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

Study Design: Prospective descriptive study.
Objective: To determine the extent of bone mineral density (BMD) interlimb differences at several hip locations in the involved versus noninvolved lower extremity following anterior cruciate ligament (ACL) surgery.
Background: Disuse following ACL reconstruction can be extensive. This disuse not only affects the soft tissue, but may also affect the skeletal structure. The extent of this disuse specific to the proximal femur has not been previously determined.
Methods and Measures: BMD was assessed in 15 subjects, 17 to 51 years old, who were between 6 and 32 months post-ACL reconstruction surgery. Bone mineral content (BMC) and BMD of the femoral neck, trochanteric region, intertrochanteric region, and entire hip were measured as a primary emphasis of this study. BMD and BMC of the entire lower extremities were also measured bilaterally.
Results: BMD was significantly less in the involved lower extremity compared to noninvolved lower extremity at several hip sites: 6.6% less (P<.001) for the trochanteric region, 4.0% less (P<.001) for the entire hip, and 3.4% less (P = .004) for the intertrochanteric region. No significant differences were noted comparing the entire lower extremities for either BMD (0.9%, P = .48) or BMC (3.7%, P = .09).
Conclusion: BMD differences at the hip are significant in patient’s postoperative ACL reconstruction, especially in the trochanteric region.

J Orthop Sports Phys Ther. 2006; 36(11):837-844. doi:10.2519/jospt.2006.2278

Key Words: ACL, anterior cruciate ligament, dual energy X-ray absorptiometry, hip

Study Design: Quasi-experimental design.
Objectives: To determine if physical manipulation of the cranial vault sutures will result in changes of the intracranial pressure (ICP) along with movement at the coronal suture.
Background: Craniosacral therapy is used to treat conditions ranging from headache pain to developmental disabilities. However, the biological premise for this technique has been theorized but not substantiated in the literature.
Methods: Thirteen adult New Zealand white rabbits (oryctolagus cuniculus) were anesthetized and microplates were attached on either side of the coronal suture. Epidural ICP measurements were made using a NeuroMonitor transducer. Distractive loads of 5, 10, 15, and 20 g (simulating a craniosacral frontal lift technique) were applied sequentially across the coronal suture. Baseline and distraction radiographs and ICP were obtained. One animal underwent additional distractive loads between 100 and 10 000 g. Plate separation was measured using a digital caliper from the radiographs. Two-way analysis of variance was used to assess significant differences in ICP and suture movement.
Results: No significant differences were noted between baseline and distraction suture separation (F = 0.045; P>.05) and between baseline and distraction ICP (F = 0.279; P>.05) at any load. In the single animal that underwent additional distractive forces, movement across the coronal suture was not seen until the 500-g force, which produced 0.30 mm of separation but no corresponding ICP changes.
Conclusion: Low loads of force, similar to those used clinically when performing a Craniosacral frontal lift technique, resulted in no significant changes in coronal suture movement or ICP in rabbits. These results suggest that a different biological basis for craniosacral therapy should be explored.

J Orthop Sports Phys Ther. 2006; 36(11):845-853. doi:10.2519/jospt.2006.2278

Key Words: cranial bone movement, cranial sutures, manual therapy

Study Design: Predictive validity/diagnostic test study.
Objective: To determine the predictive validity and interrater reliability of selected clinical exam items and to develop a clinical prediction rule (CPR) to determine which patients respond successfully to patellar taping.
Background: Patellar taping is often used to treat patients with PFPS. However, the characteristics of the patients who respond best to patellar taping intervention have not been identified.
Methods and Measures: Fifty volunteers (27 males, 23 females) with PFPS underwent a standardized clinical examination. Diagnosis of PFPS was based on the complaint of retropatellar pain that was provoked by a partial squat or stair ascent/descent. Subjects performed 3 functional activities and rated their pain during each activity on a numerical rating scale (NPRS). All subjects received treatment with a medial glide patellar-taping technique and repeated the functional activities and pain ratings. An immediate 50% reduction in pain or moderate improvement on a global rating of change (GRC) questionnaire was considered a treatment success. Likelihood ratios (LRs) were calculated to determine which examination items were most predictive of treatment outcome. Logistic regression analysis identified items included in the CPR.
Results: Twenty-six subjects (52%) had an immediate successful response to the intervention. Two examination items (positive patellar tilt test or tibial varum greater than 5°, +LR = 4.4) comprised the CPR. Application of the CPR improved the probability of a successful outcome from 52% to 83%. Fifty-eight percent of the lower extremity measures were associated with moderate to good reliability (reliability coefficient range, 0.52-0.84). The reliability coefficients for the items that comprised the CPR were 0.49 (patellar tilt) and 0.66 (tibial varum).
Conclusion: A CPR was developed to predict an immediate successful response to a medial glide patellar taping technique. Validation of the CPR in an independent sample is necessary before widespread clinical use can be recommended.

