STUDY DESIGN: Observational, cross-sectional reliability study. OBJECTIVES: To examine the interrater reliability of novice raters in their use of the treatment-based classification (TBC) system for low back pain and to explore the patterns of disagreement in classification errors. BACKGROUND: Although the interrater reliability of individual test items in the TBC system is moderate to good, some error persists in classification decision making. Understanding which classification errors are common could direct further refinement of the TBC system. METHODS: Using previously recorded patient data (n = 24), 12 novice raters classified patients according to the TBC schema. These classification results were combined with those of 7 other raters, allowing examination of the overall agreement using the kappa statistic, as well as agreement/disagreement among pairwise comparisons in classification assignments. A chi-square test examined differences in percent agreement between the novice and more experienced raters and differences in classification distributions between these 2 groups of raters. RESULTS: Among 12 novice raters, there was 80.9% agreement in the pairs of classification (κ = 0.62; 95% confidence interval: 0.59, 0.65) and an overall 75.5% agreement (κ = 0.57; 95% confidence interval: 0.55, 0.69) for the combined data set. Raters were least likely to agree on a classification of stabilization (77.5% agreement). The overall percentage of pairwise classification judgments that disagreed was 24.5%, with the most common disagreement being between manipulation and stabilization (11.0%), followed by a mismatch between stabilization and specific exercise (8.2%). CONCLUSION: Additional refinement is needed to reduce rater disagreement that persists in the TBC decision-making algorithm, particularly in the stabilization category.

J Orthop Sports Phys Ther 2012;42(9):797-805, Epub 7 June 2012. doi:10.2519/jospt.2012.4078

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

Musculoskeletal conditions are important contributors to United States healthcare spending and are certain to play an important role in the future as the population continues to age. Almost half of the population of the United States experiences a musculoskeletal condition annually. Meeting the needs of these individuals within a changing healthcare delivery and reimbursement environment prompted a recent Summit sponsored by the United States Bone and Joint Initiative (USBJI). The Summit dealt with a topic critical to the future of healthcare for clinicians, consumers, and payers alike: value. We do not operate within a value-based healthcare system. Our current delivery system continues to reward volumes, not value. Failure to focus on value has had devastating consequences. The challenge of shifting from a volume-based to a value-based system is central to the future of healthcare. Discussion and action will be critical for the physical therapy profession moving into the future.

J Orthop Sports Phys Ther 2012;42(1):1-2. doi:10.2519/jospt.2012.0101

KEY WORDS: cost, musculoskeletal conditions, outcomes, United States healthcare

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

The availability of population-based survey data provides a unique opportunity to understand issues related to access and utilization of physical therapy in the United States, and to better gauge public perceptions of the profession. In our day-to-day routine, we all tend to consider our work as physical therapists on a one-to-one level with the patients we serve. Examining data from national population-based surveys can elevate our daily, ground-level viewpoint to a 30 000-foot perspective on the profession. This vantage point allows certain things to come into focus that would otherwise be obscured, and the vision may not always comport with our expectations.

