STUDY DESIGN: Systematic review. OBJECTIVES: To systematically outline the risk factors for patellofemoral pain syndrome (PFPS). BACKGROUND: PFPS is the most commonly diagnosed condition in young individuals with knee complaints. High incidence among athletes suggests a possibility of prevention. The first step toward prevention is identification of possible risk factors. METHODS: Prospective studies that included 20 or more patients with PFPS and examined at least 1 possible risk factor for PFPS were included. An assessment list was applied to evaluate the quality of the studies. A meta-analysis was conducted using a random-effects model. Significant differences were based on calculated mean differences, with matching 95% confidence intervals (CIs). For dichotomous data, odds ratios or relative risks were calculated. RESULTS: Of the 3845 potentially relevant articles, 7 were included in this review. These studies examined a total of 135 variables, and pooling was possible for 13 potential risk factors. The pooled data showed that knee extension peak torques were significantly lower in the PFPS group than in controls. Mean differences in torque, with negative differences reflecting lower means in the PFPS group, were as follows: (a) standardized relative to body weight at 60°/s, –0.24 Nm (95% CI: –0.39, –0.09); (b) standardized relative to body weight at 240°/s, –0.11 Nm (95% CI: –0.17, –0.05); (c) standardized relative to body mass index at 60°/s, –0.84 Nm (95% CI: –1.23, –0.44); (d) standardized relative to body mass index at 240°/s, –0.32 Nm (95% CI: –0.52, –0.12); (e) nonstandardized in a concentric mode at 60°/s, –17.54 Nm (95% CI: –25.53, –9.54); (f) nonstandardized in a concentric mode at 240°/s, –7.72 Nm (95% CI: –12.67, –2.77). CONCLUSION: Weaker knee extension strength, expressed by peak torque, appears to be a risk factor for PFPS, based on meta-analyses of pooled results from multiple studies. Because several other risk factors for PFPS were described only in single studies, these additional risk factors, as well as those with conflicting evidence, need to be confirmed in future studies. LEVEL OF EVIDENCE: Prognosis, level 1a–.

J Orthop Sports Phys Ther 2012;42(2):81-94, Epub 25 October 2011. doi:10.2519/jospt.2012.3803

KEY WORDS: knee extension, knee flexion, literature review, meta-analysis, torque

STUDY DESIGN: Randomized controlled trial. OBJECTIVES: To examine the effectiveness of isolated hip abductor and external rotator strengthening on pain, health status, and hip strength in females with patellofemoral pain (PFP). BACKGROUND: Altered hip kinematics resulting from hip muscle weakness has been proposed as a contributing factor in the development of PFP. To date, no study has examined clinical outcomes associated with isolated hip muscle strengthening in those with PFP. METHODS: Twenty-eight females with PFP were sequentially assigned to an exercise (n = 14) or a no-exercise control group (n = 14). The exercise group completed bilateral hip abductor and external rotator strengthening 3 times per week for 8 weeks. Pain (visual analog scale), health status (WOMAC), and hip strength (handheld dynamometer) were assessed at baseline and postintervention. Pain and health status were also evaluated at 6 months postintervention in the exercise group. Two-factor mixed-model analyses of variance were used to determine the effects of the intervention on each outcome variable. RESULTS: Significant group-by-time interactions were observed for each variable of interest. Post hoc testing revealed that pain, health status, and bilateral hip strength improved in the exercise group following the 8-week intervention but did not change in the control group. Improvements in pain and health status were sustained at 6-month follow-up in the exercise group. CONCLUSION: A program of isolated hip abductor and external rotator strengthening was effective in improving pain and health status in females with PFP compared to a no-exercise control group. The incorporation of hip-strengthening exercises should be considered when designing a rehabilitation program for females with PFP. LEVEL OF EVIDENCE: Therapy, level 2b.

J Orthop Sports Phys Ther 2012;42(1):22-29, Epub 25 October 2011. doi:10.2519/jospt.2012.3704

KEY WORDS: anterior knee pain, clinical trial, patella, rehabilitation, self-report

STUDY DESIGN: Prospective cohort study with an age-matched and sex-matched control group. OBJECTIVES: To assess the clinical outcomes of a high-intensity rehabilitation program (HI) compared to those of a group of age-matched and sex-matched controls who underwent a lower intensity rehabilitation program. BACKGROUND: Total knee arthroplasty (TKA) successfully alleviates pain from knee osteoarthritis; but deficits in function can persist long term. Despite these well-known deficits, there is little evidence supporting the use of rehabilitation interventions following TKA. METHODS: Eight patients, who participated in the HI program, were compared to 8 age-matched and sex-matched patients who participated in a lower intensity rehabilitation program (control group). Patients were assessed preoperatively, and at 3.5, 6.5, 12, 26, and 52 weeks postoperatively. Assessment of patients included measures of pain, range of motion (ROM), functional performance, and quadriceps strength and activation. RESULTS: There were no differences in knee ROM and pain between the HI and control groups at any postoperative time point. At the 3.5-week and 12-week (end of rehabilitation) time points, the HI group had better functional performance and quadriceps strength compared to the control group (P<.05). At the 52-week time point, the HI group continued to demonstrate better functional performance compared to the control group (P<.05), along with greater quadriceps strength (P = .08). CONCLUSION: A HI program leads to better short- and long-term strength and functional performance outcomes compared to a lower intensity rehabilitation program. The HI program did not impair knee ROM and did not result in any musculoskeletal injuries in this small group of patients. LEVEL OF EVIDENCE: Therapy, level 2b.