J Orthop Sports Phys Ther. 2006; 36(11):854-866. doi:10.2519/jospt.2006.2208

Key Words: bracing, knee pain, physical examination, physical therapy, rehabilitation

Study Design: Prospective cohort study.
Objectives: To classify patients with nonacute, nontraumatic neck pain according to the dominant impairment of spinal function, and to determine whether there were differences in the amount of treatment sessions required (treatment dose) to achieve a significant change in the patient’s disorder.
Background: Classification of patients with mechanical neck pain may be an important process in optimizing treatment prescription and evaluating treatment response. However, patient classification has not been used to consider possible differences in the amount of treatment sessions (treatment dose) required to achieve a significant change in the neck pain disorder.
Methods and Measures: Ninety-two patients with nonacute, nontraumatic neck pain were classified into 2 groups, according to the dominant impairment of spinal function. Of the 77 patients who completed treatment, 63 (82%) were classified as having a ‘‘movement disorder,’’ while the remainder was classified into a ‘‘loading disorder’’ group. Physical therapists who were blinded to the patient classification provided multimodal physical therapy treatment as considered appropriate and the patients were discharged when the optimal treatment response had been achieved.
Results: There was no difference in pain intensity or global disability level between the groups at baseline. Both groups achieved a significant improvement in neck pain and disability following treatment, and there was no significant difference between groups in the magnitude of the treatment response. The number of treatment sessions received by the loading group (mean ± SD, 7.3 ± 4.5) was significantly lower than the number received by the movement group (mean ± SD, 11.5 ± 5.9; 95% CI: –7.6 to –0.8; P<.01). Patients in the loading group were 2.4 times as likely to be discharged at any particular treatment session (95% CI: 1.1 to 4.1, P<.005) compared to those in the movement group.
Conclusion: For patients with nontraumatic neck pain, classification according to impairment of spinal function may be a useful indicator of the number of physical therapy treatment sessions required to achieve a significant treatment response.

J Orthop Sports Phys Ther. 2006; 36(11):867-875. doi:10.2519/jospt.2006.2299

Key Words: classification, neck pain, physical therapy, treatment dose

Study Design: Nonexperimental, normative research design.
Objectives: To test a proposed model to locate the level of the transverse processes (TPs) of the thoracic spine through surface palpation.
Background: Palpation of the TPs of the thoracic spine is challenging because of their depth relative to the more superficial structures of the spine. Many clinicians use the more superficial spinous processes (SPs) of the thoracic spine to orient themselves for palpation of the TPs. In 1979, Mitchell described a ‘‘rule of threes,’’ which attempted to predict the location of the level of the thoracic TPs relative to their corresponding SPs. We previously conducted a pilot study to investigate the validity of the rule of threes and concluded that it is not an accurate predictor of the level of the location of the TPs of the thoracic spine. Based on that previous work, we hypothesized that a more accurate model for predicting the level of the TPs would be that they are generally at the level of the SP of the adjacent cranial thoracic vertebra throughout the thoracic spine.
Methods and Measures: We dissected 15 cadavers and measured the vertical distance between the transverse (horizontal) plane of the TPs of 1 vertebra and the SP of the adjacent cranial thoracic vertebra for all levels of the thoracic spine.
Results: Mean vertical distances ranged from 2.0 to 4.0 mm. The means for all thoracic vertebral levels except for T11 and T12 were significantly less than the normal 6-mm threshold of 2-point discrimination of the fingertips (P<.01).
Conclusion: The results of this study indicate that the TPs of each thoracic vertebra are generally at the level of the SP of the vertebra 1 level above, throughout the thoracic spine. It may be more difficult to predict the location of the TPs of the 2 most caudal levels (T11 and T12), given their greater variability of position.

J Orthop Sports Phys Ther. 2006; 36(11):876-881. doi:10.2519/jospt.2006.2243

Key Words: thoracic vertebrae, rule of threes, palpation, surface anatomy

Study Design: Resident’s case problem.
Background: The popularity of weight training has increased dramatically during the past 20 years. With the increase in popularity of weight training, the rate of injury has also increased dramatically. The types of injuries range from benign to life threatening.
Diagnosis: The patient was a 21-year-old woman originally referred for pelvic pain who presented with new complaints of right upper extremity swelling, discomfort, and cyanosis after recently beginning a comprehensive weight-lifting program. Additional signs, including paresthesias, decreased pulses, and venous distension, warranted a timely referral by the physical therapist back to the referring physician.
Discussion: The primary injury in this case report was hypothesized to have been induced by the recent start of a weight-lifting program, with no other significant contributing risk factors. A comprehensive examination by the physical therapist revealed clinical signs of an upper extremity deep vein thrombosis, leading to a same-day referral back to the referring physician. Further research, resulting in a clinical decision rule for upper extremity deep vein thrombosis or estimates of diagnostic accuracy of clinical signs and symptoms, would improve the diagnostic process.