J Orthop Sports Phys Ther 2011;41(7):465-466. doi:10.2519/jospt.2011.0105

KEY WORDS: physical therapy, population-based survey

STUDY DESIGN: Prospective case series. OBJECTIVE: To examine the relation between improved disability and changes in abdominal and lumbar multifidus (LM) thickness using ultrasound imaging following spinal manipulative therapy (SMT) in patients with low back pain (LBP). BACKGROUND: Although there is a growing body of literature demonstrating physiologic effects following the application of SMT, few studies have attempted to correlate these changes with clinically relevant outcomes. METHODS: Eighty-one participants with LBP underwent 2 thrust SMT treatments and 3 assessment sessions within 1 week. Transversus abdominis (TrA), internal oblique (IO), and LM muscle thickness was assessed during each session, using ultrasound imaging of the muscles at rest and during submaximal contractions. The Modified Oswestry Disability Index was used to quantify participants’ improvement in LBP-related disability. Stepwise hierarchical multiple linear regression and repeated-measures analysis of variance were performed to examine the multivariate relationship between change in muscle thickness and clinical improvement over time. RESULTS: After controlling for the effects of age, sex, and body mass index, change in contracted LM muscle thickness was predictive of improved disability at 1 week (P = .02). As expected, larger increases in contracted LM muscle thickness at 1 week were associated with larger improvements in LBP-related disability. Contrary to our hypothesis, significant decreases in both contracted TrA and IO muscle thickness were observed immediately following SMT; but these changes were transient and unrelated to whether participants experienced clinical improvements. CONCLUSION: These findings provide evidence that clinical improvement following SMT is associated with increased thickening of the LM muscle during a submaximal task. LEVEL OF EVIDENCE: Prognosis, level 4.

J Orthop Sports Phys Ther 2011;41(6):389-399, Epub 6 April 2011. doi:10.2519/jospt.2011.3632

KEY WORDS: low back pain, muscle contraction, transversus abdominis, ultrasound

STUDY DESIGN: A case report and literature review. BACKGROUND: Optimizing clinical outcomes following lumbar disc surgery is a research priority; however, relatively little attention has been paid to the postoperative management of this population. The transversus abdominis and lumbar multifidus (LM) muscles appear to play a unique role in lumbar spine stability, and may relate to clinical outcome following lumbar disc surgery. The purpose of this case report was to describe the preoperative LM morphology, clinical outcome, and change in transversus abdominis and LM muscle activation in a patient following lumbar disc surgery and motor control exercise initiated in the early postoperative period. CASE DESCRIPTION: A 29-year-old female underwent an 8-week postoperative rehabilitation program emphasizing motor control exercises to restore trunk muscle function 10 days following lumbar disc surgery. OUTCOMES: The patient experienced clinically important improvements in pain and disability following the postoperative rehabilitation program. Substantial improvements in muscle activation were observed of the transversus abdominis and the LM at the L4-5 level. Minimal change in LM activation and a higher proportion of intramuscular fat was observed at the L5-S1 level. DISCUSSION: This case report represents limited evidence regarding the feasibility of instituting a rehabilitation program in the early postoperative period following lumbar disc surgery. Improvements in clinical status and muscle function were observed, and a differential change in muscle activation between the L4-5 and L5-S1 levels was noted. The literature regarding rehabilitation following lumbar disc surgery, as well as the neuromuscular changes observed in this population, was reviewed. Additionally, a novel method of examining LM morphology was described and suggestions were made for directions of future research. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2010;40(7):402-412, Epub 12 April 2010. doi:10.2519/jospt.2010.3332

KEY WORDS: adipose, discectomy, exercise therapy, rehabilitation, skeletal muscle, ultrasonography

STUDY DESIGN: Clinical measurement, reliability study. OBJECTIVES: To investigate the improvements in precision when averaging multiple measurements of percent change in muscle thickness of the transversus abdominis (TrA) and lumbar multifidus (LM) muscles. BACKGROUND: Although the reliability of TrA and LM muscle thickness measurements using rehabilitative ultrasound imaging (RUSI) is good, measurement error is often large relative to mean muscle thickness. Additionally, percent thickness change measures incorporate measurement error from both resting and contracted conditions. METHODS: Thirty volunteers with nonspecific low back pain participated. Thickness measurements of the TrA and LM muscles were obtained using RUSI at rest and during standardized tasks. Percent thickness change was calculated with the formula (thickness_contracted – thickness_rest/thickness_rest). Standard error of measurement (SEM) quantified precision when using 1 or a mean of 2 to 6 consecutive measurements. RESULTS: Compared to when using a singlemeasurement, SEM of both the TrA and LM decreased by nearly 25% when using a mean of 2 measures, and by 50% when using the mean of 3 measures. Little precision was gained by averaging more than 3 measurements. CONCLUSION: When using RUSI to determine percent change in TrA and LM muscle thickness, intraexaminer measurement precision appears to be optimized by using an average of 3 consecutive measurements.

