STUDY DESIGN: Prospective cohort study. OBJECTIVE: To derive a preliminary clinical prediction rule for identifying a sub-group of patients with low back pain (LBP) likely to benefit from Pilates-based exercise. BACKGROUND:  Pilates-based exercise has been shown to be effective for patients with LBP, however no work has previously been done to characterize patient attributes for those most likely to have a successful outcome from treatment. METHODS: Ninety six individuals with non-specific low back pain participated in the study.  Treatment response was categorized based on changes in the Oswestry Disability Questionnaire (ODQ) scores after 8 weeks. An improvement of 50% or greater was categorized as achieving a successful outcome.  Thirty seven variables measured at baseline were analyzed with univariate and multivariate methods to derive a clinical prediction rule for successful outcome with Pilates exercise.  Accuracy statistics, Receiver Operator Curves (ROC), and regression analyses were used to determine the association between standardized examination variables and treatment response status. RESULTS:  Ninety five of the 96 participants completed the study, with 51 (53.7%) achieving a successful outcome. A preliminary clinical prediction rule with 5 variables was identified: total trunk flexion ROM of 70 degrees or less, duration of current symptoms of 6 months or less, no leg symptoms in the last week, body mass Index (BMI) of 25 or greater, and left or right hip average  rotation of 25 degrees or greater.  If 3 or more of the 5 attributes were present (positive likelihood ratio 10.64), the probability of experiencing a successful outcome increased from 54% to 93%. CONCLUSION: These data provide preliminary evidence to suggest that the response to Pilates -based exercise in patients with LBP can be predicted from variables collected from the clinical examination. If subsequently validated in a randomized clinical trial, this prediction rule may be useful to improve clinical decision-making in determining which patients are most likely to benefit from Pilates-based exercise.

J Orthop Sports Phys Ther, Epub 25 January 2012. doi:10.2519/jospt.2012.3826

KEY WORDS: classification, low back pain, Pilates-based exercise

Prior to the era of evidence-based practice, a common approach taught in entry-level physical therapy programs was relatively simplistic: (1) learn how to administer a clinical diagnostic test; (2) learn the result considered "positive" and the result considered "negative"; (3) conclude that a patient with a positive test result would likely have the target condition and a patient with a negative test result would not. Much has changed in the last 15 years. We have seen a significant shift in the way evidence is used to make clinical decisions about physical therapy interventions. However, despite these gains, more attention is needed to improve our understanding of the accuracy of commonly used diagnostic tests. Only in this way can we properly integrate evidence for diagnostic accuracy of clinical tests into our practice and truly consider ourselves as evidence-based practitioners.

J Orthop Sports Phys Ther 2010;40(10):603-605. doi:10.2519/jospt.2010.0108

KEY WORDS: diagnostic tests, evidence-based practice

Although tape measurement of thigh girth is a common component of a clinical knee examination, the implications of thigh girth asymmetry are not well understood. The purpose of this study was to examine the relationship between thigh girth asymmetry and torque asymmetry for extension and flexion of the knee.

Thirty subjects with thigh girth asymmetry of at least 2 cm, measured at a site 15 cm proximal to the superior pole of the patella, were studied. Subjects were measured for girth at 10 sites along each thigh. Knee flexion and extension torque production were also tested on a Cybex II isokinetic dynamometer. Girth asymmetry was determined by the difference in measurements between the subjects' smaller and larger thighs. Percent girth asymmetries varied by site, with the greatest average girth asymmetry (asymmetry = 5.94%) at 16 cm proximal to the superior patellar pole. Percent peak torque asymmetries were computed from the differences between subjects' stronger versus weaker thighs.

Correlations and regressions of both extension and flexion torque asymmetries upon girth asymmetry sites showed higher associations and less error for more proximal measurements. Fair to moderate correlation coefficients (r = .37-.42, p<.05) were statistically significant for extension torque asymmetry compared with girth asymmetry at sites 12, 14, 16, and 20 cm proximal to the patella and for flexion torque asymmetry only at the 14 cm site. Although girth and torque asymmetries were found to be somewhat related, percent girth asymmetry provided only a limited prediction of percent peak torque asymmetry.

J Orthop Sports Phys Ther. 1993;18(6):661-666.

Key Words: knee, girth, muscle strength

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:

• Letter regarding the editorial, Risk and Physical Therapy?. J Orthop Sports Phys Ther. 2007:37(9):570-572. doi:10.2519/jospt.2007.0209.
• Authors' Response. J Orthop Sports Phys Ther. 2007:37(9):571-572. doi:10.2519/jospt.2007.0210.

It is understandable that physical therapists prefer to focus on patient improvements rather than think about risk. But PTs must recognize that risk reduction is a postive result--indeed, an optimistic result--attainable through physical therapy. Physical therapists should make reporting absolute risk reduction (ARR), relative risk reduction (RRR), and number needed to treat (NNT), as well as the numbers of patients who fail to improve a meaningful amount (MCID). It's good to consider how physical therapy promotes good outcomes, but in some ways it's even more important to report how physical therapy interventions reduce risk for bad outcomes.