J Orthop Sports Phys Ther. 2006; 36(11):882-886. doi:10.2519/jospt.2006.2250

Key Words: Paget-Schroetter syndrome, primary axillary-subclavian thrombosis, thoracic outlet syndrome, upper extremity deep vein thrombosis

Study Design: Case report.
Background: Back pain is a common presentation of patients in the orthopedic physical therapy setting. In an athletic environment, back pain can limit an athlete’s ability to perform running, cutting, and throwing. This case report describes the use of a spinal nonthrust manipulation in conjunction with therapeutic exercise for the management of thoracic and rib pain in an adolescent athlete.
Case Description: A 16-year-old male presented to the outpatient clinic without physician referral. His chief complaint was right-sided thoracic and rib pain during running, jumping, cutting, and kicking that began 1 month before the initial physical therapy visit. He had no previous episodes of pain or associated injuries. A screening examination for serious underlying pathology was negative. After physical examination, it was determined that manual therapy was indicated. A thoracic nonthrust manipulation was applied to the painful area (the right-side thoracic facet joints of segments 5-7).
Outcomes: Immediately after the thoracic nonthrust manipulation, the patient experienced a decrease in tenderness to palpation of the thoracic erector spinae musculature and the associated intercostal spaces of ribs 6 through 8 (a decrease of 1-2 points on the pain scale), an increase in thoracic side-bending active range of motion recorded at T3 and T9, and improved chest expansion, which had been limited by pain before treatment.
Discussion: This case report demonstrates the use of a spinal nonthrust manipulation that seems to have helped an adolescent return to pain-free sports activity, with an immediate decrease in pain after 1 visit. Follow-up telephone calls were made 1 month and 9 months after treatment, in which no return of symptoms was reported.

J Orthop Sports Phys Ther. 2006; 36(11):887-892. doi:10.2519/jospt.2006.2248

Key Words: back, mobilization, spine, thorax

The Third International Ankle Symposium (IAS3), a multidisciplinary conference focused on topics related to ankle sprains, instability, and rehabilitation, was recently held in Dublin, Ireland on the campus of University College Dublin. The organizing committee included: Brian Caulfield (University College Dublin), Garrett Coughlan (University College Dublin), Eamonn Delahunt (University College Dublin), Ruth Gibson (St. Vincent’s University Hospital, Dublin), Jay Hertel (University of Virginia), Thomas Kaminski (University of Delaware), Phillip Gribble (University of Toledo) and Kenneth Monaghan (University College Dublin). This symposium served to follow up on the solid foundations laid down at previous symposia in Ulm, Germany in 2000 and Delaware, USA in 2004.

IAS3 brought together over 150 clinicians and scientists from disciplines such as physiotherapy, athletic training, orthopaedics, podiatry, and biomechanics. Participants represented many countries, including Australia, New Zealand, Brazil, Belgium, Germany, Ireland, Great Britain, Denmark, Switzerland, Portugal, Norway, Canada, and the United States. A call for abstracts was initially distributed in late 2005. Prospective attendees were invited to submit abstracts of work relating to original research, case studies, or clinical commentaries. All submitted abstracts were reviewed for scientific merit by members of the organizing committee. Fifty-four abstracts were accepted and presented at the symposium.

The scientific program consisted of 8 invited keynote lectures from internationally recognized experts and 22 podium and 32 poster presentations of original research. The choice of keynote lecture topics and speakers was designed to appeal to clinicians and scientists alike and the keynote series included lectures on features and causes of ankle instability as well as clinical lectures relating to assessment and rehabilitation of ankle injuries. The symposium was kicked off with a presentation from an Irish rugby star, Mr. Gordon D’Arcy, who spoke about injury management and scientific research from the perspective of the professional sportsperson. The symposium also provided for considerable scholarly and social interaction among the attendees. A highlight of the weekend was a state reception that was hosted by An Tánaiste, Mary Harney TD (the Irish Deputy Prime Minister) in the historic Iveagh House to honor the occasion of the symposium being held in Ireland.

The meeting also provided an opportunity for further development of the work of the International Ankle Consortium, a multidisciplinary group that was formed at IAS2 with the aim of promoting increased harmonization and collaboration in ankle research. Members of this group presented a discussion poster at the conference with the aim of stimulating debate on standards for classification of subjects in ankle instability research. Plans have already commenced for the Fourth International Ankle Symposium, which will be held in Australia during July 2008. Included in this article are a summary statement for the conference, abstracts of the keynote lectures, and the abstracts of the original research presentations (podium and poster) from IAS3.