J Orthop Sport Phys Ther 2009;39(8):604-611 Epub 24 June 2009. doi:10.2519/jospt.2009.3088

KEY WORDS: abdominal muscles, lumbar spine, reliability, ultrasonography

Clinical prediction rules (CPRs) are tools designed to aid in clinical decision making by statistically combining clinical findings to improve the accuracy of diagnosis, prognosis, or prediction of response to treatment for individual patients. In physical therapy the majority of CPR-related research has focused on prediction of treatment response. An appeal of CPRs is their potential to make the process of subgrouping patients more evidence based and less reliant on unfounded theories and tradition. The development of CPRs, however, may not be the best solution in every situation. If physical therapy care for a condition is characterized by complex decision making, with a variety of potential options for different subgroups of patients, a CPR may be extremely valuable for improving care. For clinical conditions with less heterogeneity, different strategies, such as randomized clinical trials or quality-improvement studies, may be more effective.

J Orthop Sports Phys Ther 2009;39(3):159-161. doi:10.2519/jospt.2009.0110

KEY WORDS: CPRs, evidence-based, heterogeneous, homogenous, subgrouping 

Twenty subjects participated in a 4-week training period, and 18 subjects served as controls. For the experimental group, a repeated measure ANOVA comparing pretest and posttest values revealed significant improvements in the leg press (p≤.05), step-ups (p≤.05), hop for distance (p≤.05), and hop for time (p≤.05) and no significant increase in isokinetic quadriceps peak torque (p≥.05). Over the course of the training period, weight used for the step-up exercise increased (p≤.05), repetitions decreased (p≤.05), and step-up work did not change (p≥.05). For the control group, no significant change (p≥.05) occurred in any variable.

The inability of the isokinetic dynamometer to detect increases in quadriceps performance is important because the isokinetic values are frequently used as criteria for return to functional activities. We conclude that closed kinetic chain testing and exercise provide additional means to assess and rehabilitate the lower extremity.

J Orthop Sports Phys Ther. 1993;18(6):646-653.

Key Words: hop tests, lateral step-up, muscle strength

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

Growing evidence suggests that spinal manipulation is effective in the management of low back pain (LBP). However, in the absence of evidence of an alternative approach, clinicians have primarily relied on diagnostic tests with questionable reliability and validity in the clinical decision-making process to identify potential candidates for spinal manipulation. These 2 cases highlight the use of a clinical prediction rule (CPR) developed by Flynn et al, which demonstrates that there are a few simple criteria from the history and physical examination that can be used to help clinicians decide if spinal manipulation and a range of motion (ROM) exercise may be helpful in the management of a patient with LBP. Importantly, these results provide clinicians with an easy-to-use procedure to accurately identify patients with LBP who are likely to achieve a dramatic improvement prior to treatment.

We believe this CPR offers clinicians an efficient and practical evidence-based tool that can be applied by even the novice physical therapist who is familiar with the CPR and the technique that was used in its development. This CPR should encourage clinicians who were previously reluctant to incorporate spinal manipulation into their clinical practice to use it more frequently based on a patient’s status with respect to the CPR.

J Orthop Sports Phys Ther. 2003;33(5):259-272.

