In the early 1960s I participated in a job analysis study that was used as a basis for deciding whether physical therapists were professionals or technicians. Because of the decisions we made about patient care, we were designated as professionals. Not only were the decisions I made about patient care in those days relatively simple but they were also based on a relatively shallow level of knowledge. One of the best-kept secrets of our profession is escalation in the complexity of our decisions over the past 40 years. The depth of knowledge upon which we base our decisions has also increased significantly. But has the respect of our referral sources for our role changed in the same manner as our clinical decisions? Probably the most obvious change in our referral relationship is that the ‘‘prescription'' or referral form no longer lists all the modalities that the physician should check. Though many clinicians are respected for their abilities to help patients, I question whether the referral source recognizes that physical therapists should be able to make diagnostic decisions. Certainly part of the problem is a lack of clarity about the type of diagnoses physical therapists make or how these diagnoses reflect our scope of practice. Does the physician clearly understand how our scope of practice complements rather than conflicts with medical practice and that we are not making medical diagnoses?

J Orthop Sports Phys Ther. 2005; 35(9):556-558. doi:10.2519/jospt.2005.0109

Key Words: diagnosis

Study Design: Correlational study. Objectives: To determine whether, and to what degree, a relationship exists between forefoot angle and weight-bearing midfoot and rearfoot position. Background: There have been conflicting reports with regard to the degree to which the structure of the foot may influence the function. The influence of forefoot structure on weight-bearing midfoot and rearfoot position has not been extensively investigated. Methods and Measures: Fifty-one healthy subjects participated in this study (26 male and 25 female). Forefoot angle was measured in prone as varus (positive numbers), neutral (0), or valgus (negative numbers). Navicular drop was measured from subtalar joint neutral to unilateral standing relaxed. Rearfoot angle was measured in relaxed single-limb stance as the angle between a line that bisected the calcaneus and a line that bisected the lower third of the leg. The relationships between forefoot angle and navicular drop, and between forefoot angle and relaxed rearfoot angle, were investigated. The same relationships were also investigated in the neutral forefoot subgroup when the sample was divided in 3 subgroups based on 1 standard deviation of forefoot angle. Results: There is a significant relationship between forefoot angle and relaxed rearfoot angle (r = 0.52, P<.001), as well as between forefoot angle and navicular drop (r = 0.55, P<.001), in the whole sample (n = 51). Average degrees of forefoot angle in the neutral subgroup (between 1.0° and 8° of varus) are not associated with predictable positions of relaxed rearfoot angle (r = 0.19, P = .24) or navicular drop (r = 0.01, P = .96). Conclusions: Based on the results of this study, there is a significant relationship between forefoot angle and relaxed rearfoot angle, as well as between forefoot angle and navicular drop, in healthy subjects. These relationships were not found when forefoot varus values were within a standard deviation of the sample mean.

J Orthop Sports Phys Ther. 2005;35(9):559-566. doi:10.2519/jospt.2005.1541

Key Words: biomechanics, foot position, pronation, subtalar joint

Study Design: Cross-sectional comparative study. Objective: To compare the performance of the deep cervical flexor muscles on the craniocervical flexion test (CCFT) in individuals with and without neck pain. Background: Significant weakness of the superficial neck muscles is often found in patients with neck pain. However, there is scant work on deep cervical flexors performance in subjects with chronic nonspecific neck pain. Methods and Measures: Twenty asymptomatic subjects and 20 subjects with chronic neck pain (duration, >3 months) were recruited. The CCFT was performed with the subject supine and required performing a gentle head-nodding action of craniocervical flexion (indicating yes) for 5 incremental stages of increasing difficulty. Each stage was held for 10 seconds, as guided by the pressure biofeedback unit. The data used for analysis were the highest pressure level each subject was able to hold for 10 seconds, up to a maximum of 30 mmHg. Results: Reliability data obtained on 10 asymptomatic subjects indicated that the CCFT was reliable, with a kappa coefficient equal to 0.72. Subjects with chronic neck pain had significantly poorer (P<.001) performance on the CCFT (median pressure achieved, 24 mmHg) when compared with those in the asymptomatic group (median pressure achieved, 28 mmHg). Conclusions: The results of this study demonstrated that patients with chronic neck pain had a poorer ability to perform the CCFT when compared with asymptomatic subjects. The study adds to the evidence that poor ability to perform the CCFT may be clinical evidence of an impairment that characterizes neck pain, regardless of origin.