J Orthop Sports Phys Ther 2011;41(12):932-941, Epub 30 September 2011. doi:10.2519/jospt.2011.3734

KEY WORDS: joint replacement, older adults, osteoarthritis, rehabilitation

STUDY DESIGN: Prospective, blinded, diagnostic accuracy study. OBJECTIVE: To investigate the reliability and diagnostic accuracy of the Lachman test, performed in a prone position, to detect the presence of an anterior cruciate ligament (ACL) tear. Direct arthroscopic visualization and a consensus of clinical findings, including joint arthrometry and magnetic resonance imaging, were used as the reference standards. BACKGROUND: An alternative position for evaluating the integrity of the ACL has been proposed as a means for examiners with smaller hands to adequately stabilize the thigh of a larger individual; however, the diagnostic accuracy of this method has not been established. METHODS: Fifty-two consecutive patients with a complaint of knee pain were independently evaluated in a prone position for the status of their ACL by 2 physical therapists, before any other diagnostic assessment. The 31 men and 21 women ranged in age from 16 to 57 (mean ± SD, 34.3 ± 4.2) years and in acuity of knee injury from 21 to 365 (mean ± SD, 195 ± 130) days. RESULTS: Twenty-three of 52 (44%) of the patients had a torn ACL. The agreement between examiners was 90%, with a kappa coefficient of 0.81. The sensitivity of the prone Lachman test was 70% and the specificity was 97%, resulting in a positive likelihood ratio of 20.17 and a negative likelihood ratio of 0.32. The positive predictive value was 94% and the negative predictive value was 80%. The diagnostic odds ratio was 64.0, with a number needed to diagnose of 1.5. CONCLUSION: The prone Lachman test is a reliable evaluation technique that can be used to confirm the presence of an ACL tear; however, the test should not be used as the sole criterion to rule out the presence of the injury. LEVEL OF EVIDENCE: Diagnosis, level 2b.

J Orthop Sports Phys Ther 2011;41(10):749-757, Epub 4 September 2011. doi:10.2519/jospt.2011.3761

KEY WORDS: ACL, anterior cruciate ligament, diagnosis, knee, sensitivity, specificity

STUDY DESIGN: Block randomized controlled trial. OBJECTIVES: To investigate whether a strengthening and movement education program, targeting the hip abductors and hip external rotators, alters hip mechanics during running and during a single-leg squat. BACKGROUND: Abnormal movement patterns during running and single-leg squatting have been associated with a number of running-related injuries in females. Therapeutic interventions for these aberrant movement patterns typically include hip strengthening. While these strengthening programs have been shown to improve symptoms, it is unknown if the underlying mechanics during functional movements is altered. METHODS: Twenty healthy females with excessive hip adduction during running, as determined by instrumented gait analysis, were recruited. The runners were matched by age and running distance, and randomized to either a training group or a control group. The training group completed a hip strengthening and movement education program 3 times per week for 6 weeks in addition to single-leg squat training with neuromuscular reeducation consisting of mirror and verbal feedback on proper mechanics. The control group did not receive an intervention but maintained the current running distance. Using a handheld dynamometer and standard motion capture procedures, hip strength and running and single-leg squat mechanics were compared before and after the strengthening and movement education program. RESULTS: While hip abductor and external rotation strength increased significantly (P<.005) in the training group, there were no significant changes in hip or knee mechanics during running. However, during the single-leg squat, hip adduction, hip internal rotation, and contralateral pelvic drop all decreased significantly (P = .006, P = .006, and P = .02, respectively). The control group exhibited no changes in hip strength, nor in the single-leg squat or running mechanics at the conclusion of the 6-week study. CONCLUSION: A training program that included hip strengthening and movement training specific to single-leg squatting did not alter running mechanics but did improve single-leg squat mechanics. These results suggest that hip strengthening and movement training, when not specific to running, do not alter abnormal running mechanics. LEVEL OF EVIDENCE: Therapy, level 2b.

J Orthop Sports Phys Ther 2011;41(9):625-632, Epub 12 July 2011. doi:10.2519/jospt.2011.3470

KEY WORDS: biomechanics, gluteus, knee, lower extremity

STUDY DESIGN: Secondary analysis of longitudinal population-based survey data. OBJECTIVES: To investigate factors associated with care seeking for physician-referred physical therapy (MD/PT), as compared to physician-only (MD) or chiropractic-only (DC) care for spinal pain. BACKGROUND: Although a large proportion of ambulatory physical therapy visits are related to spinal pain, physical therapists are not the most commonly seen provider. The majority of visits are to physicians, followed by chiropractors. We attempted to understand more about this disparity by examining social and demographic factors that differentiate between persons who see these providers. METHODS: Episodes of care were constructed from participants in 2 panels from the Medical Expenditure Panel Survey who had spinal pain. The provider of care was identified for each episode, and logistic regression was used to determine factors associated with MD/PT use compared to MD use, and MD/PT use compared to DC use. RESULTS: The majority of patients (61%) received MD care for spinal pain, followed by those who received DC (28%) and MD/PT (11%) care. Female sex, higher levels of education, and higher income were significantly associated with MD/PT care over MD care. Increased age, female sex, lower self-health rating, and presence of at least 1 disability day were all significantly associated with MD/PT care over DC care. CONCLUSION: Sociodemographic and clinical factors are associated with those who get MD/PT care as compared to MD or DC care. We found evidence of an access disparity for physical therapy and identified population characteristics that both increase and reduce the likelihood of physical therapy service use.

