STUDY DESIGN: Prospective cohort study. OBJECTIVES: To characterize knee cartilage change in individuals with knee osteoarthritis (KOA) who have completed a therapeutic exercise program. BACKGROUND: While therapeutic exercise is frequently used successfully to improve pain and function in individuals with KOA, no studies have reported the volume of cartilage change or individual factors that may impact volume of cartilage change in those completing an exercise program for KOA. METHODS: Thirteen individuals with KOA underwent magnetic resonance imaging to quantify cartilage volume change in the weight-bearing regions of the medial and lateral femoral condyles and the entire surface of the tibial plateaus from baseline to 1-year follow-up. Body structure and function measures were taken for body mass index, knee axis alignment, knee motion, and knee strength. Activity limitations and activity levels were also measured prior to the therapeutic exercise program, using the Western Ontario and McMaster Universities Osteoarthritis Index and the Physical Activity Scale for the Elderly. At 6 months from baseline, follow-up clinical measurements of knee strength and motion were performed. At 1 year from baseline, imaging of the knee cartilage and knee alignment were performed, and participants completed the Western Ontario and McMaster Universities Osteoarthritis Index and Physical Activity Scale for the Elderly. RESULTS: The central region of the medial femoral condyle (cMF) had a median volume of cartilage loss of 3.8%. The other 3 knee tibiofemoral articular surfaces had minimal median cartilage volume change. Individuals were dichotomized into progressors (n = 6) and nonprogressors (n = 7), based on the standard error of measurement of cartilage volume change for the cMF. Progressors were younger, had a larger body mass index, had a higher Kellgren-Lawrence grade in the medial compartment of the knee, and had a greater increase in knee varus alignment from baseline to 1-year follow-up. The progressors also had frontal plane hip and knee kinetics during baseline gait analysis that potentially increased medial knee joint loading. CONCLUSION: The loss of cMF cartilage volume was highly variable and the median loss of cartilage was within the range previously reported. Seven of the 13 individuals did not have cMF cartilage volume loss greater than the standard error of measurement. Change in cartilage volume of the cMF may be influenced to a greater extent by personal factors than by completion of a therapeutic exercise program. Additional research is needed to decipher the interactions among therapeutic exercise and personal characteristics that impact knee cartilage loss.

J Orthop Sports Phys Ther 2011;41(10):708-722, Epub September 2011. doi:10.2519/jospt.2011.3633

KEY WORDS: arthritis, biomechanics, magnetic resonance imaging, MRI

STUDY DESIGN: Case report. BACKGROUND: Patellar fracture is a rare but significant complication following anterior cruciate ligament (ACL) reconstruction when using a bone-patellar tendon-bone (BPTB) autograft. The purpose of these case reports is to describe 2 cases in which patellar fracture occurred during rehabilitation after ACL reconstruction using a BPTB. CASE DESCRIPTION: Both patients were 23-year-old males referred for rehabilitation after ACL reconstruction using a BPTB autograft. They were both progressing satisfactorily in rehabilitation until sustaining a fracture of the patella. One fracture occurred during the performance of the eccentric phase of a knee extension exercise during the sixth week of rehabilitation (7 weeks postsurgery), whereas the other fracture occurred during testing of the patientís quadriceps maximum voluntary isometric contraction in the ninth week of rehabilitation (10 weeks postsurgery). Both patients were subsequently treated with open reduction and internal fixation of the patella. DISCUSSION: During rehabilitation following ACL reconstruction using BPTB autograft, clinicians should consider the need to balance the sometimes-competing goals of improving quadriceps strength while providing protection to the healing graft, minimization of patellofemoral pain, and protection of the patellar donor site. LEVEL OF EVIDENCE: Harm, level 4.