Key Words: low back pain, spinal manipulation, clinical prediction rule

Study Design: A retrospective, cohort study of children and adolescents with low back pain (LBP) referred to physical therapy. Objectives: To describe the clinical presentation, examination findings, and classification of children and adolescent patients with LBP, and to explore the concurrent validity of the Oswestry questionnaire as a disability measure in this group. Background: Little information is available regarding the clinical presentation, physical examination findings, and outcome assessment in children and adolescents with LBP. Methods and Measures: Charts were reviewed for historical, diagnostic, physical examination, and outcome information. Diagnoses given by the referring physicians were recorded. A treatment-based classification was made for each subject. Descriptive statistics were calculated for all variables. The validity of the Oswestry questionnaire was examined. Results: The children and adolescents included in this study represented 5% (n = 25) of all cases of LBP referred to physical therapy. A greater percentage of patients had difficulty with extension than with flexion range of motion (ROM). Initial pain scores were lower if a specific pathology was present (P = .001). Initial pain and Oswestry scores were poorly correlated (r = 0.16). Forty-four percent (n = 11) of patients scored under the floor value of 12% on the Oswestry. Conclusion: The referral rate of children and adolescents with LBP seems to be low. Compared to adults, children and adolescents appear more likely to have a specific diagnosis given to them by their physician. The physical examination findings appear to indicate that spinal stabilization approaches may be beneficial for many patients. The Oswestry questionnaire may not be a valid tool for documenting changes in disability in these patients. Further research is needed on the conservative management of children and adolescents with LBP.

J Orthop Sports Phys Ther. 2003;33(9):513-522.

Key Words: clinical presentation, low back pain, lumbar spine, Oswestry, retrospective study

Study Design: A prospective methodological interrater reliability study. Objectives: To calculate the interrater reliability among clinicians newly trained in a classification system for acute low back pain and to determine the level of agreement at key junctures within the classification algorithm. Background: The utility of a classification system for patients with low back pain depends on its reliability and generalizability. To be practical, clinicians must be able to apply the system after a reasonable amount of training. Identifying key points in the classification algorithm where disagreement occurs can lead to better operational definitions. Methods: Four physical therapists read an article and attended a 1-day training session in the classification system. Randomly paired therapists classified patients referred for treatment of acute low back pain and noted decisions at key junctures in the system algorithm. Results: Forty-five patients were classified. Repeated examinations did not increase the patient’s pain (P>.05). For 3 out of the 4 therapists, the interrater reliability showed a kappa value of 0.45. The fourth therapist, excluded from the overall analysis, exhibited a bias towards the immobilization classification. Among the 3 therapists, major disagreement occurred with the determination of symmetry with trunk side bending and the effects of repeated movements. Conclusions: Three out of 4 clinicians newly trained in the system showed moderate reliability. The reliability was slight when the fourth therapist was included. Refinement of the operational definitions and criteria for determining lumbar capsular patterns are needed. One day of training is probably not adequate for all therapists, especially for those biased towards specific low back pain syndromes.

J Orthop Sports Phys Ther. 2004;34(8):430-439. doi:10.2519/jospt.2004.1555

Key Words: examination, evaluation, low back syndrome, lumbar spine, rehabilitation

Study Design: Secondary analysis of a randomized trial. Objectives: To examine the influence of experience and specialty certification on outcomes for patients with low back pain receiving a standardized manipulation or stabilization exercise intervention program. Background: Little research has examined the impact of therapist-related factors on the outcomes of clinical care for patients with low back pain. It is assumed that therapists with more clinical experience or specialty certification will achieve better clinical outcomes; however, few studies have examined this hypothesis. Methods and Measures:One hundred thirty-one participants in a randomized trial were included (70 randomized to receive manipulation, 61 stabilization). All subjects completed an Oswestry Disability Questionnaire at baseline, and after 1 and 4 weeks of treatment. Therapists were categorized based on total years of experience, years of experience with manual therapy, and specialty certification status. Two-way repeated-measures analyses of covariance were performed within each intervention group to examine the effects of the therapist characteristics on outcomes. Hierarchical linear regression models were used to examine the relative effects of therapist characteristics and intervention on clinical outcomes. Results: Thirteen therapists participated (average 6.0 years of experience [standard deviation, 4.0], 4 (30.8%) with specialty certification). A significant interaction between time and specialty certification status (P = .04) was detected for subjects receiving the manipulation intervention. No significant interactions were detected in the stabilization group. The regression models found that the intervention group significantly contributed to explaining clinical outcomes, but that therapist characteristics did not. Conclusions: With the standardized protocol utilized in this study, it appears that the therapist-related factors of increased experience and specialty certification status do not result in an improvement in patients’ disability associated with low back pain.