J Orthop Sports Phys Ther 2011;41(7):467-476, Epub 7 June 2011. doi:10.2519/jospt.2011.3637

KEY WORDS: health services utilization, low back pain, neck pain, treatment

STUDY DESIGN: Randomized clinical trial. OBJECTIVES: To determine if females with patellofemoral pain syndrome (PFPS) who perform hip strengthening prior to functional exercises demonstrate greater improvements than females who perform quadriceps strengthening prior to the same functional exercises. BACKGROUND: Although PFPS has previously been attributed to quadriceps dysfunction, more recent research has linked this condition to impairment of the hip musculature. Lower extremity strengthening has been deemed an effective intervention. However, research has often examined weight-bearing exercises, making it unclear if increased strength in the hip, quadriceps, or both is beneficial. METHODS: Thirty-three females with PFPS performed either initial hip strengthening (hip group) or initial quadriceps strengthening (quad group) for 4 weeks, prior to 4 weeks of a similar program of functional weight-bearing exercises. Self-reported pain, function, and functional strength were measured. Isometric strength was assessed for hip abductors, external rotators, and knee extensors. A mixed-model analysis of variance was used to determine group differences over time. RESULTS: After 4 weeks, there was less mean ± SD pain in the hip group (2.4 ± 2.0) than in the quad group (4.1 ± 2.5) (P = .035). From baseline to 8 weeks, the hip group demonstrated a 21% increase (P<.001) in hip abductor strength, while that remained unchanged in the quad group. All participants demonstrated improved subjective function (P<.006), objective function (P<.001), and hip external rotator strength (P = .004) from baseline to testing at 8 weeks. CONCLUSION: Both rehabilitation approaches improved function and reduced pain. For patients with PFPS, initial hip strengthening may allow an earlier dissipation of pain than exercises focused on the quadriceps. LEVEL OF EVIDENCE: Therapy, level 2b–.

J Orthop Sports Phys Ther 2011;41(8):560-570. Epub 7 June 2011. doi:10.2519/jospt.2011.3499

KEY WORDS: anterior knee pain, clinical trial, kinetic chain, knee rehabilitation

Figure 7 on page 566 was amended in the September 2011 Erratum, and the article PDF with the Erratum page included is provided here. Please see: September 2011 Erratum

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: Case control. OBJECTIVES: To use modified NFL Combine testing methodology to test for functional deficits in athletes following anterior cruciate ligament (ACL) reconstruction following return to sport. BACKGROUND: There is a need to develop objective, performance-based, on-field assessment methods designed to identify potential lower extremity performance deficits and related impairments in this population. METHODS: Eighteen patients (mean ± SD age, 16.9 ± 2.1 years; height, 170.0 ± 8.7 cm; body mass, 71.9 ± 21.8 kg) who returned to their sport within a year following ACL reconstruction (95% CI: 7.8 to 11.9 months from surgery) participated (ACLR group). These individuals were asked to bring 1 or 2 teammates to serve as control participants, who were matched for sex, sport, and age (n = 20; mean ± SD age, 16.9 ± 1.1 years; height, 169.7 ± 8.4 cm; body mass, 70.1 ± 20.7 kg). Functional performance was tested using the broad jump, vertical jump, modified long shuttle, modified pro shuttle, modified agility T-test, timed hop, triple hop, single hop, and crossover hop tests. A 1-way multivariate analysis of variance (MANOVA) was used to evaluate group differences for dependent performance variables. RESULTS: The functional performance measurements of skills requiring bilateral involvement of both lower extremities showed no group differences between the ACLR and control groups (P>.05). An overall group difference (P = .006) was observed for the combined limb symmetry index (LSI) measures. However, the modified double-limb performance tasks (long shuttle, modified agility T-test, and pro shuttle) were not, independently, sufficiently sensitive to detect limb deficits in individuals with ACL reconstruction. Conversely, the LSI on the distance measures of the single-limb performance tasks all provided moderate to large effect sizes to differentiate between the ACLR and control groups, as the individuals who had ACL reconstruction demonstrated involved limb deficits on all measures (P<.05). Finally, the LSI for the timed hop test was not different between groups (P>.05). CONCLUSIONS: These findings indicate that, while unilateral deficits are present in individuals following ACL reconstruction, they may not be evident during bipedal performance or during modified versions of double-limb performance activities. Isolation of the involved limb with unilateral hopping tasks should be used to identify deficits in performance.

