SYNOPSIS: Musculoskeletal imaging of the spine can be an invaluable tool to inform clinical decision making in patients with spinal pain. An understanding of the technology involved in producing and interpreting high-resolution images produced from magnetic resonance imaging (MRI) of the human spine is necessary to better appreciate which sequences can be used for, or tailored to, individual patients and their conditions. However, there is substantial variability in the clinical meaningfulness of some MRI findings of spinal tissues. For example, normal variants can often mimic significant musculoskeletal pathology, which could increase the risk of misinformed clinical decisions and, even worse, poor or adverse outcomes. This clinical commentary will highlight some of the pearls and pitfalls of MRI for the cervical, thoracic, and lumbar regions, and include cases to illustrate some of the common imaging artifacts and normal variants for MRI of the spine.

J Orthop Sports Phys Ther 2011;41(11):848-860. doi:10.2519/jospt.2011.3636

KEY WORDS: MRI, medical imaging, radiology, spinal pain, whiplash

SYNOPSIS: The rate of lumbar spine magnetic resonance imaging in the United States is growing at an alarming rate, despite evidence that it is not accompanied by improved patient outcomes. Overutilization of lumbar imaging in individuals with low back pain correlates with, and likely contributes to, a 2- to 3-fold increase in surgical rates over the last 10 years. Furthermore, a patient's knowledge of imaging abnormalities can actually decrease self-perception of health and may lead to fear-avoidance and catastrophizing behaviors that may predispose people to chronicity. The purpose of this clinical commentary is as follows: (1) to describe an outline of the appropriate use, as defined in recent guidelines, of diagnostic imaging in patients with low back pain; (2) to describe how inappropriate use of lumbar spine imaging can increase the risk of patient harm and contributes to the recent large increases in healthcare costs; (3) to provide physical therapists with clear guidelines to educate patients on both appropriate imaging and information to dampen the potential negative effects of imaging on patients' perceptions and health; and (4) to present an example of a successful clinical pathway that has reduced imaging and improved outcomes. LEVEL OF EVIDENCE: Diagnosis/prognosis/therapy, level 5.

J Orthop Sports Phys Ther 2011;41(11):838-846, Epub 3 June 2011. doi:10.2519/jospt.2011.3618

KEY WORDS: lumbar spine, MRI, magnetic resonance imaging, overutilization, screening, prognosis

STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To compare the effectiveness of 2 different conservative management approaches in the treatment of plantar heel pain. BACKGROUND: There is insufficient evidence
to establish the optimal physical therapy management strategies for patients with heel pain, and little evidence of long-term effects. METHODS: Patients with a primary report of plantar heel pain underwent a standard evaluation and completed a number of patient self-report questionnaires, including the Lower Extremity Functional Scale (LEFS), the Foot and Ankle Ability Measure (FAAM), and the Numeric Pain Rating Scale (NPRS). Patients were randomly assigned to be treated with either an electrophysical agents and exercise (EPAX) or a manual physical therapy and exercise (MTEX) approach. Outcomes ofinterest were captured at baseline and at 4-week and 6-month follow-ups. The primary aim (effects of treatment on pain and disability) was examined with a mixed-model analysis of variance (ANOVA). The hypothesis of interest was the 2-way interaction (group by time). RESULTS: Sixty subjects (mean [SD] age, 48.4 [8.7] years) satisfied the eligibility criteria, agreed to participate, and were randomized into the EPAX (n = 30) or MTEX group (n = 30). The overall group-by-time interaction for the ANOVA was statistically significant for the LEFS (P = .002), FAAM (P = .005), and pain (P = .043). Between-group differences favored the MTEX group at both 4-week (difference in LEFS, 13.5; 95% CI: 6.3, 20.8) and 6-month (9.9; 95% CI: 1.2, 18.6) follow-ups. CONCLUSION: The results of this study provide evidence that MTEX is a superior management approach over an EPAX approach in the management of individuals with plantar heel pain at both the short- and long-term follow-ups. Future studies should examine the contribution of the different components of the exercise and manual physical therapy programs. LEVEL OF EVIDENCE: Therapy, level 1b.

