STUDY DESIGN: Psychometric study design. OBJECTIVES: To assess the test-retest reliability and convergent validity of the Functional Impairment Test- Hand and Neck/Shoulder/Arm (FIT-HaNSA) in patients with shoulder disorders. BACKGROUND: Performance tests that assess functional ability of patients with shoulder disorders can provide useful information for making clinical or return to activity decisions. No performance based shoulder test has yet demonstrated sufficient relevance or clinical measurement properties. The FIT-HaNSA examines upper extremity performance during repetitive tasks that emphasize shoulder reaching and static postures and therefore has greater relevance for assessing performance. METHODS: Thirty six patients with shoulder disorders and 65 healthy controls were recruited in the study. The FIT-HaNSA, Disabilities of the Arm, Shoulder and Hand (DASH), Shoulder Pain and Disability Index (SPADI), isometric shoulder strength, and shoulder range of motion (ROM) were assessed at baseline and repeated 7 days later. Test-retest reliability was described using intraclass correlation coefficient (ICC) and standard error of measurement. Pearson correlation coefficients were used to examine the level of association between the FIT-HaNSA scores and the other measures. RESULTS: The ICCs_2,1 for test retest reliability for the FIT-HaNSA ranged from 0.89-0.97 in the patient group and 0.79-0.91 in the control group. The FIT-HaNSA showed a high correlation with the DASH and the SPADI and moderate correlations with the shoulder ROM and muscle strength. CONCLUSION: The FIT-HaNSA demonstrated high test-retest reliability and convergent validity with other related outcomes in patients with shoulder disorders. Further longitudinal studies are required to evaluate the responsiveness of the FIT-HaNSA in patients with different upper extremity conditions.

J Orthop Sports Phys Ther, Epub 25 January 2012. doi:10.2519/jospt.2012.3796

KEY WORDS: performance measure, psychometrics, return to work, shoulder disability

This month’s issue of JOSPT contains a bibliometric analysis of the publishing history of the Journal of Orthopaedic & Sports Physical Therapy. The results provide an opportunity to reflect on trends at JOSPT and, more generally, in the evidence base of orthopaedic and sports physical therapy practice. Results of the bibliometric review by Coronado and colleagues are encouraging for JOSPT and the profession of physical therapy as a whole. The results indicate an increase in the publication of research articles involving symptomatic subjects, with fewer narrative and nonsystematic review papers. The results also raise an interesting issue about whether we have a sufficient number of randomized controlled trials in our literature and to what extent our future progress should be based on the publication of more randomized trials.

J Orthop Sports Phys Ther 2011;41(12):907-908. doi:10.2519/jospt.2011.0110

KEY WORDS: evidence-based medicine, physical therapy, profession, randomized controlled trials

STUDY DESIGN: Longitudinal cohort study. OBJECTIVES: To determine whether pressure pain threshold (PPT), tested at 2 standardized sites, could provide additional prognostic ability to predict short-term outcomes in people with acute whiplash, after controlling for age, sex, and baseline pain intensity. BACKGROUND: PPT may be a valuable assessment and prognostic indicator for people with whiplash-associated disorder. The extent to which PPT can predict short-term disability scores has yet to be explored in people with acute (of less than 30 days in duration) whiplash-associated disorder in a clinical setting. METHODS: Eligible patients were recruited from community-based physiotherapy clinics in Canada. Baseline measurements included PPT, as well as pain intensity, age, and sex. Neck-related disability was collected with the Neck Disability Index 1 to 3 months after PPT testing. Multiple linear regression models were constructed to evaluate the unique contribution of PPT in the prediction of follow-up disability scores. RESULTS: A total of 45 subjects provided complete data. A regression model that included sex, baseline pain intensity, and PPT at the distal tibialis anterior site was the most parsimonious model for predicting short-term Neck Disability Index scores 1 to 3 months after PPT testing, explaining 38.6% of the variance in outcome. None of the other variables significantly improved the predictive power of the model. CONCLUSION: Sex, pain intensity, and PPT measured at a site distal to the injury were the most parsimonious set of predictors of short-term neck-related disability score, and represented promising additions to assessment of traumatic neck pain. Neither age nor PPT at the local site was able to explain significant variance beyond those 3 predictors. Limitations to interpretation are addressed.