J Orthop Sports Phys Ther 2011;41(6):377-387, Epub 2 February 2011. doi:10.2519/jospt.2011.3547

KEY WORDS: anterior cruciate ligament, hop tests, knee, prevention

STUDY DESIGN: Systematic literature review. OBJECTIVES: To evaluate the diagnostic accuracy of clinical tests used to diagnose patients with structural lumbar segmental instability (LSI). BACKGROUND: Patients with structural LSI represent an important, identifiable subgrouping of individuals with low back pain. Numerous clinical tests have been proposed to diagnose structural LSI; however, data on the diagnostic accuracy of these tests have not yet been evaluated through a systematic review of the literature. METHODS: A systematic review was conducted in 6 electronic databases for diagnostic accuracy studies, published between January 1950 and March 2010, that evaluated clinical tests against radiological diagnosis of structural LSI. The diagnostic accuracy of the clinical tests from the retrieved articles was independently evaluated, reviewed, and quality scored using the QUADAS tool. RESULTS: Four articles and a total of 11 clinical tests used in the diagnosis of structural LSI met the study inclusion criteria. The majority of tests had high specificity but low sensitivity, with positive likelihood ratios ranging from very small to moderate. QUADAS scores ranged from 16 to 25 out of a possible 26. The passive lumbar extension test was the most accurate clinical test, with high sensitivity (84%), specificity (90%), and a positive likelihood ratio of 8.8 (95% CI: 4.5, 17.3), indicating that this clinical test may be useful in the differential diagnosis of structural LSI. CONCLUSION: This systematic review found that the majority of clinical tests routinely employed to diagnose structural LSI demonstrated only limited ability to do so. The results do, however, indicate that the passive lumbar extension test may be useful in orthopaedic clinical practice to diagnose structural LSI. Additional research is required to further validate its use for diagnosing structural LSI in all populations of those with low back pain. LEVEL OF EVIDENCE: Diagnosis, level 2a.

J Orthop Sports Phys Ther 2011;41(3):130-140, Epub 2 February 2011. doi:10.2519/jospt.2011.3457

KEY WORDS: accuracy, low back pain, physical examination, validity

STUDY DESIGN: Controlled laboratory study using a repeated-measures design. OBJECTIVE: To quantify patellofemoral joint reaction force (PFJRF) and stress (PFJS) during forward step-up (FSU), lateral step-up (LSU), and forward step-down (FSD) exercises. BACKGROUND: Although FSU, LSU, and FSD exercises are commonly used in patellofemoral joint rehabilitation programs, the influence of these stepping tasks on patellofemoral joint kinetics has not been quantified. METHODS: Three-dimensional lower extremity kinematics and kinetics and electromyographic (EMG) data were obtained from 20 healthy adults during their performance of FSU, LSU, and FSD exercises. The step height for each participant was adjusted to permit a standardized knee flexion angle of 45°. A previously described biomechanical model of the patellofemoral joint was used to quantify PFJRF and PFJS during each task. Peak PFJRF and PFJS during the concentric and eccentric phases of each step task were compared using a 2-factor analysis of variance (ANOVA). RESULTS: When collapsed across concentric and eccentric phases, peak PFJS was significantly greater during the FSD (mean ± SD, 13.8 ± 0.4 MPa) compared to the LSU (11.5 ± 0.8 MPa; P<.001) and FSU (11.2 ± 0.6 MPa; P = .002) exercises. Peak PFJRF also was significantly greater during the FSD (51.1 ± 2.7 N/kg) compared to the LSU (44.1 ± 3.4 N/kg; P<.001) and FSU (43.6 ± 2.3 N/kg; P = .023) exercises. CONCLUSION: In selecting exercises that promote lower extremity muscle strengthening while minimizing patellofemoral joint loading, LSU and FSU should be considered over FSD exercises, if the same step height is used.

J Orthop Sports Phys Ther 2011;41(4):241-248, Epub 2 February 2011. doi:10.2519/jospt.2011.3408

KEY WORDS: anterior knee pain, biomechanics, patella, patellofemoral pain syndrome, step exercises

STUDY DESIGN: Controlled laboratory study. OBJECTIVES: To examine the effect of 2 adhesive tape conditions compared to a no-tape condition on muscle activity of the fibularis longus during a sudden inversion perturbation in male athletes (soccer, team handball, basketball). BACKGROUND: Ankle sprains are common in sports, and the fibularis muscles play a role in providing functional stability of the ankle. Prophylactic ankle taping with nonelastic sports tape has been used to restrict ankle inversion. Kinesio Tape, an elastic sports tape, has not been studied for that purpose. METHODS: Fifty-one male premier-league athletes were tested for functional stability of both ankles with the Star Excursion Balance Test. Based on the results, those with the 15 highest and those with the 15 lowest stability scores were selected for further testing. Muscle activity of the fibularis longus was recorded with surface electromyography during a sudden inversion perturbation. Each participant was tested under 3 conditions: ankle taped with nonelastic white sports tape, ankle taped with Kinesio Tape, and no ankle taping. Differences in mean muscle activity were evaluated with a 3-way mixed-model analysis of variance (ANOVA) for the 3 conditions, across four 500-millisecond time frames, and between the 2 groups of stable versus unstable participants. Differences in peak muscle activity and in the time to peak muscle activity were evaluated with a 2-way mixed-model ANOVA. RESULTS: Significantly greater mean muscle activity was found when ankles were taped with nonelastic tape compared to no tape, while Kinesio Tape had no significant effect on mean or maximum muscle activity compared to the no-tape condition. Neither stability level nor taping condition had a significant effect on the amount of time from perturbation to maximum activity of the fibularis longus muscle. CONCLUSION: Nonelastic sports tape may enhance dynamic muscle support of the ankle. The efficacy of Kinesio Tape in preventing ankle sprains via the same mechanism is unlikely, as it had no effect on muscle activation of the fibularis longus.