J Orthop Sports Phys Ther 2009;39(8):573-585, Epub 24 June 2009. doi:10.2519/jospt.2009.3036

KEY WORDS: iontophoresis, manipulation, mobilization, plantar fasciitis, plantar fasciosis

STUDY DESIGN: Analytic observational prospective study performed in a controlled laboratory setting. OBJECTIVES: To assess the ability of a new screening tool, the active hip abduction test, to predict low back pain development during prolonged standing in previously asymptomatic individuals. BACKGROUND: Most screening tools used for a patient with low back pain do not assess the patient’s ability to maintain postural control in the frontal plane, when placed in an unstable position. Postural-control differences in pain developers, as compared to non-pain developers, during standing have been found previously. An attempt was made to predict pain development with a simple screening test. METHODS: Forty-three previously asymptomatic volunteers underwent a clinical assessment prior to a 2-hour standing protocol designed to induce low back pain. Participants rated low back pain with a visual analog scale and were classified into pain developers or non-pain developers. RESULTS: Forty percent of participants developed low back pain. The active hip abduction test was the only test that discriminated between pain-developer groups. When the examiner scored the test, the odds ratio was 3.85 (95% confidence interval [CI]: 1.05-19.07), and when the test was self-rated, the odds ratio was 6.55 (95% CI: 1.14-37.75) for pain development during standing. CONCLUSION: The active hip abduction test appears to show promise for predicting individuals who are at risk for low back pain development during prolonged standing. More work is required to validate the test in clinical populations, and to assess interrater and intrarater reliability. LEVEL OF EVIDENCE: Diagnosis, level 2b.

J Orthop Sports Phys Ther 2009;39(9):649-657, Epub 24 June 2009. doi:10.2519/jospt.2009.3093

KEY WORDS: clinical assessment, diagnostic tests, lumbar spine, stabilization

Recently, there has been increasing interest in using backward running (BR) as an exercise and rehabilitation tool. To date, no study has been performed that combined electromyography (EMG) and joint kinetics to study BR. The purpose of this study was to compare selected EMG and kinetic parameters in the stance phase of forward running (FR) and backward running (BR). The sagittal plane of the right knee was analyzed during three trials of FR and BR in six male subjects. Four 60-Hz video cameras collected motion data, and a link segment model of the right lower extremity was established. Force plate and EMG data were collected at 1000 Hz and synchronized with the video data. The knee muscle peak (+) and peak (-) mechanical power and total (+) and total (-) mechanical work were calculated. Electromyography signals were captured from the right lower extremity on the rectus femoris, vastus lateralis, vastus medialis, biceps femoris, gastrocnemius, and tibialis anterior muscles. Statistical analysis indicated that significantly less (p < 0.05) peak (+) and (-) power and total (+) work occurred at the knee during BR than during FR. Significant differences (p < .05) in muscle firing patterns between conditions were observed. Muscle action of the vastus lateralis (VL) and vastus medialis oblique (VMO) was largely eccentric and concentric during FR and isometric and concentric during BR. Backward running appears to be a good method for achieving isometric and concentric muscle action of the VMO and VL and may be useful in clinical conditions that require an increase in knee extensor strength.

J Orthop Sports Phys Ther 1993;17(2):108-112.

Key Words: backward running, muscle action, biomechanics

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

STUDY DESIGN: Resident's case problem. BACKGROUND: The role of premanipulative testing of the cervical spine is an area of controversy, and there are very few data to inform and guide practitioners on the use of ligamentous stability tests when assessing the upper cervical spine. DIAGNOSIS: A 23-year-old female was referred to physical therapy by a neurologist for the management of intractable headaches of possible musculoskeletal origin. Her Neck Disability Index score was 54% and she rated her headache pain from 3/10 to 9/10 on a Numerical Pain Rating Scale. She reported a 2-year history of intermittent lower extremity paresthesias without a known mechanism or current symptoms. She was treated in physical therapy for 11 visits with improvements in cervical range of motion, strength, and intensity of her headaches, but noted no change in the frequency of headaches. She was subsequently referred to the primary author for a second opinion and potential manual therapy interventions. Initial neurological screening examination for upper and lower motor neuron lesions was unremarkable. Assessment of the transverse ligament, using the anterior shear test in supine, brought on paresthesias in both feet and her toes. The paresthesias continued after the cessation of the test. The Sharp-Purser test performed in sitting, immediately after the transverse ligament test, abolished the paresthesias. She was then referred back to her primary care physician for further evaluation. Subsequent radiographs and magnetic resonance imaging revealed that the patient had a C2-C3 Klippel-Feil congenital fusion and os odontoideum. The patient was examined by a neurosurgeon who concluded that she was not a surgical candidate. Her neurological symptoms completely resolved, but she continued to have headaches. DISCUSSION: Os odontoideum is a clinically important condition, given that the mobile dens may render the transverse ligament incompetent, leading to atlantoaxial instability. Both the role and sequencing of upper cervical ligamentous testing is controversial. The results of this case report suggest that physical therapists should be cognizant of this condition and consider screening the upper cervical ligaments prior to manual or mechanical interventions to this region. LEVEL OF EVIDENCE:  Differential diagnosis, level 4.

