STUDY DESIGN: Cross-sectional. OBJECTIVES: To measure fear of movement/reinjury levels and determine the association with function at different timeframes during anterior cruciate ligament (ACL) reconstruction rehabilitation. We hypothesized that fear of movement/reinjury would decrease during rehabilitation and be inversely related with function. BACKGROUND: Fear of movement/reinjury can prevent return to sports after ACL reconstruction, but it has not been studied during rehabilitation. METHODS AND MEASURES: Demographic data and responses on the shortened version of Tampa Scale for Kinesiophobia (TSK-11), 8-Item Short-Form Health Survey (SF-8), and International Knee Documentation Committee (IKDC) subjective form were extracted from a clinical database for 97 patients in the first year after ACL reconstruction. Three groups were formed: group 1, less than or equal to 90 days; group 2, 91 to 180 days; group 3: 181 to 372 days post-ACL reconstruction. Group differences in TSK-11 score, SF-8 bodily pain rating, and IKDC scores were determined. Hierarchical linear regression models were created for each group, with IKDC score as the dependent variable and demographic factors, SF-8 bodily pain rating, and TSK-11 score as independent variables. RESULTS: TSK-11 score was higher in group 1 than in group 3 (P < .05). Across the groups, SF-8 bodily pain rating decreased (P < .001) and IKDC score increased (P < .001). SF-8 bodily pain rating was a significant factor in the regression model for all groups, whereas TSK-11 score only contributed to the regression model in group 3 (partial correlation, -0.529). CONCLUSIONS: Pain was consistently associated with function across the timeframes studied. Fear of movement/reinjury levels appear to decrease during ACL reconstruction rehabilitation and are associated with function in the timeframe when patients return to sports. LEVEL OF EVIDENCE: Prognosis, level 4.

J Orthop Sports Phys Ther. 2008;38(12):746-753, published online 19 September 2008. doi:10.2519/jospt.2008.2887

KEY WORDS: ACL, knee injury, outcomes, psychosocial

For some patients, spinal manipulative therapy is an effective treatment for spine pain, yet we really don't fully understand how or why. The mechanisms of spinal manipulative therapy are not well defined, and common explanations for why spinal manipulative therapy works lack supporting evidence. Traditionally, the decision to incorporate spinal manipulative therapy into a plan of care is based on a seductively plausible biomechanical theory. Examination techniques, sometimes quite elaborate in nature, are used to determine painful structures and associated abnormalities related to alignment and mobility. The appropriately matched spinal manipulative therapy treatment techniques are then implemented to correct "pathological" findings. The underlying implication of these approacheds is that success of spinal manipulative therapy is dependent upon correction of biomechanical faults detected on examination.

J Orthop Sports Phys Ther. 2008;38(6):293-295. doi:10.2519/jospt.2008.0118

KEY WORDS: biomechanics, spine

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

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.

STUDY DESIGN: Cross-sectional. OBJECTIVES: To (1) determine the association between pain severity and pain drawing area for men and women; (2) determine if sex differences exist in pain severity or pain drawing area; (3) determine the relative influence of pain sever­ity, anatomical location of pain, personality, and psychological coping factors on pain drawing area for men and women. BACKGROUND: Pain drawings have been pos­tulated to assist in clinical decision making regard­ing classification and treatment of musculoskeletal pain. Prior studies have been ambiguous on this topic, possibly because they have not considered if sex differences exist for pain drawing area. METHODS AND MEASURES: One hundred twenty-six subjects referred to a multidisciplinary chronic pain clinic with chronic musculoskeletal pain were included in this study. Subjects com­pleted a pain drawing, the Multidimensional Pain Inventory (MPI), the Coping Strategies Question­naire (CSQ), and the Minnesota Multiphasic Per­sonality Inventory (MMPI-2). Pearson correlations investigated the associations of pain severity and pain drawing area, independent t tests investigated sex differences in pain severity and pain drawing area, and multiple regression investigated factors that influenced pain drawing area. RESULTS: Pain severity was positively corre­lated with pain drawing area for men (r = 0.38, P = .003) and women (r = 0.23, P = .052), account­ing for approximately 14% and 5% of the total variance, respectively. There was no significant sex difference in pain severity ratings, but women reported a significantly larger area of symptoms on the pain drawings (effect size, 0.61; P = .002). The sex difference in pain drawing area was consistent across different anatomical locations of pain. In women, the final regression model accounted for 39% (P<.001) of the variance in pain drawing area, with anatomical location of pain (β = .42, P<.001) and hypochondriasis (β = .31, P = .005) as the only unique predictors in the final model. In men, the regression model accounted for 27% (P = .003) of the variance in pain drawing area, with pain severity (β = .32, P = .021) and a coping style of ignoring pain (β = –.32, P = .018) as the only unique predictors in the final model. CONCLUSIONS: Women had larger pain draw­ing area and this area was significantly associated with anatomical location of pain and hypochon­driasis. Men had smaller pain drawing area and this area was associated with pain severity and a coping style of ignoring pain. These findings sug­gest that clinicians interpreting pain diagram area should consider the sex of the individual. 