J Orthop Sports Phys Ther., 2007;37(6):287-289. doi:10.2519/jospt.2007.0106.

Study Design: This study utilized a quasi-experimental design in which subjects served as their own controls. Objective: To determine whether heart rate, pain threshold velocity, and pain perception varied in patients running on a soft-belt treadmill versus a standard hard-belt treadmill. Background: According to promotional literature, the relatively new Orbiter soft-belt treadmill produces a greater increase in heart rate at a given velocity as well as a higher velocity tolerance while walking or running. The manufacturer also asserts that decreased forces transmitted through the lower extremity should decrease pain levels while exercising on the soft-belt treadmill. Methods and Measures: Twenty-seven subjects walked or ran on each of 2 treadmills at incrementally increasing velocities until they experienced either the onset of pain or an increase in pain from baseline levels. Locomotion continued for 2 minutes after that, during which time heart rate and pain level on a visual analog scale (VAS) were recorded. Results: Two univariate paired t tests and a Wilcoxon’s signed rank test revealed a greater heart rate and pain threshold velocity when using the soft-belt treadmill with no statistical difference in the pain reported between the 2 treadmills. Conclusion: Our study revealed a 10% higher heart rate and a 14.5% higher pain threshold velocity with the soft-belt treadmill compared to a hard-belt treadmill. These differences are considered clinically meaningful.

J Orthop Sports Phys Ther. 2003;33(9):532-537.

Key Words: ambulation, running, walking

Publication of an article in a peer-reviewed journal does not guarantee that the evidence is valid, sincere efforts of reviewers and editors notwithstanding. For the sake of our patients, clinicians must consider strengths and weaknesses of research literature, rejecting some evidence and embracing other relevant research with adequate protections against key validity threats. Although it's almost impossible to find published research without some flaw or limitation, the savvy reader will be able to distinguish the fatal flaws from lesser problems. Even when an excellent article is found, we must realize that clinical research is cumulative; a single article will rarely provide a definitive answer about a clinical topic. Academicians have an obligation to perform this same evidence-sorting and interpretive process, and to make the process transparent while teaching, so that students can learn to do it for themselves.

J Orthop Sports Phys Ther. 2005; 35(5):271-272. doi:10.2519/jospt.2005.0105

Key Words: evidence, research

Study Design: A crossover experimental design with repeated measures. Objective: To determine whether the forearm support band alters wrist extensor muscle fatigue. Background: Fatigue of the wrist extensor muscles is thought to be a contributing factor in the development of lateral epicondylitis. The forearm support band is purported to reduce or prevent symptoms of lateral epicondylitis but the mechanism of action is unknown. Methods and Measures: Fifty unimpaired subjects (36 men, 14 women; mean age = 29 ± 6 years) were tested with and without a forearm support band before and after a fatiguing bout of exercise. Peak wrist extension isometric force, peak isometric grip force, and median power spectral frequency for wrist extensor electromyographic activity were measured before and after exercise and with and without the forearm support band. A 2 x 2 repeated measures multivariate analysis of variance was used to analyze the data, followed by univariate analysis of variance and Tukey's multiple comparison tests. Results: Peak wrist extension isometric force, peak grip isometric force, and median power spectral frequency were all reduced after exercise. However, there was a significant reduction in peak grip isometric force and peak wrist extension isometric force values for the with-forearm support band condition (grip force 28%, wrist extension force 26%) compared to the without-forearm support band condition (grip force 18%, wrist extension force 15%). Conclusions: Wearing the forearm support band increased the rate of fatigue in unimpaired individuals. Our findings do not support the premise that wearing the forearm support band reduces muscle fatigue in the wrist extensors.

J Orthop Sports Phys Ther. 1999;29(11):677-685.

Key Words: forearm support band, lateral epicondylitis, median power spectral frequency

Short-arc quadriceps exercises are commonly prescribed in physical therapy for strengthening knee extensor musculature. Determining the appropriate starting resistance has traditionally been a trial-and-error procedure. Therefore, developing an expedient method of estimating the correct starting resistance may lead to a more accurate exercise prescription. The primary purpose of this study was to establish a technique for predicting an individual's 10 repetition maximum (10 RM) based on hand-held dynamometer (HHD) strength recording and additional anthropometric predictor variables. Fifty healthy subjects (31 males and 19 females), aged 22-53 years, participated in the study. A prediction equation for determining 10 RM using HHD strength recording, weight, gender, and age was developed. By implementing this equation, clinicians can predict a normal, healthy, young to middle-aged adult's 10 RM within 2 ± 4.17 kg with a 95% confidence level (SEE = 2.13 kg).

J Orthop Sports Phys Ther. 1998;28(2):97-104.

Key Words: knee, muscle strength, prediction