J Orthop Sports Phys Ther. 2008;38(8):465-475, published online 27 June 2008. doi:10.2519/jospt.2008.2747

KEY WORDS: Klippel-Feil syndrome, manual therapy, neck, transverse ligament, upper cervical instability

SYNOPSIS: The development of chronic pain and disability following whiplash injury is common and contributes substantially to personal and economic costs related with this condition. Emerging evidence demonstrates the clinical presence of alterations in the sensory and motor systems, including psychological distress in all individuals with a whiplash injury, regardless of recovery. However, individuals who transition to the chronic state present with a more complex clinical picture characterized by the presence of widespread sensory hypersensitivity, as well as significant posttraumatic stress reactions. Based on the diversity of the signs and symptoms experienced by individuals with a whiplash condition, clinicians must take into account the more readily observable/measurable differences in motor, sensory, and psychological dysfunction. The implications for the assessment and management of this condition are discussed. Further review into the pathomechanical, pathoanatomical, and pathophysiological features of the condition also will be discussed. LEVEL OF EVIDENCE: Level 5.

J Orthop Sports Phys Ther 2009;39(5):312-323, Epub 3 June 2008. doi:10.2519/jospt.2009.2826

KEY WORDS: cervical spine, neck, WAD

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

In December of 2006, the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) convened a task force to create a framework for standardizing manual physical therapy procedures. The impetus came from many years of frustration with our ability to precisely communicate to each other, as well as to stakeholders outside our profession. To this end, a contribution titled "A Model for Standardizing Manipulation Terminology In Physical Therapy Practice" is published in this issue of the Journal.

J Orthop Sports Phys Ther. 2008;38(3):97-98. doi:10.2519/jospt.2008.0103

KEY WORDS: guidelines, manual physical therapy, terminology

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

In this issue of the journal, we explore rehabilitative ultrasound imaging's potential as a tool that physical therapists use in examining low back muscle function. As an assessment tool, RUSI can assist practitioners in recognizing impairments such as a decreased ability to increase muscle thickness (eg, transversus abdominis or multifidus) during specific physical tasks, excessive use of more global muscles (eg, rectus abdominis or erector spinae muscles) during low-level activities, and muscular atrophy. Identifying these impairments can help practitioners formulate a specific exercise program matched to the patient's underlying impairments during early stages of rehabilitation. From a treatment perspective, RUSI can provide feedback to both the physical therapist and patient that may help determine which verbal or tactile cues are most effective to facilitate proper performance of therapeutic exercises during the early phase of rehabilitation. Additionally, it may assist physical therapists in their decision-making process related to exercise prescription and progression. Finally, RUSI may help determine when specific impairments have been sufficiently addressed to permit the exercise progression necessary to achieve maximal pain-free function.