J Orthop Sports Phys Ther 2011;41(5):328-335, Epub 5 January 2011. doi:10.2519/jospt.2011.3501

KEY WORDS: electromyography, joint instability, SEBT, sprain

Table 2 on page 330 was amended in the August 2011 Erratum, and the article PDF with the Erratum page included is provided here. Please see: August 2011 Erratum  

STUDY DESIGN: Randomized, blinded, controlled crossover trial. OBJECTIVE: To determine if thrust joint manipulation (TJM) to the lumbar spine would result in changes to the resting and contraction thickness of transversus abdominis (TrA) in healthy individuals. BACKGROUND: Recent studies have demonstrated an immediate decrease in resting thickness and an increase in contraction thickness in TrA following lumbar TJM in patients with low back pain (LBP) who met a clinical prediction rule (CPR) for spinal manipulation. This observed phenomenon has not been investigated in healthy individuals. METHODS: Thirty-five healthy participants were randomly assigned to receive a TJM or sham manipulation treatment. All participants received instruction on how to produce an isolated concentric contraction of the TrA that involved visual ultrasound imaging biofeedback. Data were analyzed using ultrasound imaging to measure changes in thickness of the TrA at rest and during contraction, following the administration of each treatment. RESULTS: There were no interactions observed between treatment and time for TrA muscle thickness at rest (P = .351) and during the contracted state (P = .761). CONCLUSION: Our results indicate that TJM to the lumbar spine does not appear to affect the resting or contraction thickness of TrA in healthy individuals. These findings are in contrast to previous research in which patients with LBP who met a CPR demonstrated an immediate decrease in resting thickness and an increase in contraction thickness in TrA following lumbar TJM.

J Orthop Sports Phys Ther 2011;41(1):13-21, Epub 22 October 2010. doi:10.2519/jospt.2011.3311

KEY WORDS: low back pain, manual therapy, rehabilitative ultrasound imaging

STUDY DESIGN: A systematic review with meta-analysis. OBJECTIVES: To compare pain and disability in individuals with persistent nonspecific low back pain who were treated with Pilates exercises compared to minimal or other interventions. METHODS: Searches of Medline, CINAHL, Embase, Cochrane library, PEDro, and ProQuest Dissertations and Thesis databases were conducted. Randomized controlled trials (RCTs) were selected and reviewed if they compared pain and disability in individuals with persistent nonspecific low back pain who were treated with Pilates exercises compared to other treatment approaches. Quality of the trials was evaluated. Data for pain and disability scores were extracted. Narrative synthesis plus meta-analyses were performed, with either a fixed-effects or random-effects model, standardized mean differences (SMDs), and tests for heterogeneity. RESULTS: Seven RCTs were identified and included in the meta-analyses. Data pooling was performed using RevMan 5. When compared to minimal intervention, Pilates-based exercise provided superior pain relief (pooled SMD, –2.72; 95% CI: –5.33, –0.11; P = .04) but the pooled disability scores were not significantly different (pooled SMD, –0.74; 95% CI: –1.81, 0.33;P = .17). No significant differences were found when comparing Pilates-based exercise to other forms of exercise for pain (pooled SMD, 0.03; 95% CI: –0.52, 0.58; P = .92) or disability scores (pooled SMD, –0.41; 95% CI: –0.96, 0.14; P = .14). CONCLUSION: Pilates-based exercises are superior to minimal intervention for pain relief. Existing evidence does not establish superiority of Pilates-based exercise to other forms of exercise to reduce pain and disability for patients with persistent nonspecific low back pain. However, the relatively low quality of existing studies and the heterogeneity of pooled studies in this systematic review combine to suggest that these results should be interpreted with caution. LEVEL OF EVIDENCE: Therapy, level 1a–.

J Orthop Sports Phys Ther 2011;41(2):70-80, Epub 22 October 2010. doi:10.2519/jospt.2011.3393

KEY WORDS: exercise therapy, lumbar spine, rehabilitation

STUDY DESIGN: Cross-sectional. OBJECTIVES: To evaluate the accuracy with which physical therapists identify fear-avoidance beliefs in patients with low back pain by comparing therapist ratings of perceived patient fear-avoidance to the Fear-Avoidance Beliefs Questionnaire (FABQ), Tampa Scale of Kinesiophobia 11-item (TSK-11), and Pain Catastrophizing Scale (PCS). To compare the concurrent validity of therapist ratings of perceived patient fear-avoidance and a 2-item questionnaire on fear of physical activity and harm, with clinical measures of fear-avoidance (FABQ, TSK-11, PCS), pain intensity as assessed with a numeric pain rating scale (NPRS), and disability as assessed with the Oswestry Disability Questionnaire (ODQ). BACKGROUND: The need to consider psychosocial factors for identifying patients at risk for disability and chronic low back pain has been well documented. Yet the ability of physical therapists to identify fear-avoidance beliefs using direct observation has not been studied. METHODS: Eight physical therapists and 80 patients with low back pain from 3 physical therapy clinics participated in the study. Patients completed the FABQ, TSK-11, PCS, ODQ, NPRS, and a dichotomous 2-item fear-avoidance screening questionnaire. Following the initial evaluation, physical therapists rated perceived patient fear-avoidance on a 0-to-10 scale and recorded 2 influences on their ratings. Spearman correlation and independent t tests determined the level of association of therapist 0-to-10 ratings and 2-item screening with fear-avoidance and clinical measures. RESULTS: Therapist ratings of perceived patient fear-avoidance had fair to moderate interrater reliability (ICC_2,1 = 0.663). Therapist ratings did not strongly correlate with FABQ or TSK-11 scores. Instead, they unexpectedly had stronger associations with ODQ and PCS scores. Both 2-item screening questions were associated with FABQ-physical activity scores, while the fear of physical activity question was also associated with FABQ-work, TSK-11, PCS, and ODQ scores. CONCLUSION: Therapists’ ratings of perceived patient fear-avoidance were not associated with self-reported fear-avoidance scores, showing a potential disconnect between therapist judgments and commonly used fear-avoidance measures. Instead, therapist ratings had small but statistically significant correlations with pain catastrophizing and disability, findings that may support therapists’ inability to discriminate fear-avoidance from these other factors. The 2-item screening questions based on fear of physical activity and harm showed potential to identify elevated FABQ physical activity scores. LEVEL OF EVIDENCE: Differential diagnosis, level 2b.