J Orthop Sports Phys Ther 2011;41(9):658-665. doi:10.2519/jospt.2011.3668

KEY WORDS: cervical spine, neck, PPT, WAD

STUDY DESIGN: Cross-sectional convenience sample. OBJECTIVES: To describe the distribution of scores for pressure pain threshold (PPT) at 2 standardized testing sites in people with neck pain of less than 90 days' duration: the angle of the upper trapezius and the belly of the tibialis anterior. A secondary objective was to identify important influences on PPT. BACKGROUND: PPT may be a valuable assessment and prognostic indicator for people with neck pain. However, to facilitate interpretation of scores, knowledge of means and variance for the target population, as well as factors that might influence scores, is needed. METHODS: Participants were recruited from community-based physiotherapy clinics and underwent PPT testing using a digital algometer and standardized protocol. Descriptive statistics (mean, standard deviations, quartiles, skewness, and kurtosis) were calculated for the 2 sites. Simple bivariate tests of association were conducted to explore potential moderators. RESULTS: A positively skewed distribution was described for the 2 standardized sites. Significant moderators were sex (male higher than female), age (r = 0.22), and self-reported pain intensity (r = –0.24). Neither litigation status nor most symptomatic/least symptomatic side influenced PPT. CONCLUSIONS: This manuscript presents information regarding the expected scores for PPT testing in people with acute or subacute neck pain. Clinicians can compare the results of individual patients against these population values, and researchers can incorporate the significant confounders of age, sex, and self-reported pain intensity into future research designs.

J Orthop Sports Phys Ther 2011;41(9):651-657. doi:10.2519/jospt.2011.3667

KEY WORDS: algometry, cervical pain, hyperalgesia, hypersensitivity, whiplash

STUDY DESIGN: Clinical measurement. OBJECTIVES: To evaluate the intrarater, interrater, and test-retest reliability of an accessible digital algometer, and to determine the minimum detectable change in normal healthy individuals and a clinical population with neck pain. BACKGROUND: Pressure pain threshold testing may be a valuable assessment and prognostic indicator for people with neck pain. To date, most of this research has been completed using algometers that are too resource intensive for routine clinical use. METHODS: Novice raters (physiotherapy students or clinical physiotherapists) were trained to perform algometry testing over 2 clinically relevant sites: the angle of the upper trapezius and the belly of the tibialis anterior. A convenience sample of normal healthy individuals and a clinical sample of people with neck pain were tested by 2 different raters (all participants) and on 2 different days (healthy participants only). Intraclass correlation coefficient (ICC), standard error of measurement, and minimum detectable change were calculated. RESULTS: A total of 60 healthy volunteers and 40 people with neck pain were recruited. Intrarater reliability was almost perfect (ICC = 0.94-0.97), interrater reliability was substantial to near perfect (ICC = 0.79-0.90), and test-retest reliability was substantial (ICC = 0.76-0.79). Smaller change was detectable in the trapezius compared to the tibialis anterior. CONCLUSIONS: This study provides evidence that novice raters can perform digital algometry with adequate reliability for research and clinical use in people with and without neck pain.

J Orthop Sports Phys Ther 2011;41(9):644-650. doi:10.2519/jospt.2011.3666

KEY WORDS: algometer, cervical spine, PPT, tibialis anterior

SYNOPSIS: Orthopaedic physical therapy is considered safe, based on a lack of reported harms. Most of the research until now has focused on benefits. Consideration of benefits and harm involves informed consent, clinical decision making, and cost-benefit analyses. Benefits and harms are treatment and dosage specific. There is currently an insufficient number of dosage trials in orthopaedic physical therapy to identify optimal dosage for common interventions, including exercise and manual therapy. Published cases of severe adverse events following chiropractic manipulation illustrate the need for physical therapy to have high-quality data documenting the safety of orthopaedic physical therapy, including cervical manipulation. A recent systematic review identified poor reporting standards of harms within clinical research in this area. Lack of standardization of terminology has contributed to this problem. Pharmacovigilence provides a framework for terms that orthopaedic physical therapy can adapt and thereafter adopt into clinical practice and research. Adverse events are unexpected events that occur following an intervention without evidence of causality. Where temporality of an event is highly suggestive of causality, the term “adverse reaction” may be more appropriate. Future studies in orthopaedic physical therapy should adopt the CONSORT statement extension on the reporting of harms, published in 2004, to ensure better reporting. Consistent reporting of harms in both research and clinical practice requires professional consensus on terminology pertaining to harms, as well as defining what constitutes an adverse event or an adverse reaction. Widespread consultation and consensus should support optimal definitions and processes and facilitate their implementation into practice. This paper is focused on theoretical considerations and evidence in terms of harm reporting within physical therapy using cervical manual therapy as an example.