J Orthop Sports Phys Ther. 2007;37(10):579-580. doi:10.2519/jospt.2007.0109

KEY WORDS: rehabilitative ultrasound imaging, low back

Study Design: Test-retest reliability and validity. Objective: To determine the validity and reliability of the Palpation Meter (PALM). Background: Leg length discrepancy (LLD) has been associated with a variety of musculoskeletal disorders. Therefore, the clinical measurement of LLD has become a routine and important part of the physical examination. The PALM is an instrument that was recently developed to indirectly measure LLD, but little is known about its measurement properties. Methods and Measures: Fifteen healthy and 15 symptomatic subjects with suspected LLD participated in this study. Measurements of pelvic crest height difference (PD) were obtained by 2 examiners using the PALM. A standing antero-posterior (AP) radiograph of each subject's pelvis was taken, and PD and LLD (femoral head height difference) were determined from the radiograph for comparison with the PALM values. Intraclass correlation coefficients (ICCs) were calculated to determine the validity and reliability estimates of the PALM. Results: For all subjects, the validity estimates (ICC2, 3) of the PALM for PD were excellent (0.90 for rater 1 and 0.92 for rater 2) when compared with the standing AP radiograph of the pelvis. The PALM was less accurate (ICC2,3 of 0.76 and 0.78 for rater 1 and 2, respectively) as an indirect estimate of LLD. Intrarater reliability for each rater was excellent (ICC3,3 = 0.97 and 0.98) and interrater reliability was very good (ICC2,3 = 0.88). Conclusion: The PALM is a reliable and valid instrument for measuring PD. Clinicians should consider this convenient, cost-effective clinical tool as an alternative to radiographic measurement of pelvic crest height difference.

J Orthop Sports Phys Ther. 2003;33(6):319-325.

Key Words: leg length inequality, measurement, pelvic obliquity, reliability, validity

As our profession evolves, it is incumbent upon those of us in the academic and clinical education community to be persistent in the integration of evidence into practice, thus modeling the expectations we place on our students every day in the classroom and clinic.

J Orthop Sports Phys Ther. 2004; 34(4):169-170. doi:10.2519/jospt.2004.0104 

Key Words: evidence, teaching

Study Design: Case-control nonexperimental design. Objectives: To compare flexural wave propagation velocity (FWPV) and tibial bone mineral density (BMD) in women with and without tibial bone stress injuries (BSls). Background: Physical therapists, particularly in military and sports medicine settings, routinely diagnose and manage stress fractures or bone stress injuries. Improved methods of preparticipation quantification of tibial strength may provide markers of BSI risk and thus potentially reduce morbidity. Methods and Measures: Bone mineral density, FWPV, bone geometry, and historical variables were collected from 14 subjects diagnosed with tibial BSls and 14 age-matched controls; all 28 were undergoing military training. Results: No difference was found between groups in FWPV and tibial BMD when analyzed with t tests (post hoc power = 0.89 and 0.81, respectively). Furthermore, no difference was found in tibial length, tibial width, femoral neck BMD, and lumbar spine BMD among the groups. There were no differences between the 2 groups in smoking history, birth control pill use, and onset of menarche. Finally, sensitivity and positive likelihood ratios for FWPV (0.14 and 0.63), tibial BMD (0.0 and 0.0), and lumbar BMD (0.18 and 2.0) were low, while specificity was high (0.77, 0.93, and 0.91, respectively). Conclusion: Current bone analysis devices and methods may not be sensitive enough to detect differences in tibial material and structure; local stresses on bone may be more important in the development of BSls than the overall structural stiffness.

J Orthop Spots Phys Ther. 2001;31(2):54-69.

Key Words: bone stiffness, overuse injuries, risk factors, stress fractures

This special issue of the Journal is dedicated to the topic of manual physical therapy. The growing body of evidence supporting the effectiveness of manual physical therapy for a wide variety of patient populations makes this a timely and important topic. The variety of patient populations addressed in this special issue highlights the diversity of conditions for which manual physical therapy should play a role in evidence-based patient management. Like many aspects of practice, however, there appear to be barriers hindering the integration of the evidence supporting manual therapy into the decision-making processes of practicing clinicians and the curricula of programs educating physical therapists. These barriers need to be identified and dismantled, beginning with the language we choose to use.

