STUDY DESIGN: Prospective single-cohort study. OBJECTIVES: To determine and document changes in pain and disability in patients with primary, nonacute acromioclavicular joint (ACJ) pain treated with a manual therapy approach. BACKGROUND: To our knowledge, there are no published studies on the physical therapy management of nonacute ACJ pain. Manual physical therapy has been successful in the treatment of other shoulder conditions. METHODS: The chief inclusion criterion was greater than 50% pain relief with an ACJ diagnostic injection. Patients were excluded if they had sustained an ACJ injury within the previous 12 months. Treatment was conducted utilizing a manual physical therapy approach that addressed all associated impairments in the shoulder girdle and cervicothoracic spine. The primary outcome measure was the Shoulder Pain and Disability Index. Secondary measures were the American Shoulder and Elbow Surgeon and global rating of change scales. Outcomes were collected at baseline, 4 weeks, and 6 months. The Shoulder Pain and Disability Index and American Shoulder and Elbow Surgeon scale values were analyzed with a repeated-measures analysis of variance. RESULTS: Thirteen patients (11 male; mean ± SD age, 41.1 ± 9.6 years) completed treatment consisting of an average of 6.4 sessions. Compared to baseline, there was a statistically significant and clinically meaningful improvement for the Shoulder Pain and Disability Index at 4 weeks (P = .001; mean, 25.9 points; 95% confidence interval [CI]: 11.9, 39.8) and 6 months (P<.001; mean, 29.8 points; 95% CI: 16.5, 43.0), and the American Shoulder and Elbow Surgeon scale at 4 weeks (P<.001; mean, 27.9 points; 95% CI: 14.7, 41.1) and 6 months (P<.001; mean, 32.6 points; 95% CI: 21.2, 43.9). CONCLUSION: Statistically significant and clinically meaningful improvements were observed in all outcome measures at 4 weeks and 6 months, following a short series of manual therapy interventions. These results, in a small cohort of patients, suggest the efficacy of this treatment approach but need to be verified by a randomized controlled trial. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2012:42(2):66-80, Epub 25 October 2011. doi:10.2519/jospt.2012.3866

KEY WORDS: distal clavicle excision, manipulation, mobilization, Mumford, shoulder

STUDY DESIGN: Prospective case series. OBJECTIVES: To investigate changes in abdominal muscle thickness with ultrasound imaging, after spinal manipulative therapy (SMT), in a subgroup of patients with low back pain (LBP) who meet a proposed clinical prediction rule for lumbar stabilization exercise (LSE). BACKGROUND: The characteristics of a subgroup of patients with LBP who respond clinically to LSE has been proposed. Although the pathoanatomical characteristics of this subgroup have not been determined, clinicians often assume that this type of LBP is related, in part, to neuromuscular deficits of the lateral abdominal muscles. Recent evidence suggests that SMT may facilitate abdominal muscle activity and, therefore, enhance exercises targeting these deficits. METHODS: Nineteen patients (mean age ± SD, 32.5 ± 7.8 years; 11 female) with LBP, who met the criteria for LSE, underwent ultrasound imaging of the transversus abdominis (TrA) and internal oblique (IO) muscles before, immediately after, and 3 to 4 days after lumbopelvic SMT. Measurements of resting thickness, contracted thickness during the abdominal drawing-in maneuver, and percent thickness change from rest to contraction of the TrA and IO muscles were analyzed with repeated-measures analysis of variance. Numeric pain rating scale and Oswestry Disability Index data were also collected. RESULTS: No significant differences in resting, contracted, or percent thickness change in the TrA or IO were found over the 3 time periods. There were statistically significant reductions in numeric pain rating scale and Oswestry Disability Index scores, but mean differences failed to meet the minimal clinically important difference. CONCLUSION: The results provide preliminary evidence that TrA and IO muscle resting and contracted thicknesses do not change post-SMT in patients with LBP in the LSE subgroup. In addition, while reductions in pain and disability were noted, they were not clinically meaningful.

J Orthop Sports Phys Ther 2011;41(9):666-674, Epub 12 July 2011. doi:10.2519/jospt.2011.3685

KEY WORDS: low back pain, manual therapy, motor control exercise, ultrasound imaging

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

The patient was a 27-year-old woman with an 18-month history of low back pain that was insidious in onset. She worked as a military pilot, and her pain was unresponsive to all nonsurgical measures. Magnetic resonance imaging revealed a L4-5 herniated nucleus pulposus, and 6 months later the patient underwent an L4-5 microdiscectomy. However, due to continued debilitating pain, she was medically removed from flight status and was pending discharge from the military. The patient underwent an L4-5 total disc replacement using the Maverick disc prosthesis. The patient began treatment with a physical therapist 1 month after total disc replacement surgery. At 6 months, 1 year, and 2 years following total disc replacement, Oswestry Disability Index scores were 0%. Additionally, the patient returned to flight status and full recreational activities.

J Orthop Sports Phys Ther 2011;41(3):200. doi:10.2519/jospt.2011.0405

KEY WORDS: digital fluoroscopic video, disc prosthesis, low back pain, magnetic resonance imaging

The patient was a 44-year-old man who reported palmar/ulnar-sided right wrist pain after injuring his wrist while
playing golf. Although pain and function were improved at 6 months following the injury with conservative treatment measures and golfing with a modified grip, the patient was still limited during golf. This prompted the ordering of
additional wrist radiographs, which included a carpal tunnel view, that revealed a fracture at the base of the hook
of the hamate. The patient was referred to an orthopaedic surgeon and underwent a hook of hamate excision, and at 12 weeks following surgery, he had returned to full golfing activities without limitations.

