrust manipulations. Outcome measures were collected at baseline and at a 1-week follow-up, and included the numeric pain rating scale, the Neck Disability Index, and the global rating of change. RESULTS: Participants in the experimental group demonstrated significantly greater improvements (P<.001) on both the numeric pain rating scale and Neck Disability Index at the 1-week follow-up compared to those in the comparison group. In addition, 31 of 33 (94%) participants in the experimental group, compared to 11 of 31 participants (35%) in the comparison group, indicated a global rating of change score of +4 or higher at the 1-week follow-up, with an associated number needed to treat of 2. CONCLUSION: Individuals with neck pain who received a combination of thoracic spine thrust manipulation and cervical spine nonthrust manipulation plus exercise demonstrated better overall short-term outcomes on the numeric pain rating scale, the Neck Disability Index, and the global rating of change. LEVEL OF EVIDENCE: Therapy, level 1b.

J Orthop Sports Phys Ther 2013;43(3):118-127. Epub 7 December 2012. doi:10.2519/jospt.2013.4221

KEY WORDS: manipulative therapy, manual therapy, mobilization

STUDY DESIGN: Randomized clinical trial. OBJECTIVES: To compare the effects of cervical versus thoracic thrust manipulation in patients with bilateral chronic mechanical neck pain on pressure pain sensitivity, neck pain, and cervical range of motion (CROM). BACKGROUND: Evidence suggests that spinal interventions can stimulate descending inhibitory pain pathways. To our knowledge, no study has investigated the neurophysiological effects of thoracic thrust manipulation in individuals with bilateral chronic mechanical neck pain, including widespread changes on pressure sensitivity. METHODS: Ninety patients (51% female) were randomly assigned to 1 of 3 groups: cervical thrust manipulation on the right, cervical thrust manipulation on the left, or thoracic thrust manipulation. Pressure pain thresholds (PPTs) over the C5-6 zygapophyseal joint, lateral epicondyle, and tibialis anterior muscle, neck pain (11-point numeric pain rating scale), and cervical spine range of motion (CROM) were collected at baseline and 10 minutes after the intervention by an assessor blinded to the treatment allocation of the patients. Mixed-model analyses of covariance were used to examine the effects of the treatment on each outcome variable, with group as the between-subjects variable, time and side as the within-subject variables, and gender as the covariate. The primary analysis was the group-by-time interaction. RESULTS: No significant interactions were found with the mixed-model analyses of covariance for PPT level (C5-6, P>.210; lateral epicondyle, P>.186; tibialis anterior muscle, P>.268), neck pain intensity (P = .923), or CROM (flexion, P = .700; extension, P = .387; lateral flexion, P>.672; rotation, P>.192) as dependent variables. All groups exhibited similar changes in PPT, neck pain, and CROM (all, P<.001). Gender did not influence the main effects or the interaction effects in the analyses of the outcomes (P>.10). CONCLUSION: The results of the current randomized clinical trial suggest that cervical and thoracic thrust manipulation induce similar changes in PPT, neck pain intensity, and CROM in individuals with bilateral chronic mechanical neck pain. However, changes in PPT and CROM were small and did not surpass their respective minimal detectable change values. Further, because we did not include a control group, we cannot rule out a placebo effect of the thrust interventions on the outcomes. LEVEL OF EVIDENCE: Therapy, level 1b.

J Orthop Sports Phys Ther 2012;42(9):806-814, Epub 18 June 2012. doi:10.2519/jospt.2012.4151