J Orthop Sports Phys Ther. 2004; 34(11):659-661. doi:10.2519/jospt.2004.0111

Key Words: language, manual therapy, patient populations

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: Randomized controlled trial among patients with low back pain (LBP). Objectives: (1) Determine the reliability of real-time ultrasound imaging for assessing activation of the lateral abdominal muscles; (2) characterize the extent to which the abdominal drawing-in maneuver (ADIM) results in preferential activation of the transverse abdominis (TrA); and (3) determine if ultrasound biofeedback improves short-term performance of the ADIM in patients with LBP. Background: Ultrasound imaging is reportedly useful for measuring and training patients to preferentially activate the TrA muscle. However, research to support these claims is limited. Methods and Measures: Thirty patients with LBP referred for lumbar stabilization training were randomized to receive either traditional training (n = 15) or traditional training with biofeedback (n = 15). Ultrasound imaging was used to measure changes in thickness of the lateral abdominal muscles. Differences in preferential changes in muscle thickness of the TrA between groups and across time were assessed using analysis of variance. Results: Intrarater reliability measuring lateral abdominal muscle thickness exceeded 0.93. On average, patients in both groups demonstrated a 2-fold increase in the thickness of the TrA during the ADIM. Performance of the ADIM did not differ between the groups. Conclusion: These data provide construct validity for the notion that the ADIM results in preferential activation of the TrA in patients with LBP. Although, the addition of biofeedback did not enhance the ability to perform the ADIM at a short-term follow-up, our data suggest a possible ceiling effect or an insufficient training stimulus. Further research is necessary to determine if there is a subgroup of patients with LBP who may benefit from biofeedback.

J Orthop Sports Phys Ther. 2005;35(6):346-355. doi:10.2519/jospt.2005.1780

Key Words: lumbar stabilization, real-time ultrasound imaging, therapeutic exercise, transverse abdominis

Clinical prediction rules have been developed, which can aid the practitioners in assessing the risk a patient has for developing pulmonary embolism. The present clinical commentary discusses the existing evidence for screening patients for pulmonary embolism. To illustrate the importance of the screening examination, a patient is presented who was referred to physical therapy 5 days after cervical discectomy and fusion. This patient was subsequently referred for medical evaluation and a confirmatory diagnosis of pulmonary embolism.

J Orthop Sports Phys Ther. 2005;35(10):637-644. doi:10.2519/jospt.2005.2109

Key Words: chest pain, dyspnea, lungs, screening, thromboembolism

This issue of the JOSPT is the second of 2 dedicated to the topic of direct access physical therapy. Achieving direct access is an important component of the Vision 2020 statement set forth by the American Physical Therapy Association.1 This aspect of Vision 2020 is coming to fruition, with the majority of states now permitting direct access to physical therapists. Other related concepts promoted within Vision 2020 are professionalism and autonomy. Vision 2020 promotes the goal that physical therapists will ‘‘hold all privileges of autonomous practice,'' with autonomous practice defined as ‘‘independent, self-determined, professional judgment and action.'' Measuring the achievement of direct access is relatively straightforward. We may simply tally the number of states whose practice acts permit such access. Gauging our advance toward the goals of autonomy or professionalism is more difficult. The first step in analyzing our progress is to define our target so that we might be aware of where we are headed and recognize the destination once we arrive.

J Orthop Sports Phys Ther. 2005; 35(11):696-698. doi:10.2519/jospt.2005.0111

Key Words: direct access physical therapy

As consumer access to physical therapy practice expands, it is important that physical therapists are familiar with and implementing accepted methods of identifying the cardiovascular status of their clients. Established guidelines for assessing cardiovascular risk prior to initiating aerobic exercise programs are available and can be readily adopted by physical therapists in diverse clinical settings. We have provided a process for integrating existing guidelines into clinical practice. Because little evidence exists regarding the clinical behaviors and knowledge of orthopedic physical therapists in the area of cardiovascular risk, we conducted a survey to assess current practice patterns. The results suggest that orthopedic physical therapists are performing cardiovascular screening at frequencies similar to other components of the history and systems review, but that monitoring baseline or exercising vital signs does not occur with every exercise session.