J Orthop Sports Phys Ther 2010;40(12):774-783, Epub 22 October 2010. doi:10.2519/jospt.2010.3381

KEY WORDS: FABQ, low back pain, screening

STUDY DESIGN: Controlled cohort repeated-measures experimental design. OBJECTIVES: To determine if a neuromuscular training program (NMTP) focused on core stability and lower extremity strength would affect performance on the star excursion balance test (SEBT). We hypothesized that NMTP would improve SEBT performance in the experimental group and there would be no side-to-side differences in either group. BACKGROUND: The SEBT is a functional screening tool that is used to assess dynamic stability, monitor rehabilitation progress, assess deficits following an injury, and identify athletes at high risk for lower extremity injury. The SEBT requires lower extremity coordination, balance, flexibility, and strength. METHODS: Twenty uninjured female soccer players (13 experimental, 7 control) participated. Players trained together as a team, so group allocation was not randomized. The SEBT was administered prior to and following 8 weeks of NMTP in the experimental group and 8 weeks of no NMTP in the control group. A 3-way mixed-model ANOVA was used to determine the effect of group (experimental versus control), training (pretraining versus posttraining), and limb (right versus left). RESULTS: After participation in a NMTP, subjects demonstrated a significant improvement in the SEBT composite score (mean ± SD) on the right limb (pretraining, 96.4% ± 11.7%; posttraining, 104.6% ± 6.1%; P = .03) and the left limb (pretraining, 96.9% ± 10.1%; posttraining, 103.4% ± 8.0%; P = .04). The control group had no change on the SEBT composite score for the right (pretraining, 95.7% ± 5.2%; posttraining, 94.4% ± 5.2%; P = .15) or the left (97.4% ± 7.2%; 93.6% ± 5.0%; P = .09) limb. Further analysis identified significant improvement for the SEBT in the posterolateral direction on both the right (P = .008) and left (P = .040) limb and the posteromedial direction of the left limb (P = .028) in the experimental group. CONCLUSION: Female soccer players demonstrated an improved performance on the SEBT after NMTP that focused on core stability and lower extremity strength. LEVEL OF EVIDENCE: Performance enhancement, level 2b-.

J Orthop Sports Phys Ther 2010;40(9):551-558, Epub 6 August 2010. doi:10.2519/jospt.2010.3325

KEY WORDS: core stability, core strengthening, injury prevention training, trunk neuromuscular control

STUDY DESIGN: Randomized, crossover study. OBJECTIVE: To examine changes in muscle activity and plantar pressure during running with the application of augmented low Dye (ALD) taping. BACKGROUND: ALD taping is used clinically as part of management for lower limb injury. As of yet, no studies have examined the effect of this taping method on muscle activity and plantar pressure during running, simultaneously. METHODS: Thirteen healthy recreational runners(mean ± SD age, 31.7 ± 4.9 years; height, 181.7 ± 4.6 cm; body mass, 81.6 ± 5.9 kg) completed a 6-minute run on a treadmill at a speed of 10 km·h^–1, with 3 different taping conditions (ALD, control tape, no tape), applied in randomized order. Peak and average EMG signal amplitude, onset time, and burst duration were calculated for the vastus medialis, vastus lateralis, and the gluteus medius. In-shoe plantar pressures were also recorded. All data were calculated based on an average of 20 steps collected after 5 minutes of treadmill running. RESULTS: ALD taping significantly altered muscle activity and plantar pressure during treadmill running by (1) delaying the onset of the EMG signal of the gluteus medius, vastus medialis, and vastus lateralis, and (2) increasing lateral midfoot plantar pressure. CONCLUSION: ALD taping significantly alters plantar pressure and muscle activation patternsduring treadmill running. These findings give insight into the neuromuscular effect of a taping procedure that is used commonly in a clinical setting.