J Orthop Sports Phys Ther 2009;39(4):278-286, Epub 15 December 2008. doi:10.2519/jospt.2009.2864

KEY WORDS: ACL, failure, knee, load, strain

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: Randomized clinical trial, single-masked. Objectives: To determine the effectiveness of using a modified neuromuscular electrical stimulation (NMES) training program as an adjunct treatment for improving quadriceps strength and physical function in rehabilitation following anterior cruciate ligament reconstruction (ACLR). Background: NMES training for quadriceps strengthening has previously been shown to be an effective adjunct treatment following ACLR when performed against isometric resistance using a dynamometer with the knee positioned in flexion. We developed a modified version of published NMES protocol because some patients have difficulty tolerating the existing protocol and many clinics may not have instrumented dynamometers. There is a need to determine the effectiveness of this modified protocol. Methods and Measures: Forty-three subjects who had undergone ACLR were randomly assigned to either a group that received (NMES group) or did not receive (comparison group) the NMES treatment in conjunction with their rehabilitation. Group means for quadriceps strength and self-reported measures of knee function were compared after 12 and 16 weeks of rehabilitation. The proportion of subjects in each group achieving clinical criteria to initiate ambulation without crutches, treadmill running, and agility training at selected times during rehabilitation were also compared. Results: The NMES group demonstrated moderately greater quadriceps strength at 12 weeks (effect size, 0.48), and moderately higher levels of self-reported knee function at both 12 (effect size, 0.72) and 16 (effect size, 0.65) weeks of rehabilitation compared to the comparison group. A greater proportion of subjects in the NMES group achieved clinical criteria for advancing to agility training at 16 weeks. Conclusions: The modified NMES quadriceps training protocol can be a useful adjunct to ACLR rehabilitation programs, but the treatment effect is smaller than what has been reported in previous studies.

J Orthop Sports Phys Ther. 2003;33(9):492-501.

Key Words: ACL, clinical trial, knee, strengthening, training

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

Study Design: Case series. Objective: To describe the management of 7 patients with grade 1 cervical compressive myelopathy attributed to herniated disc using intermittent cervical traction and manipulation of the thoracic spine. Background: Intermittent cervical traction has been indicated for the treatment of patients with herniated disc and has been suggested to be helpful for patients with cervical compressive myelopathy. Manipulation of the thoracic spine has been utilized to safely improve active range of motion and decrease pain in patients with neck pain. Methods and Measures: Seven women with neck pain, 35 to 45 years of age, were identified as having signs and symptoms consistent with grade 1 cervical compressive myelopathy. Symptom duration ranged from less than 1 week to 52 weeks. All patients were treated with intermittent cervical traction and thoracic manipulation for a median of 9 sessions (range, 2-12 sessions) over a median of 56 days (range, 14-146 days). Numeric Pain Rating Scale and Functional Rating Index scores served as the primary outcome measures. Results: The median decrease in pain scores was 5 (range, 2-8) from a baseline of 6 (range, 4-8), and median improvement in Functional Rating Index scores was 26% (range, 10%-50%) from a baseline of 44% (range, 35%-71%). Dizziness was eliminated in 3 out of 4 patients and chronic headache symptoms were improved in 3 out of 3 patients. There were no adverse events or outcomes. Conclusions: Intermittent cervical traction and manipulation of the thoracic spine seem useful for the reduction of pain scores and level of disability in patients with mild cervical compressive myelopathy attributed to herniated disc. A thorough neurological screening exam is recommended prior to mechanical treatment of the cervical spine.

J Orthop Sports Phys Ther. 2004;34(11):701-712. doi:10.2519/jospt.2004.1519

Key Words: conservative, Hoffmann’s reflex, mechanical traction, spinal cord impingement, upper motor neuron

Cervical radiculopathy (CR) is a problem that is frequently encountered by physical therapists. The incidence of CR in the fifth decade of life is 2.03%, approximately 3 times more prevalent than in other age groups. Radiculopathy is defined as any diseased condition of spinal nerve roots. Cervical radiculopathy, or disease to the nerve roots in the cervical spine, is manifested primarily by unilateral motor and sensory symptoms into the upper limb, muscle weakness, sensory alteration, and reflex hypoactivity. Generally, onset of CR is insidious and the most common causes are cervical disc lesions and osteophytic encroachment, which results in nerve root or spinal nerve impingement or inflammation. The purpose of this resident's case problem is to demonstrate the dynamics of the diagnostic process in determining the appropriate treatment for a patient with CR. Treatment selection and progression will use the treatment algorithm proposed by Erhard, combined with the information from history, physical examination findings, and the patient's response to treatment interventions during the course of rehabilitation.