J Orthop Sports Phys Ther 2010;40(8):455-463, Epub 13 May 2010. doi:10.2519/jospt.2010.3229

KEY WORDS: harm, manipulation, manual therapy, neck

STUDY DESIGN: Prospective cohort study with repeated measures. OBJECTIVE: To establish the responsiveness of the Simple Shoulder Test (SST) in comparison to other commonly used clinical outcomes in patients undergoing shoulder arthroplasty. BACKGROUND: Responsiveness statistics are a useful means to compare different outcomes in terms of their ability to detect clinical change. While the responsiveness of the SST has been established for rotator cuff repair, it has not been determined for patients undergoing arthroplasty. METHODS: Patients undergoing shoulder arthroplasty (n = 120) were evaluated prior to surgery and 6 months after. The evaluation included the SST, Disabilities of the Arm, Shoulder and Hand questionnaire, range of motion, and isometric strength. Responsiveness to change was assessed using standardized response mean (SRM), while longitudinal construct validity was evaluated using Pearson correlation. Receiver operating characteristics curves were plotted to determine clinically important difference of SST. RESULTS: The SST and Disabilities of the Arm, Shoulder and Hand questionnaire were highly responsive (SRM, >1.70) for this population. For the assessment of impairment, range of motion (SRM, 0.64-1.03) was moderately to highly responsive, while isometric strength was minimally to moderately responsive (SRM, 0.32-0.69). The clinically important difference of the SST was established at 3.0 SST points. Pearson correlations indicated moderate associations between the change scores of the SST and the Disabilities of the Arm, Shoulder and Hand questionnaire (r = 0.49). CONCLUSIONS: The SST has been previously shown to be valid and highly reliable. The present results show that the SST is also responsive following shoulder arthroplasty and that it has a clinically important difference of 3.0 SST points. This should provide confidence to clinicians who wish to use a brief shoulder-specific measure in their practice.

J Orthop Sports Phys Ther 2010;40(7):413-421, Epub 15 April 2010. doi:10.2519/jospt.2010.3209

KEY WORDS: psychometric properties, questionnaire, responsiveness, shoulder

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

• "Centralization" and "Directional Preference" Are Not Synonyms and Author's Response
• Factor Analysis Findings for the NDI and Author's Response

STUDY DESIGN: Systematic review of clinical measurement. OBJECTIVE: To find and synthesize evidence on the psychometric properties and usefulness of the neck disability index (NDI). BACKGROUND: The NDI is the most commonly used outcome measure for neck pain, and a synthesis of knowledge should provide a deeper understanding of its use and limitations. METHODS AND MEASURES: Using a standard search strategy (1966 to September 2008) and 4 databases (Medline, CINAHL, Embase, and PsychInfo), a structured search was conducted and supplemented by web and hand searching. In total, 37 published primary studies, 3 reviews, and 1 in-press paper were analyzed. Pairs of raters conducted data extraction and critical appraisal using structured tools. Ranking of quality and descriptive synthesis were performed. RESULTS: Horizon estimation suggested the potential for 1 missed paper. The agreement between raters on quality assessments was high(kappa = 0.82). Half of the studies reached a quality level greater than 70%. Failures to report clear psychometric objectives/hypotheses or to rationalize the sample size were the most common design flaws. Studies often focused on less clinically applicable properties, like construct validity or group reliability, than transferable data, like known group differences or absolute reliability (standard error of measurement [SEM] or minimum detectable change [MDC]). Most studies suggest that the NDI has acceptable reliability, although intraclass correlation coefficients (ICCs) range from 0.50 to 0.98. Longer test intervals and the definition of stable can influence reliability estimates. A number of high-quality published (Korean, Dutch, Spanish, French, Brazilian Portuguese) and commercially supported translations are available. The NDI is considered a 1-dimensional measure that can be interpreted as an interval scale. Some studies question these assumptions. The MDC is around 5/50 for uncomplicated neck pain and up to 10/50 for cervical radiculopathy. The reported clinically important difference (CID) is inconsistent across different studies ranging from 5/50 to 19/50. The NDI is strongly correlated (>0.70) to a number of similar indices and moderately related to both physical and mental aspects of general health. CONCLUSION: The NDI has sufficient support and usefulness to retain its current status as the most commonly used self-report measure for neck pain. More studies of CID in different clinical populations and the relationship to subjective/work/function categories are required.