J Orthop Sports Phys Ther 2010;40(10):648-655, Epub 20 July 2010. doi:10.2519/jospt.2010.3164

KEY WORDS: electromyography, EMG, gluteus medius, pronation, vastus medialis

SYNOPSIS: Injuries to the posterolateral corner of the knee pose a significant challenge to sports medicine team members due to their complex nature. Identifying posterolateral corner injuries is paramount to determining proper surgical management of the injured athlete, with the goal of preventing chronic pain, instability, and/or surgical failure. Postoperative rehabilitation is based on the specific structural involvement and surgical procedures. A firm understanding of the anatomy and biomechanics of the structures of the posterolateral corner is essential for successful rehabilitation outcomes. Emphasis is placed on protection of the healing surgical repair/reconstruction, with gradual restoration of range of motion, strength, proprioception, and dynamic function of the knee. The purpose of this paper is to provide an overview of the anatomy, biomechanics, and mechanism of injury for posterolateral corner injuries, with a review of clinical examination techniques for identifying these injuries. Furthermore, a review of current surgical management and postoperative guidelines is provided. LEVEL OF EVIDENCE: Diagnosis/therapy, level 5.

J Orthop Sports Phys Ther 2010;40(8):502-516; Epub 13 May 2010. doi:10.2519/jospt.2010.3269

KEY WORDS: fibular collateral ligament, multiligamentous knee injuries, rehabilitation

STUDY DESIGN: Case report. BACKGROUND: Differential diagnosis for patients with radial wrist pain requires consideration of systemic disease, referred pain to the radial aspect of the wrist, and local dysfunction. The list of possible local dysfunctions should include De Quervain syndrome, as well as entrapment neuropathy of the superficial radial nerve. CASE DESCRIPTION: The patient was a 57-year-old man with right radial wrist pain of 6 months’ duration. The referral diagnosis was De Quervain syndrome, but a previous course of electrophysical agents-based physical therapy management had been unsuccessful. The physical examination ruled out the cervical, shoulder, elbow, and wrist joints as possible sources of pain. In this case, the diagnosis of entrapment neuropathy of the superficial radial nerve, rather than De Quervain syndrome, was primarily based on the symptom provocation resulting from a modified radial bias upper limb nerve tension test. Based on this diagnosis, treatment consisted of active and passive exercises using neurodynamic techniques. OUTCOMES: After 1 treatment session, the patient noted changes with regard to current pain intensity and function that exceeded the minimal clinically important difference and the minimal detectable change, respectively. After only 2 treatment sessions, the patient reported a complete resolution of symptoms and a full return to work. DISCUSSION: This case report critically evaluates the diagnostic process for patients with radial wrist pain and suggests neuropathy of the superficial sensory branch of the radial nerve as a differential diagnostic option. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2010;40(6):361-368, Epub 22 April 2010. doi:10.2519/jospt.2010.3210

KEY WORDS: De Quervain syndrome, neuropathy, superficial sensory branch radial nerve, thumb

STUDY DESIGN: Systematic literature review. OBJECTIVE: To perform a systematic review of randomized controlled trials assessing the effects of neuromuscular electrical stimulation (NMES) on quadriceps strength, functional performance, and self-reported function after anterior cruciate ligament reconstruction. BACKGROUND: Conflicting evidence exists regarding the effectiveness of NMES following anterior cruciate ligament reconstruction. METHODS: Searches were performed for randomized controlled trials using electronic databases from 1966 through October 2008. Methodological quality was assessed using the Physiotherapy Evidence Database Scale. Between-group effect sizes and 95% confidence intervals (CIs) were calculated. RESULTS: Eight randomized controlled trials were included. The average Physiotherapy Evidence Database Scale score was 4 out of possible maximum 10. The effect sizes for quadriceps strength measures (isometric or isokinetic torque) from 7 studies ranged from –0.74 to 3.81 at approximately 6 weeks postoperatively; 6 of 11 comparisons were statistically significant, with strength benefits favoring NMES treatment. The effect sizes for functional performance measures from 1 study ranged from 0.07 to 0.64 at 6 weeks postoperatively; none of 3 comparisons were statistically significant, and the effect sizes for self-reported function measures from 1 study were 0.66 and 0.72 at 12 to 16 weeks postoperatively; both comparisons were statistically significant, with benefits favoring NMES treatment. CONCLUSION: NMES combined with exercise may be more effective in improving quadriceps strength than exercise alone, whereas its effect on functional performance and patient-oriented outcomes is inconclusive. Inconsistencies were noted in the NMES parameters and application of NMES. LEVEL OF EVIDENCE: Therapy, level 1a–.

J Orthop Sports Phys Ther 2010;40(7):383-391, Epub 15 April 2010. doi:10.2519/jospt.2010.3184

KEY WORDS: ACL, electromodality, postsurgical knee rehabilitation, randomized clinical trials