J Orthop Sports Phys Ther. 2000;30(12):745-754.

Key words: cervical spine, nerve roots, rehabilitation

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

Study Design: Resident’s case problem. Background: The signs and symptoms of cervical radiculopathy (CR) warrant the consideration of several other conditions in CR’s differential diagnosis. One condition that may mimic CR, which is not well known among physical therapists, is Parsonage-Turner syndrome (PTS). PTS is characterized by an onset of intense pain that typically subsides within days to weeks. However, as pain subsides, weakness and/or paralysis may develop in upper extremity muscles. The purpose of this resident’s case problem is to describe a patient who presented to our clinic with a diagnosis of CR, but had findings consistent with PTS. Diagnosis: The patient was a 43-year-old male referred to physical therapy with a diagnosis of CR. He had a previous episode of CR 1 year ago that was treated successfully. He had positive magnetic resonance imaging findings of structural abnormalities suggestive of causative factors for CR. The patient was treated for CR with thoracic and cervical spine manipulations and intermittent cervical traction. The initial acute severe pain subsided, but weakness in the upper extremity worsened. Diagnosis of PTS was made upon exclusion of other potential confounding diagnoses and the findings of fibrillation potentials and positive waves in electrodiagnostic studies. Discussion: CR and PTS are characterized by pain in the cervical spine, shoulder, and upper extremity. CR generally has an insidious onset, while PTS has a rapid onset of intense pain. Symptoms of CR are exacerbated with neck movements, while symptoms related to PTS should not be exacerbated with neck movements. In patients that do not respond to conventional therapy and have a progression of upper extremity muscle weakness, regardless of decreased pain, the diagnosis of PTS should be considered.

J Orthop Sports Phys Ther. 2005;35(10):659-664. doi:10.2519/jospt.2005.2075

Key Words: cervical spine, neck, nerve, upper extremity

Study Design: Case control design. Objectives: To investigate whether differences exist in lower extremity muscle strength and soft tissue length between patients with patellofemoral pain syndrome (PFPS) and age- and gender-matched control subjects. Background: Based on our clinical experience and emerging data, impairments such as muscular weakness surrounding the hip and limited flexibility of key lower extremity muscles may be important impairments to consider in the conservative management of PFPS. Methods and Measures: Thirty patients with PFPS and 30 age- and gender-matched controls without PFPS (17 females and 13 males in each group) participated in the study. Data were collected during 1 testing session by an examiner not blinded to group assignment. Demographic, health history, physical activity levels, and pain and function were assessed using patient-completed measures. Physical examination measures included assessment of hip external rotation strength, hip abduction strength, length of the iliotibial band/tensor fascia lata complex, gastrocnemius length, soleus length, and quadriceps and hamstrings muscles length. Results: Patients with PFPS demonstrated significantly less flexibility of the gastrocnemius, soleus, quadriceps, and hamstrings compared to healthy control subjects. No differences existed in flexibility of the iliotibial band/tensor fascia lata complex and strength of the hip external rotators and abductors. Multivariate stepwise discriminant analysis identified gastrocnemius length, hip abduction strength, and soleus length as being able to distinguish between patients with PFPS and healthy individuals without PFPS. Conclusion: This study suggests that further research is warranted regarding the association of these impairments of muscle strength and soft tissue length in patients with PFPS.

J Orthop Sports Phys Ther. 2005;35(12):793-801. doi:10.2519/jospt.2005.2026

Key Words: ankle plantar flexors, anterior knee pain, case control, hip abduction, hip external rotation

J Ortho Sports Phys Ther. 2003;33(1):4-20.

Keywords: bias, decision making, evidence, grading, methodology