Invited Commentary by Linda Resnik 

J Orthop Sports Phys Ther. 2004;34(11):662-675. doi:10.2519/jospt.2004.1535

Key Words: experience, expertise, low back pain manipulation, stabilization

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

It is likely that patients with neck pain are not a homogeneous group, but, instead, consist of a variety of subgroups, each of which may benefit from a specific intervention matched to the patient’s signs and symptoms. Studies to date have largely failed to account for this possibility, which may compromise the statistical power of research and ultimately fail to provide guidance for clinical decision making. Classification provides a means of breaking down a larger entity into more homogeneous subgroups of patients, based on examination data. Classification can guide the determination of a patient’s prognosis, and the selection of the most appropriate intervention strategy. Classification has received considerable attention in the management of patients with low back pain, and evidence is emerging regarding its benefits. There has been considerably less effort made toward examining classification as it pertains to patients with neck pain. The purpose of this clinical commentary is to examine the current literature and to propose a classification system for patients with neck pain, based on the overall goal of treatment. The approach is based on published evidence when possible and is also informed by clinical experience and expert opinion. Classification decisions are based on the integration of data from a variety of information from the history and physical examination. The end result of the classification process is to determine the treatment approach believed to be most likely to maximize the clinical outcome for an individual patient with neck pain.

Invited Commentary by Michele Sterling

J Orthop Sports Phys Ther. 2004;34(11):686-700. doi:10.2519/jospt.2004.1451

Key Words: conservative treatment, decision making, diagnosis, neck pain, staging

Growing evidence supports the effectiveness of manual therapy interventions in patients with neck pain; however, considerable attention has also been afforded to the potential risks, such as vertebrobasilar insufficiency (VBI). Despite the existence of guidelines advocating specific screening procedures, research does not support the ability to accurately identify patients at risk. The logical question becomes, ‘‘How does one proceed in the absence of certainty?’’ Given the lack of clear direction for decision making in the peer-reviewed literature, this commentary discusses the uncertainties that exist regarding the ability to identify patients at risk for VBI. The authors hope that this commentary adds additional perspective on manual therapy decision-making strategies in the presence of uncertainty.

J Orthop Sports Phys Ther. 2005;35(5):300-306. doi:10.2519/jospt.2005.1312

Key Words: cervical spine, diagnostic accuracy, manipulation, mobilization, vertebral artery

This issue of the JOSPT is the second of 2 dedicated to the topic of direct access physical therapy. Achieving direct access is an important component of the Vision 2020 statement set forth by the American Physical Therapy Association.1 This aspect of Vision 2020 is coming to fruition, with the majority of states now permitting direct access to physical therapists. Other related concepts promoted within Vision 2020 are professionalism and autonomy. Vision 2020 promotes the goal that physical therapists will ‘‘hold all privileges of autonomous practice,'' with autonomous practice defined as ‘‘independent, self-determined, professional judgment and action.'' Measuring the achievement of direct access is relatively straightforward. We may simply tally the number of states whose practice acts permit such access. Gauging our advance toward the goals of autonomy or professionalism is more difficult. The first step in analyzing our progress is to define our target so that we might be aware of where we are headed and recognize the destination once we arrive.

J Orthop Sports Phys Ther. 2005; 35(11):696-698. doi:10.2519/jospt.2005.0111

Key Words: direct access physical therapy

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

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

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

Treatment of meniscal injuries in the knee has evolved over the past 3 decades. New research regarding the functional roles of the menisci has increased emphasis on the preservation of meniscal tissue. Meniscal transplantation has developed as a surgical technique for individuals whose menisci have been compromised through trauma or previous meniscectomy. The purpose of this article is to review the current literature regarding meniscal function, the deleterious effects of meniscectomy, and the development of transplantation of allograft menisci as a surgical technique. A case study of a 28-year-old male undergoing medial meniscus transplantation is presented, with emphasis on the development of postoperative rehabilitation guidelines.