J Orthop Sports Phys Ther. 2005;35(9):567-571. doi:10.2519/jospt.2005.2055

Key Words: cervical spine, pressure biofeedback, strength

Study Design: Randomized multicenter retrospective chart review of medical referral diagnoses and corresponding referral, patient, and physician demographic data. Objective: To examine the information content of medical referral diagnoses provided to outpatient physical therapists with respect to physician and patient characteristics. Background: Previous studies indicate that physicians commonly provide nonspecific referral diagnoses to physical therapists. The effects of patient and physician characteristics on information contained in referral diagnoses are not well elucidated. Methods and Measures: A team of blinded raters categorized the information content of referral diagnoses (n = 2183) using a classification system adapted from a previous study. Results: One third (32%) of analyzed diagnoses were anatomically oriented and reported specific pathology. These specific diagnoses were provided significantly more commonly by specialist physicians (odds ratio [OR], 3.4; 95% confidence interval [CI], 2.7-4.2; P<.001), male physicians (OR, 2.2; 95% CI, 1.6-3.1; P<.001), both early- and late-career physicians (P<.001), and for male patients (OR, 1.3; 95% CI, 1.1-1.6; P<.05). Conclusion: Physicians frequently provide nonspecific referral diagnoses to physical therapists. The practice of evidence-based physical therapy seems challenged by the high rate of nonspecific referral diagnoses. Physical therapists may also have the responsibility to conduct differential diagnosis of pathology more commonly than formally recognized by many state practice acts and third-party payers.

J Orthop Sports Phys Ther. 2005;35(9):572-579. doi:10.2519/jospt.2005.2050

Key Words: differential diagnosis, direct access, primary care

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

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

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

Study Design: Test-retest methodological design using a sample of convenience. Objective: To determine the criterion-related validity and the reliability of measuring first ray mobility with a ruler. Background: Studies have questioned the accuracy of assessing first ray mobility by manual examination. Use of a ruler and adherence to strict guidelines in positioning of the patient may improve the measure. This study investigates the validity, and the intrarater and interrater reliability of measuring dorsal first ray mobility with a ruler while following recent recommendations to standardize the position of measurement. A valid and reliable mechanical device designed to measure first ray mobility was used as the validation criterion of measurement. Methods: Three clinicians performed ruler measurement of dorsal mobility on 14 subjects. A separate examiner measured dorsal mobility with the mechanical device. Intraclass correlation coefficients (ICCs) and standard error of measurements (SEMs) were computed to quantify the intrarater reliability of both testing procedures and the interrater reliability of the ruler measurement. ICCs of agreement were also computed to determine the concurrent validity of the ruler measurement for each clinician. Results: Mechanical device intrarater reliability ICC was 0.98 (SEM = 0.15 mm). Ruler intrarater ICCs were equal or less than –0.06 (SEMs = 1.1 mm); ruler interrater ICC was 0.05 (SEM = 1.2 mm). The ICCs of agreement between the mechanical device and ruler method ranged from –0.44 to 0.06. Conclusion: The ruler method of testing demonstrates poor reliability and validity as a clinical measure.

J Orthop Sports Phys Ther. 2005;35(9):589-593. doi:10.2519/jospt.2005.2023

Key Words: first metatarsal, foot, reliability

Study Design: Nonexperimental, descriptive study, including 2 independent samples. Objectives: To assess the levels of mental distress and self-perceived health in subjects with long-term patellofemoral pain syndrome (PFPS) compared to a group of healthy subjects, and the relationship between knee function and knee pain to these psychological variables. Background: Psychological variables and those describing self-perceived health status have been given little focus in PFPS research. Methods and Measures: One group of 25 men and women between 19 and 44 years of age with unilateral long lasting PFPS, and a control group (n = 23) of healthy subjects (age range, 18-44 years) participated in the study. Knee function was assessed with the use of the Cincinnati Knee Rating System (CKRS) and the triple jump test, and knee pain was measured by a visual analogue scale (VAS). Self-perceived health and mental distress were assessed with the Coop Wonca Chart and the Hopkins Symptoms Checklist-25 (HSCL-25) questionnaire. Results: The mean (±SD) score on the Coop-Wonca Chart was 2.02 ± 0.73 in the PFPS group, compared to 1.20 ± 0.53 in the controls (P<.001). HSCL-25 mean (±SD) scores were 1.46 ± 0.47 and 1.08 ±0.18 (P<.001) for the PFPS and the control group, respectively. When analyzed with correlation statistics, CKRS and VAS scores were found to correlate to those of the Coop-Wonca Chart and HSCL-25 scores. Conclusion: Levels of mental distress were higher in the group with PFPS than in the control group, while levels of self-perceived health were lower. Our data indicate that the levels of knee pain and knee function correlate closely to the degree of mental distress and self-perceived health in individuals with PFPS.

J Orthop Sports Phys Ther. 2005;35(9):594-600. doi:10.2519/jospt.2005.2119

Key Words: anterior knee pain, personality, psychological counseling, psychology