J Orthop Sports Phys Ther. 2005;35(11):730-737. doi:10.2519/jospt.2005.2102

Key Words: aerobic capacity, cardiovascular risk, risk factor screening

The use of backward running is becoming more common in the rehabilitation setting. In particular, backward running has been suggested as a treatment modality in patients experiencing patellofemoral pain syndrome. To date, no study has examined the loads at the patellofemoral joint during backward running. The purpose of this study was to compare patellofemoral joint compressive forces during forward and backward running. Ground reaction force and kinematic data were collected on 5 male joggers during free speed forward and backward running. A floor reaction force vector model was used to calculate the stance phase knee extension moments. The distance used for the extensor muscle lever arm was 4.9 cm. Patellar mechanism angle was calculated based on knee joint angle. There was a reduction in the peak patellofemoral joint compressive forces in backward compared with forward running (2277 ± 192N vs. 4253 ± 1292N; p < 0.05) at self-selected speeds. Peak patellofemoral joint compressive force occurred significantly later (p < 0.05) in the stance phase of backward running (52 ± 4%) than in forward running (35 ± 3%). The peak patellofemoral joint compressive force normalized to subject body weight was 5.6 ± 1.3 body weight in forward running and 3.0 ± 0.6 body weight in backward running. The results suggest that backward running at a self-selected speed may reduce patellofemoral joint compressive forces and, coupled with the quadriceps strengthening that has previously been reported, may be beneficial in the rehabilitation of patellofemoral pain syndrome in runners. However, constant speed comparisons or other models may yield different results.

J Orthop Sports Phys Ther. 1995;21(5):277-282.

Key words: patellofemoral pain, backward running, rehabilitation

An increased emphasis should be placed on evidence-based decision making and the development of hands-on skills that can be performed proficiently, and yet are easily modifiable when individual physical therapist or patient characteristics dictate. When it comes to manual physical therapy interventions, in particular thrust manipulation techniques, it appears that there really is more than one way to manipulate a spine.

J Orthop Sports Phys Ther. 2006; 36(4):198-199. doi:10.2519/jospt.2006.0105

Spinal manipulation for low back complaints is an intervention supported by randomized clinical trials and its use recommended by clinical practice guidelines. Physical therapists in this country and internationally have used thrust spinal manipulation at much lower-than-expected rates, despite evidence supporting its efficacy for the treatment of acute low back pain (LBP). The purpose of this clinical commentary is to describe a physical therapist professional degree curriculum in thrust spinal manipulation and outline a method of monitoring ongoing student performance during the clinical education experience.

Increased emphasis on evidence-based decision making and on the psychomotor skills of thrust spinal manipulation was introduced into a physical therapist professional degree curriculum. As part of ongoing student performance monitoring, physical therapy students on their first full-time (8-week) clinical education experience, collected practice pattern and outcome data on individuals with low back complaints. Eight of 18 first-year students were in outpatient musculoskeletal clinical settings and managed 61 individuals with low back complaints. Patients were seen for an average (±SD) of 6.2 ± 4.0 visits. Upon initial visit, the student therapists employed spinal manipulation at a rate of 36.2% and spinal mobilization at 58.6%. At the final visit, utilization of manipulation and mobilization decreased (13% and 37.8%, respectively), while the utilization of exercise interventions increased, with 75% of patients receiving some form of lumbar stabilization training.

Physical therapist students used thrust spinal manipulation at rates that are more consistent with clinical practice guidelines and substantially higher then previously reported by practicing physical therapists. Education within an evidence-based framework is thought to contribute to practice behaviors and outcomes that are more consistent with best practice guidelines.

J Orthop Sports Phys Ther. 2006;36(8):577-587. doi:10.2519/jospt.2006.2159

Key Words: curriculum, low back pain, outcomes, physical therapy education, spinal manipulation

As a professional responsibility, we must provide procedures, such as manual therapy techniques and exercise interventions that are supported by evidence, to our patients who experience headaches as well as spinal and extremity disorders.

J Orthop Sports Phys Ther. 2006:36(11):834-836. doi:10.2519/jospt.2006.0112

Direct access is "the right of the public to direct consultation with physical therapists for examination, evaluation, and intervention." The challenge for physical therapists in this country is to actively engage on alllevels (patient, reimbursement, political, etc) to insure the rights of individuals to receive our services without unnecessary hassles and financial burdens. Direct access to physical therapy services has been a part of the US Army Health Care system for over 30 years and is a legal reality in the majority of states throughout the US.

J Orthop Sports Phys Ther. 2003; 33(3):102-103.

Key Words: direct access, military