STUDY DESIGN: Single-group, prospective, repeated-measures design. OBJECTIVES: To determine differences in the changes of diffusion of water in the L5-S1 intervertebral disc between subjects with nonspecific low back pain (LBP) who reported an immediate reduction in pain intensity of 2 or greater on an 11-point (0-10) numeric rating scale after a 10-minute session of lumbar joint mobilization, followed by prone press-up exercises, compared to those who did not report an immediate reduction in pain intensity of 2 or greater on the pain scale. BACKGROUND: Combining lumbar joint mobilization and prone press-up exercises is a common intervention for patients with LBP; however, there is conflicting evidence regarding the effectiveness and efficacy of this approach. Increased knowledge of the physiologic effects of the combined use of these treatments, and the relationship to pain reports, can lead to refinement of their clinical application. METHODS: Twenty adults, aged 22 to 54, participated in this study. All subjects reported LBP of at least 2 on an 11-point (0-10) verbally administered numeric rating scale at the time of enrollment in the study and were classified as being candidates for the combination of joint mobilization and prone press-ups. Subjects underwent T2- and diffusion-weighted lumbar magnetic resonance imaging scans before and immediately after receiving a 10-minute session of lumbar pressures in a posterior-to-anterior direction and prone press-up exercises. Subjects who reported a decrease in current pain intensity of 2 or greater immediately following treatment were classified as immediate responders, while the remainder were classified as not-immediate responders. The apparent diffusion coefficient, representing the diffusion of water in the nucleus pulposis, was calculated from the midsagittal diffusion-weighted images. RESULTS: Following treatment, immediate responders (n = 10) had a mean increase in the apparent diffusion coefficient in the middle portion of the L5-S1 intervertebral disc of 4.2% compared to a mean decrease of 1.6% for the not-immediate responders (P<.005). CONCLUSION: In a group of subjects with LBP, who were classified as being candidates for extension-based treatment, the report of an immediate reduction in pain intensity of 2/10 of greater after a treatment of posterior-to-anterior–directed pressures, followed by prone press-up exercises, was associated with an increase in diffusion of water in the nuclear region of the L5-S1 intervertebral disc. Subjects who did not report a pain reduction of at least 2/10 did not have a change in diffusion.

J Orthop Sports Phys Ther 2010;40(5):256-264, Epub 12 March 2010. doi:10.2519/jospt.2010.3284

KEY WORDS: low back pain, magnetic resonance imaging, manual therapy

STUDY DESIGN: Single-subject with repeated measures. OBJECTIVES: To determine if runners can use real-time visual feedback from an accelerometer to achieve immediate reductions in tibial acceleration and vertical-force loading rates. BACKGROUND: Stress fractures are a common injury among runners. Previous studies suggest that runners with higher than normal tibial acceleration and vertical-force loading rates are at increased risk for tibial stress fractures. If these runners can be trained to reduce the loading on their lower extremities, it may reduce their risk of stress fractures. METHODS: Five subjects participated in this study. All subjects ran on a treadmill, instrumented with force transducers, during a single 30-minute session that was divided into warm-up, feedback, no-feedback, and cool-down periods. During running, the subjects also wore an accelerometer taped to their distal right tibia. Peak positive acceleration of the tibia, vertical force impact peak, and average and instantaneous vertical-force loading rates were assessed at the end of the warm-up, feedback, and no-feedback periods. RESULTS: Single-subject analysis revealed that 4 of the 5 subjects had significant reductions in their peak positive acceleration at the end of the no-feedback period compared to the warm-up. In addition, all of the subjects had significant decreases in impact peak and vertical ground reaction force loading rates at the end of the no-feedback period. CONCLUSION: In a single session of training with real-time visual feedback, it appears that most runners can reduce the types of lower extremity loading associated with stress fractures. This may lead to training programs that reduce the risk of stress fractures for runners. LEVEL OF EVIDENCE: Prevention, level 5.

J Orthop Sports Phys Ther 2010;40(4):206-213, Epub 12 March 2010. doi:10.2519/jospt.2010.3166

KEY WORDS: accelerometer, gait retraining, ground reaction forces, stress fracture, tibia

STUDY DESIGN: Randomized clinical trial. OBJECTIVES: Determine effective interventions for improving readiness to return to sports postoperatively in patients with complete, unilateral, anterior cruciate ligament (ACL) rupture who do not compensate well after the injury (noncopers). Specifically, we compared the effects of 2 preoperative interventions on quadriceps strength and functional outcomes. BACKGROUND: The percentage of athletes who return to sports after ACL reconstruction varies considerably, possibly due to differential responses after acute ACL rupture and different management. Prognostic data for noncopers following ACL reconstruction is absent in the literature. METHODS: Forty noncopers were randomly assigned to receive either progressive quadriceps strength-training exercises (STR group) or perturbation training in conjunction with strength-training exercises (PERT group) for 10 preoperative rehabilitation sessions. Postoperative rehabilitation was similar between groups. Data on quadriceps strength indices [(involved limb/uninvolved limb force) × 100], 4 hop score indices, and 2 self-report questionnaires were collected preoperatively and 3, 6, and 12 months postoperatively. Mann-Whitney U tests were used to compare functional differences between the groups. Chi-square tests were used to compare frequencies of passing functional criteria and reasons for differences in performance between groups postoperatively. RESULTS: Functional outcomes were not different between groups, except a greater number of patients in the PERT group achieved global rating scores (current knee function expressed as a percentage of overall knee function prior to injury) necessary to pass return-to-sports criteria 6 and 12 months after surgery. Mean scores for each functional outcome met return-to-sports criteria 6 and 12 months postoperatively. Frequency counts of individual data, however, indicated that 5% of noncopers passed RTS criteria at 3, 48% at 6, and 78% at 12 months after surgery. CONCLUSION: Functional outcomes suggest that a subgroup of noncopers require additional supervised rehabilitation to pass stringent criteria to return to sports. LEVEL OF EVIDENCE: Therapy, level 2b.

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J Orthop Sports Phys Ther 2010;40(3):141-154, Epub 30 January 2010. doi:10.2519/jospt.2010.3168

KEY WORDS: ACL, knee, outcomes measures, rehabilitation