J Orthop Sports Phys Ther. 1996;24(2):98-106.

Key Words: meniscus, transplantation, rehabilitation

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

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

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

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

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

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

Study Design: Secondary analysis of pooled data from 3 randomized trials. Objective: This study investigated sex differences in response to physical therapy intervention for acute low back pain. Background: Sex differences in experimental pain sensitivity have been consistently described in the literature. However, clinical consequences of these sex differences have not been widely reported. Methods and Measures: Subjects (n = 165) were participants in 3 randomized trials of physical therapy interventions from outpatient physical therapy clinics in the general and military communities. Subjects were randomly assigned spinal manipulation with range-of-motion exercise, lumbar stabilization exercise, or directional-preference exercise. Outcomes were measured at 4 weeks through self-report of pain intensity and pain-related disability. Sex differences were investigated with independent t tests (baseline data), 2 x 3 analysis of variance (4-week reductions in pain and pain-related disability), and regression models (predictors of outcome). Results: Men and women had similar reductions of pain intensity (raw mean difference, 0.5; 95% CI, -1.4 to 0.4) and pain-related disability (raw mean difference, 5.3; 95% CI, -0.1 to 10.7) over 4 weeks. Baseline pain intensity, duration of symptoms, and baseline pain-related disability significantly predicted change in pain intensity for women (r² = 26%, P<.01). Baseline pain intensity and stabilization exercise predicted change in pain intensity for men (r² = 33%; P<.01). Baseline pain-related disability, duration of pain, and pain intensity predicted change in disability for women (r² = 24%, P<.01). Baseline pain-related disability, fear-avoidance beliefs, stabilization exercise, and leg pain predicted change in disability for men (r² = 32%, P<.01). Conclusion: For patients with acute low back pain, men and women had similar physical therapy outcomes for reductions in pain intensity and pain-related disability. However, men and women had different factors that predicted treatment outcome.

J Orthop Sports Phys Ther. 2006; 36(6):354-363. doi:10.2519/jospt.2006.2270

Key Words: acute pain, gender differences, lumbar spine, rehabilitation, treatment response

Spinal manipulation for low back complaints is an intervention supported by randomized clinical trials and its use recommended by clinical practice guidelines. Physical therapists in this country and internationally have used thrust spinal manipulation at much lower-than-expected rates, despite evidence supporting its efficacy for the treatment of acute low back pain (LBP). The purpose of this clinical commentary is to describe a physical therapist professional degree curriculum in thrust spinal manipulation and outline a method of monitoring ongoing student performance during the clinical education experience.

Increased emphasis on evidence-based decision making and on the psychomotor skills of thrust spinal manipulation was introduced into a physical therapist professional degree curriculum. As part of ongoing student performance monitoring, physical therapy students on their first full-time (8-week) clinical education experience, collected practice pattern and outcome data on individuals with low back complaints. Eight of 18 first-year students were in outpatient musculoskeletal clinical settings and managed 61 individuals with low back complaints. Patients were seen for an average (±SD) of 6.2 ± 4.0 visits. Upon initial visit, the student therapists employed spinal manipulation at a rate of 36.2% and spinal mobilization at 58.6%. At the final visit, utilization of manipulation and mobilization decreased (13% and 37.8%, respectively), while the utilization of exercise interventions increased, with 75% of patients receiving some form of lumbar stabilization training.

Physical therapist students used thrust spinal manipulation at rates that are more consistent with clinical practice guidelines and substantially higher then previously reported by practicing physical therapists. Education within an evidence-based framework is thought to contribute to practice behaviors and outcomes that are more consistent with best practice guidelines.

J Orthop Sports Phys Ther. 2006;36(8):577-587. doi:10.2519/jospt.2006.2159

Key Words: curriculum, low back pain, outcomes, physical therapy education, spinal manipulation