Note: Appendix B is online-only and is included in this downloadable PDF.

J Orthop Sports Phys Ther 2009;39(5):400-417. doi:10.2519/jospt.2009.2930

KEY WORDS: cervical spine, outcome measure, reliability, validity

SYNOPSIS: Neck pain is a common and episodic condition that is treated using a spectrum of interventions known to be moderately effective but is associated with a significant incidence of chronic pain. Recently, there has been increased focus on defining biological aspects of neck pain. Studies have indicated that neurophysiological, biomechanical, and motor control abnormalities are present and may be useful either in prognosis or classification. We review some of these findings in the context of our own work defining biological markers that may form the basis for clinical tests that can be used for prognosis, classification, or outcome evaluation in patients with neck pain. We have identified abnormalities in neurophysiology using quantitative sensory testing (vibration, touch, and current perception) and response to cold provocation that are related to neck disability. We have identified altered muscle biochemistry by measuring circulating muscle proteins in a lumbar surgery model and are now applying those methods to whiplash injury. We have incorporated capnography into treatment to address central physiological changes present in some patients by monitoring and training CO₂ levels. We have developed an innovative new test, the Neck Walk Index, that captures abnormal control of head movementduring slow gait as a means of differentiating patients with neck pain from either unaffected controls or individuals with other pathologies. We have used time-varying 3-dimensional joint orientation kinematics to assess deficits in motor control during an upper extremity reach task, the results showing that poor coordination and control of the shoulder girdle leads to shoulder guarding and inconsistencies in elbow joint movement. Despite some promising early results, future research is needed to determine how these measures help clinicians to diagnose, evaluate, and forecast future outcome for patients who present with neck pain. LEVEL OF EVIDENCE: Diagnosis, level 5.

Note: Appendices A and B are online-only and are included in this downloadable PDF.

J Orthop Sports Phys Ther 2009;39(5):388-399. doi:10.2519/jospt.2009.3126

KEY WORDS: biochemistry, capnography, cold intolerance, muscle, neck, pain, sensory evaluation

STUDY DESIGN: Single-group, repeated-measures study. OBJECTIVE: To estimate the test-retest reliability, construct validity, and responsiveness of the Lower Extremity Functional Scale (LEFS) on inpatients attending an orthopaedic rehabilitation ward. BACKGROUND: The LEFS has acceptable validity on outpatients in assessing functional mobility, but it has not been tested for use on an inpatient orthopaedic ward. METHODS AND MEASURES: Inpatients in an orthopaedic ward (n = 142) completed the 20-item, self-report LEFS on admission, 7 to 10 days after admission, and on discharge. To test reliability, 24 patients had the LEFS repeated 1 day after the admission test, and the intraclass correlation (ICC) and the standard error of measurement (SEM) were calculated. Change scores of the LEFS were evaluated against patients’ and therapists’ rating of improvement, and change scores of comparison measures that included pain, functional performance, and the composite index created from scores of these comparison measures. The standardized response mean (SRM) of the LEFS was also computed. RESULTS: The ICC of the LEFS was 0.88, and the SEM was 4 LEFS points (LEFS score range, 0-80). The change in LEFS correlated with changes of comparison measures in the same direction of improvement. Patients rated as improved by both themselves and their therapists had significantly larger change in LEFS scores than subjects rated as no change. The SRM of the LEFS from admission to discharge was 1.76 on patients rated as improved. CONCLUSION: The LEFS is reliable and valid toassess group and individual change, and has large responsiveness. The LEFS and the comparison measures likely assess different constructs.

