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

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

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

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

The diagnosis and nonoperative management of hip disorders are important clinical issues. Physical therapists can provide an alternative to surgical and pharmacological solutions for patients with lower quarter musculoskeletal complaints with noninvasive, low-risk interventions that are effective for reducing pain and disability. These interventions have none of the health risks associated with medications, surgery, and other invasive treatment options. Although effective low-risk physical therapy interventions exist for these patients, the real question is whether patients know about physical therapy and whether they are afforded an opportunity to access this type of care. Equally important is whether we physical therapists are adequately delivering it.

J Orthop Sports Phys Ther. 2007;37(9):511-513. doi:10.2519/jospt.2007.0108

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

Study Design: One group pretest-posttest exploratory design. Objectives: Primary purposes of this study were to examine the short-term effect of hip mobilizations on pain and range of motion (ROM) measurements in patients with knee osteoarthritis (OA) and to determine the prevalence of painful hip and squat test findings in both patients with knee OA and asymptomatic subjects. The secondary purposes were to assess intrarater reliability and to determine whether fewer subjects experienced painful test findings following hip mobilization. Background: Conservative intervention, including manual physical therapy applied to the lower extremity, has been shown to reduce impairments associated with knee OA. Methods and Measures: One rater pair administered 4 clinical hip tests to 22 patients with knee OA (mean age, 61.2 years; SD, 6.1 years) and 17 subjects without lower extremity symptoms or known pathology (mean age, 64.0 years; SD, 7.9 years). Intrarater reliability was examined for each clinical test. Patients with knee OA and painful-hip and squat test findings received hip mobilizations. Pain and ROM responses for each test were dependent variables. Results: Intraclass correlation coefficients for all tests were greater than 0.87. Composite and individual test pain scores and ROM scores improved significantly following hip mobilization. All clinical test findings were more frequent in the group with knee OA, except for those of the FABER test, and the number of subjects with painful test findings following hip mobilization was reduced for all tests except the hip flexion test. Conclusions: Patients experienced increases in ROM, decreased pain, and fewer subjects had painful test findings immediately following a single session of hip mobilizations. Examination and intervention of the hip may be indicated in patients with knee OA.

J Orthop Sports Phys Ther. 2004;34(11):676-685. doi:10.2519/jospt.2004.1432

The original article was corrected in September 2007, and the amended article PDF is provided here. Please see Correction: Altman's criteria for osteoarthritis of the hip and knee. J Orthop Sports Phys Ther. 2007; 37(9):573.

Key Words: arthritis, lower extremity, manual therapy, provocation

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

We are excited to introduce 2 special issues in the Journal that feature articles relevant to direct access physical therapist practice. The rationale for covering these topics in the physical therapy literature is clear: the American Physical Therapy Association's (APTA's) Vision 2020 states that, ‘‘By 2020, physical therapy will be provided by physical therapists who are doctors of physical therapy, recognized by consumers and other health care professionals as the practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, functional limitations, and disabilities related to movement, function, and health.'' To achieve this goal, APTA's Board of Directors suggests that we should focus our efforts on 5 key areas: professionalism, direct access, the doctor of physical therapy, evidence-based practice, and practitioner of choice. Because a majority of first professional degree programs have now transitioned to the professional doctoral degree and physical therapists can provide direct access care in 39 states, it is clear that we are quickly moving toward the Vision 2020. However, it would be helpful to reflect on where we are as a profession and what it is, exactly, that we want in our journey toward the goals set forth by our national organization.

J Orthop Sports Phys Ther. 2005; 35(10):624-627. doi:10.2519/jospt.2005.0110

Key Words: direct access, physical therapy practice

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

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

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

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

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

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

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

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

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

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

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

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