J Orthop Sports Phys Ther 2010;40(5):325. doi:10.2519/jospt.2010.0408

KEY WORDS: carpal tunnel view radiograph, golf, radiographs, wrist

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: Resident's case problem. BACKGROUND: Cauda equina syndrome (CES) is a rare, potentially devastating, disorder and is considered a true neurologic emergency. CES often has a rapid clinical progression, making timely recognition and immediate surgical referral essential. DIAGNOSIS: A 32-year-old male presented to a medical aid station in Iraq with a history of 4 weeks of insidious onset and recent worsening of low back, left buttock, and posterior left thigh pain. He denied symptoms distal to the knee, paresthesias, saddle anesthesia, or bowel and bladder function changes. At the initial examination, the patient was neurologically intact throughout all lumbosacral levels with negative straight-leg raises. He also presented with severely limited lumbar flexion active range of motion, and reduction of symptoms occurred with repeated lumbar extension. At the follow-up visit, 10 days later, he reported a new, sudden onset of saddle anesthesia, constipation, and urinary hesitancy, with physical exam findings of right plantar flexion weakness, absent right ankle reflex, and decreased anal sphincter tone. No advanced medical imaging capabilities were available locally. Due to suspected CES, the patient was medically evacuated to a neurosurgeon and within 48 hours underwent an emergent L4-5 laminectomy/decompression. He returned to full military duty 18 weeks after surgery without back or lower extremity symptoms or neurological deficit. DISCUSSION: This case demonstrates the importance of continual medical screening for physical therapists throughout the patient management cycle. It further demonstrates the importance of immediate referral to surgical specialists when CES is suspected, as rapid intervention offers the best prognosis for recovery. LEVEL OF EVIDENCE: Differential diagnosis, level 4.

J Orthop Sports Phys Ther 2009;39(7):541-549, Epub 24 February 2009. doi: 10.2519/jospt.2009.2999

KEY WORDS: direct access, lumbar spine, low back pain, red flags, spinal cord

J Orthop Sports Phys Ther. 2007;37(10):635-643, published online 29 August 2007. doi: 10.2519/jospt.2007.2532

KEY WORDS: rehabilitative ultrasound imaging, sonography, transfemoral, transtibial, transversus abdominis

Rehabilitative ultrasound imaging (RUSI) of the abdominal muscles is increasingly being used in the management of conditions involving musculoskeletal dysfunctions associated with the abdominal muscles, including certain types of low back and pelvic pain. This commentary provides an overview of current concepts and evidence related to RUSI of the abdominal musculature, including issues addressing the potential role of ultrasound imaging in the assessment and training of these muscles. Both quantitative and qualitative aspects associated with clinical and research applications are considered, as are the possible limitations related to the interpretation of measurements made with RUSI. Research to date has utilized a range of methodological approaches, including different transducer placements and imaging techniques. The pros and cons of the various methods are discussed, and guidelines for future investigations are presented. Potential implications and opportunities for clinical use of RUSI to enhance evidence-based practice are outlined, as are suggestions for future research to further clarify the possible role of RUSI in the evaluation and treatment of abdominal muscular morphology and function.

J Orthop Sports Phys Ther. 2007:37(8):450-466; published online 30 May 2007. doi:10.2519/jospt.2007.2558

KEY WORDS: morphometry, obliquus internus abdominis, rectus abdominis, sonography, transversus abdominis

STUDY DESIGN: Case report. BACKGROUND: The use of spinal manipulation as a treatment to facilitate neuromuscular control of the paraspinal musculature is not well described in the literature. The use of rehabilitative ultrasound imaging (RUSI) may offer a convenient way to investigate and document possible changes occurring in the lumbar multifidus associated with manipulation intervention. CASE DESCRIPTION: The patient was a 33-year-old male with a 21-year history of low back pain and left posterior thigh pain who presented with lumbar hypomobility and met a previously published clinical prediction rule for spinal manipulation. During examination, the patient was asked to perform a prone upper extremity lifting task to assess activation in the lumbar multifidus during an automatic task. Through palpation, the examiner noted a decreased contraction of the left multifidus between L4-S1 compared to the right. To explore this further, a decision was made to assess the multifidus with RUSI, which confirmed the activation deficit noted during palpation. A lumbar regional manipulation was performed with the intention of reducing spinal hypomobility and assessing changes in multifidus activation. Imaging of the multifidus muscles at the L4-5 and L5-S1 levels were obtained premanipulation, immediately postmanipulation, and 1 day after manipulation. OUTCOMES: An increased ability to thicken the multifidus during a prone upper extremity lifting task was noted immediately and 1 day after manipulation. Average percent change in thickness at the L4-5 and L5-S1 levels with the prone arm lift was 3.6% premanipulation, 17.2% immediately postmanipulation, and 20.6% approximately 24 hours postmanipulation. Improvements in the thickening of the multifidus muscle during the upper extremity lifting task were greater than 3 standard errors of the measurement. Other changes included immediate palpable improvement in the contraction of the multifidus during the upper extremity lifting task, along with the patient report of increased ease of lifting. DISCUSSION: In this case report we quantified the short-term influence of spinal manipulation on multifidus muscular activation using RUSI. No cause-and-effect claims can be made; however, the results provide preliminary evidence to suggest that spinal manipulation may influence multifidus muscle function. RUSI offers a convenient way to investigate and document these changes.

J Orthop Sports Phys Ther. 2007;37(10):613-619, published online 29 May 2007. doi:10.2519/jospt.2007.2470