Journal of Orthopaedic & Sports Physical Therapy - May 2003 Volume 33, No. 5

Priorities for Orthopaedic and Sports Physical Therapy Research: Assessing Outcomes or Understanding Mechanisms?

The future of orthopaedic and sports physical therapy will ultimately depend on the combination of outcomes and mechanistic research. One could argue that clinic-based research meets our more immediate needs, however, basic and applied research is certainly necessary in the long term. We cannot afford to make the same mistake of the last 30 years by focusing too heavily on 1 type of research, as neither type can exist in isolation and both should be occurring simultaneously. The fact of the matter is that many of the future researchers in physical therapy are still being trained in basic and applied sciences laboratories and their potential contribution to physical therapy science cannot be ignored. Such research efforts should be viewed as opportunities and embraced by the granting agencies within the American Physical Therapy Association, whether it is the Foundation for Physical Therapy or individual sections. Ultimately, the combination of basic, applied, and clinical research will provide a more comprehensive scientific foundation for practice by ensuring that the immediate and future research needs of physical therapy are met.

J Orthop Sports Phys Ther. 2003;33(5):219-220.

Key Words: basic research, applied research

Limb Length Inequality: Clinical Implications for Assessment and Intervention

Rebecca J. Brady, John B. Dean, T. Marc Skinner, Michael T. Gross

The purpose of this paper is to review relevant literature concerning limb length inequalities in adults and to make recommendations for assessment and intervention based on the literature and our own clinical experience. Literature searches were conducted in the MEDLINE, PubMed, and CINAHL databases. Limb length inequality and common classification criteria are defined and etiological factors are presented. Common methods of detecting limb length inequality include direct (tape measure methods), indirect (pelvic leveling), and radiological techniques. Interventions include shoe inserts or external shoe lift therapy for mild cases. Surgery may be appropriate in severe cases. Little agreement exists regarding the prevalence of limb length inequality, the degree of limb length inequality that is considered clinically significant, and the reliability and validity of assessment methods. Based on correlational studies, the relationship between limb length inequality and orthopaedic pathologies is questionable. Stronger support for the link between low back pain (LBP) and limb length inequality is provided by intervention studies. Methods involving palpation of pelvic landmarks with block correction have the most support for clinical assessment of limb length inequality. Standing radiographs are suggested when clinical assessment methods are unsatisfactory. Clinicians should exercise caution when undertaking intervention strategies for limb length inequality of less than 5 mm when limb length inequality has been identified with clinical techniques. Recommendations are provided regarding intervention strategies.

J Orthop Sports Phys Ther. 2003;33(5):221-234.

Key Words: assessment, leg length discrepancy, leg length inequality, treatment, unequal leg lengths

Reliability of Classifications Derived From Cyriax’s Resisted Testing in Subjects With Painful Shoulders and Knees

Karen W. Hayes, Cheryl M. Petersen
Study Design: Intrarater and interrater reliability. Objectives: Examine intrarater and interrater reliability of the resisted-testing component of Cyriax’s selective tension testing for patients with painful shoulders and knees. Background: Clinicians make diagnostic and intervention decisions about lesions in contractile tissues based on resisted testing. Diagnostic and intervention decisions require reliable data gathering, especially when more than 1 physical therapist manages a patient. No studies have examined agreement of the results of the resisted tests used in selective tension testing, either within or between physical therapists, in subjects having pathology. Methods and Measures: Subjects with pain in 1 knee (18 male, 22 female; mean age ± SD = 31.8 ± 9.5 years) or shoulder (21 male, 25 female; mean age ± SD = 34.3 ± 12.9 years) were examined twice. Referring diagnoses included ligament injuries, overuse syndromes, joint instability, and postsurgical symptoms, with some subjects seeking initial diagnosis. Two physical therapists used standardized positions to evaluate 2 knee motions or 6 shoulder and elbow motions. Evaluators applied maximal isometric manual resistance and rated the contraction as strong or weak while subjects identified the presence or absence of pain during the contraction. Evaluators did not interview the subjects and were masked to previous test results. Analyses included percentage of agreement, kappa coefficients, confidence intervals, and maximum kappa coefficients. Results: Intrarater kappa coefficients ranged from 0.44 to 0.82 and interrater coefficients ranged from 0.00 to 0.46. The small number of subjects who were classified as weak affected the kappa coefficients. In the intrarater condition, evaluators averaged 91% of maximum kappa for the knee and 66.5% for the shoulder. In the interrater condition, they averaged 60.4% of the maximum kappa for both the knee and the shoulder. Conclusions: Based on 2 physical therapist evaluators with previous education in the selective tension system and an additional 6 hours of formal training on the methods, intrarater reliability of resisted tests was generally acceptable for the knee but not for the shoulder. Interrater reliability of these tests, however, was generally not acceptable. Results were limited by subjects who were younger and had mostly chronic conditions that were mildly to moderately severe and by the small subject samples in the analyses. Reliability might be improved by more intensive training of the evaluators and by standardizing the magnitude of the applied resistance and stabilization of the subjects.