J Orthop Sports Phys Ther. 2007;37(3):115-121. doi:1.2519/jospt.2007.2399 

KEY WORDS: chronic pain, coping styles, personality style, pain drawing, sex difference, yellow flags

The process of differential diagnosis involves the development of working hypotheses concerning dysfunction. These working hypotheses are revised, if necessary, based on the results of a physical examination. Some of the hypotheses to consider for a patient with symptoms involving the posterior thigh include lumbar radiculopathy, hamstring strain or tear, and sciatic nerve irritation. Involvement of the lumbar spine is assessed by evaluating the range and pattern of active lumbar movements. For example, a patient with asymmetrical lumbar sidebending may have facet joint restriction. In addition to range of motion, lumbar movements that centralize or peripheralize lower extremity symptoms are determined. Centralization of symptoms is defined as lumbar spine movements that abolish lower extremity symptoms, or make the symptoms move towards the spine. Peripheralization of symptoms is defined as lumbar spine movements that produce lower extremity symptoms or make the symptoms move farther away from the spine. The purpose of this case problem is to highlight the decision making process involved in determining the treatment of a patient with posterior thigh symptoms. In addition, the method of treatment will be described, and the patient's response to the treatment will be included in this article.

J Orthop Sports Phys Ther. 2000;30(8):468-472.

Key Words: lumbar, posterior thigh symptoms

Study Design: Secondary analysis of a prospective cohort of patients with acute low back pain (LBP). Objectives: To determine if the centralization phenomenon and fear-avoidance beliefs predict measurement of pain and disability 6 months after entering the study. Background: The centralization phenomenon and fear-avoidance are predictive of future pain and disability. However, previous prognostic studies have not routinely included both measures in homogenous subgroups of patients with acute LBP. Methods and Measures: Patients completed self-report questionnaires and were evaluated and treated with treatment-based classification guidelines. Only the patients classified for specific exercise were included in this analysis (n = 28). Measures of disability and pain intensity were reassessed at 6 months by mail. Separate hierarchical regression models predicted measures of disability and pain intensity with the centralization phenomenon, fear-avoidance beliefs, and prespecified covariates. Results: There were no significant differences in duration of symptoms, fear-avoidance beliefs, and history of LBP based on the centralization phenomenon (P>.05). Patients reporting the centralization phenomenon were significantly more likely to have leg pain (P<.01). A regression model including initial disability, the centralization phenomenon, and fear-avoidance beliefs about work significantly predicted 6-month disability, explaining 49% of the total variance (P<.001). A regression model that included initial pain intensity and the centralization phenomenon significantly predicted 6-month pain intensity, explaining 29% of the total variance (P<.016). These factors also appeared to be clinically meaningful predictors of outcome, but lacked precision for immediate use in clinical settings. The following covariates were not included in the final regression models: presence of leg pain, history of LBP, and duration of LBP. Conclusions: Baseline elevation in fear-avoidance beliefs about work and lack of centralization phenomenon predicted higher disability. Baseline lack of centralization phenomenon predicted higher pain intensity. These results can only be generalized to patients with acute LBP classified for specific exercise. It will be necessary to independently validate these prediction models before they can be implemented in clinical settings.

J Orthop Sports Phys Ther. 2005;35(9):580-588. doi:10.2519/jospt.2005.2073

Key Words: McKenzie, pain intensity, physical therapy, treatment-based classification

For certain patients, fear of pain can be as disabling as pain itself. Clinicians and researchers interested in reducing the societal impact of chronic musculoskeletal pain must work together to manage relevant psychological influences like fear of pain. Collaborative efforts are necessary to address the following issues in a wide range of musculoskeletal pain conditions: (1) refine current screening techniques to make them more efficient and accurate, and (2) develop and test interventions that effectively reduce pain-related fear. Otherwise, an important contributor to our patients' pain and disability will continue to be mismanaged by the same professionals trying to prevent chronic conditions.

J Orthop Sports Phys Ther. 2006; 36(5):264-266. doi:10.2519/jospt.2006.0106

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