J Orthop Sports Phys Ther 2009;39(6):468-477, Epub 2 February 2009. doi:10.2519/jospt.2009.2971

KEY WORDS: inpatients, LEFS, orthopaedic, outcome measure

STUDY DESIGN: Systematic review and meta-analysis. BACKGROUND: Whiplash-associated disorder (WAD) is the most common reported injury following motor vehicle accident. Evidence for prognosis and intervention are difficult to interpret due to differences in inception times, outcomes used, and sample heterogeneity. METHODS: An extensive literature search was conducted to identify published studies of prognosis following whiplash. Rigorous inclusion criteria were applied to allow for meaningful results to be drawn. Data were extracted, transformed where necessary, and pooled to allow estimation of the odds ratio for any factor with at least 3 data points in the literature. RESULTS: From 11 cohorts (n = 3193), 25 factors were identified with at least 3 data points in the existing literature. Of these, 9 were found to be significant predictors based on the odds ratio and confidence limits: no postsecondary education, female gender, history of previous neck pain,baseline neck pain intensity greater than 55/100, presence of neck pain at baseline, presence of headache at baseline, catastrophizing, WAD grade 2 or 3, and no seat belt in use at time of collision. Neck pain intensity, WAD grade, headache, and no postsecondary education were robust to publication bias. CONCLUSIONS: Using a rigorous process for the identification and extraction of data from a homogenous subset of the prognostic WAD literature, we were able to identify several factors for which information is easy to collect clinically and could provide clinicians with a good sense of prognosis following whiplash injury. LEVEL OF EVIDENCE: Prognosis, level 1a.

J Orthop Sports Phys Ther 2009;39(5):334-350, Epub 18 July 2008. doi:10.2519/jospt.2009.2765

KEY WORDS: cervical spine, neck, prognosis, WAD, whiplash-associated disorder

STUDY DESIGN: Single-group repeated-measures study. OBJECTIVE: To examine the test-retest reliability of the timed up and go (TUG) test and its validity for measuring change and predicting length of stay (LOS) on an inpatient orthopaedic rehabilitation ward. BACKGROUND: The TUG test is used to measure functional mobility of persons with musculoskeletal conditions but it has not been thoroughly tested for use in an inpatient orthopaedic rehabilitation ward. METHODS AND MEASURES: The TUG test was administered to 142 patients on admission to an orthopaedic rehabilitation ward 7 to 10 days after admission and on discharge. To test reliability, 24 subjects had these tests repeated 1 day after admission, and the intraclass correlation (ICC) and standard error of measurement (SEM) were calculated. Change scores of the TUG test were evaluated against change scores in pain and function, and the rating of improvement of the patient and therapist. The standardized response mean (SRM) was also calculated. A regression analysis was performed to determine whether the admission TUG test score could predict LOS. RESULTS: The ICC of the TUG test was 0.80 and the SEM was 10.2 seconds. The change in TUG test scores correlated with the changes in pain (r = 0.21, P<.01) and function (r = -0.23, P<.01), and resulted in an SRM of 0.89 for subjects rated as improved. The admission TUG test scores accounted for only 3.4% of the variance in inpatient LOS. CONCLUSION: The TUG test is reliable and valid to assess group change of inpatients on an orthopaedic rehabilitation ward but is not a good predictor of LOS. LEVEL OF EVIDENCE: Prognosis, level 1b.

J Orthop Sports Phys Ther. 2008;38(7):410-417, published online 22 February 2008. doi:10.519/jospt.2008.2657

KEY WORDS:  joint replacement, length of stay, outcome measure, TUG test

Carpal Tunnel Syndrome (CTS) is a pressure-induced neuropathy that causes sensorimotor disturbances of the median nerve, which impair functional ability. A clear history that elicits relevant personal and work exposures and the nature of symptoms can lead to a high probability of a correct diagnosis. Hand diagrams and diagnostic questionnaires are available to provide structure to this process. A variety of provocative tests have been described and have variable accuracy. The Phalen’s wrist flexion and the carpal compression tests have the highest overall accuracy, while Tinel’s nerve percussion test is more specific to axonal damage that may occur as a result of moderate to severe CTS. Sensory evaluation of light touch, vibration, or current perception thresholds can detect early sensory changes, whereas 2-point discrimination changes and thenar atrophy indicate loss of nerve fibers occurring with more severe disease. Electrodiagnosis can encompass a variety of tests and is commonly used to assess the presence/severity of neuropathic changes and to preclude alternative diagnoses that overlap with CTS in presentation. The pathophysiologic changes occurring with different stages of nerve compression must be considered when interpreting diagnostic test results and predicting response to physical therapy management.

J Orthop Sports Phys Ther. 2004;34(10):565-588. doi:10.2519/jospt.2004.1505

Key Words: hand, median nerve, wrist