J Orthop Phys Sports Ther. 2003;33(5):235-246.

Key Words: orthopedics, physical therapy, tests and measurements

Surface Electromyographic Analysis of Exercises for the Trapezius and SerratusAnterior Muscles

Robert A. Donatelli, Richard A. Ekstrom, Gary L. Soderberg
Study Design: This study used a prospective, single-group repeated-measures design to analyze differences between the electromyographic (EMG) amplitudes produced by exercises for the trapezius and serratus anterior muscles. Objective: To identify high-intensity exercises that elicit the greatest level of EMG activity in the trapezius and serratus anterior muscles. Background: The trapezius and serratus anterior muscles are considered to be the only upward rotators of the scapula and are important for normal shoulder function. Electromyographic studies have been performed for these muscles during active and low-intensity exercises, but they have not been analyzed during high intensity exercises. Methods and Measures: Surface electrodes recorded EMG activity of the upper, middle, and lower trapezius and serratus anterior muscles during 10 exercises in 30 healthy subjects. Results: The unilateral shoulder shrug exercise was found to produce the greatest EMG activity in the upper trapezius. For the middle trapezius, the greatest EMG amplitudes were generated with 2 exercises: shoulder horizontal extension with external rotation and the overhead arm raise in line with the lower trapezius muscle in the prone position. The arm raise overhead exercise in the prone position produced the maximum EMG activity in the lower trapezius. The serratus anterior was activated maximally with exercises requiring a great amount of upward rotation of the scapula. The exercises were shoulder abduction in the plane of the scapula above 120° and a diagonal exercise with a combination of shoulder flexion, horizontal flexion, and external rotation. Conclusion: This study identified exercises that maximally activate the trapezius and serratus anterior muscles. This information may be helpful for clinicians in developing exercise programs for these muscles.

J Orthop Sports Phys Ther. 2003;33(5):247-258.

Key Words: scapula, shoulder, strength, upper extremity

Clinical Decision Making in the Identification of Patients Likely to Benefit From Spinal Manipulation: A Traditional Versus an Evidence-Based Approach

Maj John D. Childs, Julie M. Fritz, Sara R. Piva, Richard E. Erhard

Growing evidence suggests that spinal manipulation is effective in the management of low back pain (LBP). However, in the absence of evidence of an alternative approach, clinicians have primarily relied on diagnostic tests with questionable reliability and validity in the clinical decision-making process to identify potential candidates for spinal manipulation. These 2 cases highlight the use of a clinical prediction rule (CPR) developed by Flynn et al, which demonstrates that there are a few simple criteria from the history and physical examination that can be used to help clinicians decide if spinal manipulation and a range of motion (ROM) exercise may be helpful in the management of a patient with LBP. Importantly, these results provide clinicians with an easy-to-use procedure to accurately identify patients with LBP who are likely to achieve a dramatic improvement prior to treatment.

We believe this CPR offers clinicians an efficient and practical evidence-based tool that can be applied by even the novice physical therapist who is familiar with the CPR and the technique that was used in its development. This CPR should encourage clinicians who were previously reluctant to incorporate spinal manipulation into their clinical practice to use it more frequently based on a patient’s status with respect to the CPR.

J Orthop Sports Phys Ther. 2003;33(5):259-272.

Key Words: low back pain, spinal manipulation, clinical prediction rule

Self-Reported Giving-Way Episode During a Stepping-Down Task: Case Report of a Subject With an ACL-Deficient Knee

Jeff R. Houck, Amy Lerner, David Gushue, H. John Yack
Study Design: Case report. Objective: To describe the knee kinematics and moments of a giving-way trial of a subject with an anterior-cruciate-ligament– (ACL) deficient knee relative to his non–giving-way trials and to healthy subjects during a step-down task. Background: Episodes of giving way are believed to damage joint structures, therefore treatments aim to prevent giving-way episodes, yet few studies document giving-way events. Methods: The giving-way trial experienced by a 32-year-old male subject with ACL deficiency during a step-down task was compared to his non–giving-way trials (n = 5) and data from healthy subjects (n = 20). Position data collected at 60 Hz were combined with anthropometric data and ground reaction force data collected at 300 Hz to estimate knee displacement and 3-dimensional angles and net joint moments. Results: The knee joint displacement was higher during the giving-way trial: from 4% to 32% of stance, reaching 9.0 mm at 18% of stance as compared to 1.6 ± 0.7 mm for the non–giving-way trials. After 4% of stance, the knee flexion angle of the giving-way trial was 6.6° higher than the non–giving-way trials and was associated with a higher knee extension moment. The knee frontal plane moment was near neutral during early stance of the giving-way trial in contrast to the non-giving way and healthy subjects which demonstrated a knee abduction moment. Conclusions: The response of this subject to the giving-way event suggests that higher knee flexion angles may enhance knee stability and, in reaction to the giving-way event, that knee extension moment may increase.

J Orthop Sports Phys Ther. 2003;33(5):273-287.

Key Words: anterior cruciate ligament, biomechanics, kinematics, knee instability