The Manipulation Education Manual (MEM) is an American Physical Therapy Association (APTA) document developed last year by the Manipulation Education Committee of the APTA Manipulation Task Force. The purpose of the MEM is to support and enhance manipulation instruction in physical therapist education programs. In fact, it was the realization that patterns in physical therapist education related to manipulation were not always consistent with the evidence regarding the safety, effectiveness, and legality of high-velocity thrust joint manipulation that led our committee to examine the resources available to faculty responsible for orthopaedic manual therapy instruction.

J Orthop Sports Phys Ther. 2005; 35(7):407-408. doi:10.2519/jospt.2005.0107

Key Words: education, evidence-based practice

Study Design: Case series. Background: Plantar flexion/inversion ankle sprains are one of the most frequently occurring sports injuries. Cuboid syndrome, which is difficult to diagnose, may result from a plantar flexion/ inversion ankle injury and could become the source of lateral ankle/midfoot pain. The objective of this case series is to describe the examination, evaluation, and treatment of the cuboid syndrome following a lateral ankle sprain. Case Description: Seven patients were seen in our clinic 1 to 8 weeks following a lateral ankle sprain with a chief complaint of lateral ankle/midfoot pain. In these 7 patients, 2 examiners identified the presence of cuboid syndrome independently. Treatment consisted of a cuboid manipulation. Outcomes: All 7 patients returned to sports activities following 1 to 2 treatments consisting of the 'cuboid whip' manipulation. No recurrence of symptoms was reported upon immediate return to competition or during the remainder of the season (mean follow-up, 5.7 months; range, 2 to 8 months). Discussion: Based on those 7 patients, our results suggest that patients who are properly diagnosed with cuboid syndrome and receive the cuboid manipulation can return to competitive activity within 1 or 2 visits without injury recurrence.

J Orthop Sports Phys Ther. 2005;35(7):409-415. doi:10.2519/jospt.2005.1596

Key Words: foot, manipulation, manual therapy

Study Design: Descriptive survey. Objective: Describe the availability of thrust joint manipulation clinical educational opportunities for physical therapy professional degree students. Background: In the United States, most of the faculty teaching manual therapy content in physical therapy programs believe that the best way for their students to develop thrust joint manipulation skills is to receive additional training during clinical education experiences. There are no data that describe the availability of such training opportunities. Methods and Measures: Seventy-three physical therapy programs that include thrust joint manipulation in their curricula were divided into 5 geographic regions. Of these programs, 27% (total, n = 20) were randomly selected per region to participate. Program academic coordinators of clinical education (ACCEs) identified their clinical instructors working in outpatient orthopaedic settings. ACCEs and clinical instructors were surveyed regarding thrust joint manipulation clinical education opportunities for students. Results: Survey return rates were 100% for ACCEs and 67.4% for clinical instructors. Of ACCEs, 70% were unsure which sites employed clinical instructors trained in thrust joint manipulation and 85% did not consider whether thrust joint manipulation training was provided when scheduling the experience. The ACCEs who did consider availability cited lack of qualified instructors as the number-one barrier to finding sites that offered thrust joint manipulation. Of clinical instructors, 30% provide thrust joint manipulation training including lecture/theory, technique demonstration, practice on "normals," and direct patient care supervision. Clinical instructors who did not teach thrust joint manipulation cited reasons that included the belief that it is not an entry-level skill (57%), lack of qualified staff (53%), liability concerns (46%), and students not being academically prepared (41%). Conclusions: Results suggest that the availability and scope of thrust joint manipulation clinical educational opportunities are limited, vary considerably, and are not considered when selecting clinical education sites for students. Potential obstacles to offering thrust joint manipulation training were identified, which suggested the need for resources, including clinical education curricula and philosophical guidelines for clinical instructors.

J Orthop Sports Phys Ther. 2005;35(7):416-423.  doi:10.2519/jospt.2005.2115

Key Words: joint mobilization, manipulation, manual therapy, physical therapy education

Study Design: Prospective study with repeated measures. Objectives: The overall goal of this investigation was to describe the time course of recovery of impairments and function after total knee arthroplasty (TKA), as well as to provide direction for rehabilitation efforts. We hypothesized that quadriceps strength would be more strongly correlated with functional performance than knee flexion range of motion (ROM) or pain at all time periods studied before and after TKA. Background: TKA is a very common surgery, but very little is known regarding the influence of impairments on functional limitations in this population. Methods and Measures: Forty subjects, who underwent unilateral TKA followed by rehabilitation, including 6 weeks of outpatient physical therapy, were studied. Testing occurred at 5 time periods: preoperatively, and at 1, 2, 3, and 6 months after surgery. Test measures included quadriceps strength, knee ROM, timed up-and-go test, timed stair-climbing test, bodily pain, and general health and knee function questionnaires. Results: Subjects experienced significant worsening of knee ROM, quadriceps strength, and performance on functional tests 1 month after surgery. Quadriceps strength went through the greatest decline of all the physical measures assessed and never matched the strength of the uninvolved limb. All measures underwent significant improvements following the 1-month test. Quadriceps strength was the most highly correlated measure associated with functional performance at all testing sessions. Conclusions: Functional measures underwent an expected decline early after TKA, but recovery was more rapid than anticipated and long-term outcomes were better than previously reported in the literature. The high correlation between quadriceps strength and functional performance suggests that improved postoperative quadriceps strengthening could be important to enhance the potential benefits of TKA.