KEY WORDS: manual therapy, mobilization, spine

STUDY DESIGN: Prospective cohort/predictive validity study. OBJECTIVE: To determine the predictive validity of selected clinical examination items and to develop a clinical prediction rule to determine which patients with neck pain may benefit from cervical thrust joint manipulation (TJM) and exercise. BACKGROUND: TJM to the cervical spine has been shown to be effective in patients presenting with a primary report of neck pain. It would be useful for clinicians to have a decision-making tool, such as a clinical prediction rule, that could accurately identify which subgroup of patients would respond positively to cervical TJM. METHODS: Consecutive patients who presented to physical therapy with a primary complaint of neck pain completed a series of self-report measures, then received a detailed standardized history and physical examination. After the clinical examination, all patients received a standardized treatment regimen consisting of cervical TJM and range-of-motion exercise. Depending on response to treatment, patients were treated for 1 or 2 sessions over approximately 1 week. At the end of their participation in the study, patients were classified as having experienced a successful outcome based on a score of +5 ("quite a bit better") or higher on the global rating of change scale. Sensitivity, specificity, and positive and negative likelihood ratios were calculated for all potential predictor variables. Univariate techniques and stepwise logistic regression were used to determine the most parsimonious set of variables for prediction of treatment success. Variables retained in the regression model were used to develop a multivariate clinical prediction rule. RESULTS: Eighty-two patients were included in data analysis, of whom 32 (39%) achieved a successful outcome. A clinical prediction rule with 4 attributes (symptom duration less than 38 days, positive expectation that manipulation will help, side-to-side difference in cervical rotation range of motion of 10° or greater, and pain with posteroanterior spring testing of the middle cervical spine) was identified. If 3 or more of the 4 attributes (positive likelihood ratio of 13.5) were present, the probability of experiencing a successful outcome improved from 39% to 90%. CONCLUSION:  The clinical prediction rule may improve decision making by providing the ability to a priori identify patients with neck pain who are likely to benefit from cervical TJM and range-of-motion exercise. However, this is only the first step in the process of developing and testing a clinical prediction rule, as future studies are necessary to validate the results and should include long-term follow-up and a comparison group. LEVEL OF EVIDENCE: Prognosis, level 2b.

J Orthop Sports Phys Ther 2012;42(7):577-592, Epub 14 May 2012. doi:10.2519/jospt.2012.4243

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

STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To compare the effectiveness of cervical spine thrust manipulation to that of Kinesio Taping applied to the neck in individuals with mechanical neck pain, using self-reported pain and disability and cervical range of motion as measures. BACKGROUND: The effectiveness of cervical manipulation has received considerable attention in the literature. However, because some patients cannot tolerate cervical thrust manipulation, alternative therapeutic options should be investigated. METHODS: Eighty patients (36 women) were randomly assigned to 1 of 2 groups: the manipulation group, which received 2 cervical thrust manipulations, and the tape group, which received Kinesio Taping applied to the neck. Neck pain (11-point numeric pain rating scale), disability (Neck Disability Index), and cervical-range-of-motion data were collected at baseline and 1 week after the intervention by an assessor blinded to the treatment allocation of the patients. Mixed-model analyses of variance 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: No significant group-by-time interactions were found for pain (F = 1.892, P = .447) or disability (F = 0.115, P = .736). The group-by-time interaction was statistically significant for right (F = 7.317, P = .008) and left (F = 9.525, P = .003) cervical rotation range of motion, with the patients who received the cervical thrust manipulation having experienced greater improvement in cervical rotation than those treated with Kinesio Tape (P<.01). No significant group-by-time interactions were found for cervical spine range of motion for flexion (F = 0.944, P = .334), extension (F = 0.122, P = .728), and right (F = 0.220, P = .650) and left (F = 0.389, P = .535) lateral flexion. CONCLUSION: Patients with mechanical neck pain who received cervical thrust manipulation or Kinesio Taping exhibited similar reductions in neck pain intensity and disability and similar changes in active cervical range of motion, except for rotation. Changes in neck pain surpassed the minimal clinically important difference, whereas changes in disability did not. Changes in cervical range of motion were small and not clinically meaningful. Because we did not include a control or placebo group in this study, we cannot rule out a placebo effect or natural changes over time as potential reasons for the improvements measured in both groups. LEVEL OF EVIDENCE: Therapy, level 1b.

J Orthop Sports Phys Ther 2012;42(8):724-730, Epub 20 April 2012. doi:10.2519/jospt.2012.4086

KEY WORDS: cervical spine, manual therapy, mobilization

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

• "Cervical and Thoracic Mobilization Versus Manipulation for Mechanical Neck Pain" and Authors' Response

J Orthop Sports Phys Ther 2012;42(4):382-392. doi:10.2519/jospt.2012.0202

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