J Orthop Sports Phys Ther. 2005;35(7):424-436. doi:10.2519/jospt.2005.2036

Key Words: disability, muscle, outcome, replacement

Study Design: Cross-sectional study. Objective: The self-reported reasons for terminating isometric back extension endurance testing and their associations with test performance and other factors were investigated to gain insight into determinants of test performance. Background: Factors limiting isometric back extension endurance performance remain unclear. Better understanding the reasons for termination of isometric extension endurance testing could provide insights into what the test actually reflects. Methods and Measures: Lifetime work, leisure activities and back pain questionnaire data, isometric back extension endurance testing (holding time, as measured in seconds), and reasons for test termination were obtained for a population-based sample of 544 working-age men. Results: The most common reason for test termination was fatigue (62.5%), followed by pain in various parts of the lower extremities (12.6% ) and back (3.2% ). A history of daily low back pain over the prior 12 months and greater pain intensity of the worst back pain episode over the same period were associated with a greater likelihood of termination due to back pain. In a regression analysis, longer holding time was associated with stopping due to fatigue rather than low back pain, with a trend of 19 seconds (95% confidence interval [CI], -2-40) longer holding time. After controlling for low back pain history, those previously involved in competitive sports were 2.6 times more likely to stop due to pain. Those with a competitive sport history had 14 seconds (95% CI, 5-23) greater holding time than those without such a history. Conclusions: Isometric back extension endurance testing is most commonly reported to be terminated due to muscle-related capacity as indicated by fatigue. Back pain is more likely to decrease performance time in men with a history of significant (frequent, intense) low back symptoms.

J Orthop Sports Phys Ther. 2005;35(7):437-442. doi:10.2519/jospt.2005.2007

Key Words: fatigue, low back pain, lumbar spine, muscle

Study Design: Cross-sectional study. Objective: The purpose of this study was to determine if a sustained fatiguing contraction of the dorsiflexor muscles alters the dynamic position sense (proprioception) and the associated central nervous system processing time of information from the ankle. Background: Ankle injury has been hypothesized to be related to altered proprioception as a consequence of fatiguing exercise. Previous reports assessing proprioception include tests of motor performance (balance and limb repositioning) or tests of a joint under static conditions. This study used a novel experimental approach to test the effects of exercise on the somatosensory system of the ankle. Methods and Measures: Nineteen healthy subjects were tested on their ability to extend the metacarpophalangeal joint of their left index finger when their left ankle was passively plantar flexed (0°-40°, 10 velocities) through a predetermined target angle (20°). Testing occurred before and after a fatiguing contraction of the dorsiflexor muscles. Results: Subjects accurately indicated the ankle target angle up to ankle velocities of 70°/s (300 ms) both before and after the sustained fatiguing contraction. At velocities above 70°/s all subjects could no longer scale to accurately indicate the target angle with the index finger and consequently overshot the target. The central nervous system processing time was estimated to be approximately 85 milliseconds before and after the sustained contraction. Conclusions: These results indicate that a sustained activity of the dorsiflexion muscles of the ankle minimally affects dynamic position sense and the ability to process dynamic position sense information. Understanding the impact of exercise on sensory system processing will be integral to establishing the scientific basis for rehabilitation programs that purport to train proprioception.

J Orthop Sports Phys Ther. 2005;35(7):443-451. doi:10.2519/jospt.2005.1758

Key Words: ankle injuries, fatigue, movement sequence, proprioception

Study Design: Cross-sectional descriptive analysis investigating intrinsic fall risk factors in postmenopausal women with osteoporosis. Objective: To examine the relationships between history of recent falls and balance, pain, quality of life, function, posture, strength, and mobility. Background: Women with osteoporosis who fall are at a high risk of fracture due to decreased bone strength. Identifying fall risk factors for older women with osteoporosis is a crucial step in decreasing the incidence of falls and fracture. Method and Measures: Seventy-three women over 60 years of age with established osteoporosis participated in comprehensive testing of fall history, physical function, and quality of life. Results: Significant correlations were found between a recent history of falls and degree of kyphosis (r = 0.29), fear of falls/emotional status (r = -0.27), and balance (r = -0.27). Degree of kyphosis and fear of falls/emotional status explained 20% of the variance of recent fall history using binary logistic regression. Women with an increased kyphosis were more likely to have had a recent fall (odds ratio [OR], 1.17; 95% CI, 1.03-1.34) and those with better emotional status and less fear of falling were less likely to have had a recent fall (OR, 0.61; 95% CI, 0.38-0.97). Conclusion: Increased thoracic kyphosis and fear of falling are 2 intrinsic factors associated with recent falls in women with osteoporosis. To design more effective interventions to decrease fall risk in this population, future prospective, longitudinal studies should monitor kyphosis, fear of falling, balance reactions, and other potential risk factors not identified in this study.

J Orthop Sports Phys Ther. 2005;35(7):452-460. doi:10.2519/jospt.2005.2029

Key Words: fracture, frail elderly, quality of life