• "Including a Single Study Multiple Times in a Meta-analysis" and Authors' Response
• "Foot Strike Patterns in Runners" and Authors' Response

The patient was a 20-year-old man who was referred to a physical therapist 6 weeks following an inversion sprain of his right ankle. Radiographs were completed and had been interpreted as normal, but due to continued complaints of instability and marked laxity on examination, ankle stress radiographs were ordered. Talar tilt stress radiographs were suggestive of lateral ligamentous insufficiency of the right ankle.

J Orthop Sports Phys Ther 2012;42(2):145. doi:10.2519/jospt.2012.0403

KEY WORDS: ankle stress radiographs, radiography, talar tilt

STUDY DESIGN: Case report. BACKGROUND: Rehabilitation that includes progressive quadriceps strengthening after total knee arthroplasty (TKA) leads to superior outcomes. Though patients with TKA show marked functional improvement after outpatient physical therapy, they continue to adopt movement asymmetries characterized by reduced knee excursion on the operated limb and excessive loading on the contralateral limb. The purpose of this case report was to describe the functional and biomechanical improvements in a patient who, after TKA, participated in a novel physical therapy protocol that included retraining of symmetrical movement patterns. CASE DESCRIPTION: A 57-year-old female with unilateral knee osteoarthritis was evaluated prior to TKA and at 3 and 10 weeks after surgery. Postoperative rehabilitation included progressive quadriceps strengthening and movement retraining that consisted of visual, verbal, and tactile feedback to promote symmetrical weight bearing during strengthening exercises and functional activities. Outcomes were compared to a historical cohort of patients with TKA. OUTCOMES: Prior to TKA, the patient scored below average on all functional measures and walked with knee biomechanics that were abnormal and asymmetrical. After symmetry retraining, her knee motion and moments were restored to normal levels. The patient also walked with greater magnitude and more symmetrical knee excursion compared to a cohort of similar patients. DISCUSSION: This case report describes the use of a novel rehabilitation protocol intended to improve walking biomechanics and functional outcomes after TKA. Restoration of symmetrical movement patterns could improve long-term outcomes of TKA. Further research is needed to evaluate the effectiveness and implementation of similar rehabilitation strategies in a wide range of patients after TKA. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2012;42(2):135-144. doi:10.2519/jospt.2012.3773

KEY WORDS: motion analysis, osteoarthritis, physical therapy, rehabilitation, total knee replacement

STUDY DESIGN: Randomized clinical trial. OBJECTIVES: To determine whether manipulation of the proximal or distal tibiofibular joint would change ankle dorsiflexion range of motion and functional outcomes over a 3-week period in individuals with chronic ankle instability. BACKGROUND: Altered joint arthrokinematics may play a role in chronic ankle instability dysfunction. Joint mobilization or manipulation may offer the ability to restore normal joint arthrokinematics and improve function. METHODS: Forty-three participants (mean ± SD age, 25.6 ± 7.6 years; height, 174.3 ± 10.2 cm; mass, 74.6 ± 16.7 kg) with chronic ankle instability were randomized to proximal tibiofibular joint manipulation, distal tibiofibular joint manipulation, or a control group. Outcome measures included ankle dorsiflexion range of motion, the single-limb stance on foam component of the Balance Error Scoring System, the step-down test, and the Foot and Ankle Ability Measure sports subscale. Measurements were obtained prior to the intervention (before day 1) and following the intervention (on days 1, 7, 14, and 21). RESULTS: There was no significant change in dorsiflexion between groups across time. When groups were pooled, there was a significant increase (P<.001) in dorsiflexion at each postintervention time interval. No differences were found among the Balance Error Scoring System foam, step-down test, and Foot and Ankle Ability Measure sports subscale scores. CONCLUSIONS: The use of a proximal or distal tibiofibular joint manipulation in isolation did not enhance outcome effects beyond those of the control group. Collectively, all groups demonstrated increases in ankle dorsiflexion range of motion over the 3-week intervention period. These increases might have been due to practice effects associated with repeated testing. LEVEL OF EVIDENCE: Therapy, level 2b–.

J Orthop Sports Phys Ther 2012;42(2):125-134. doi:10.2519/jospt.2012.3729

KEY WORDS: ankle sprain, CAI, manual therapy, mobilization

J Orthop Sports Phys Ther 2012;42(2):95. doi:10.2519/jospt.2012.0502

KEY WORDS: patellofemoral pain syndrome, prevention, quadriceps muscle

STUDY DESIGN: Clinical measurement, longitudinal; multicenter prospective cohort study. OBJECTIVES: To examine the validity, reliability, and responsiveness of the Patient-Specific Functional Scale (PSFS) in patients with musculoskeletal upper extremity problems being treated in physical therapy. BACKGROUND: The clinimetric properties of the PSFS have not been established nor compared with region-specific outcome measures in patients with upper extremity problems. METHODS: Patients completed the PSFS, Upper Extremity Functional Index (UEFI), and numeric pain rating scale (NPRS) at baseline and follow-up, and were categorized as improved, stable, or worsened, using the global rating of change. Construct validity was assessed by comparing the change scores of the stable and improved groups, using independent-samples t tests. Reliability was evaluated using intraclass correlation coefficient (ICC_2,1) with 95% confidence intervals. Bland-Altman plots determined limits of agreement. Responsiveness and minimal important difference (MID) were determined with receiver operator characteristic (ROC) curves. RESULTS: One hundred eighty patients met the inclusion criteria. Construct validity was supported for the PSFS and the UEFI (P<.001). Reliability was moderate to good for the PSFS (ICC_2,1 = 0.713) and UEFI (ICC_2,1 = 0.848). Reported estimates of reliability may be lower than true values because the group of “stable” patients from this cohort had, on average, a small positive change. Bland-Altman plots indicated good agreement. The area under the ROC curve (AUC) was significantly different from the null value of 0.5 for the PSFS (0.887) and the UEFI (0.877), indicating good accuracy in distinguishing improved patients from stable patients. MID was 1.2 for the PSFS (scale, 0-10) and 8.5 for the UEFI (scale, 0-80). CONCLUSION: The PSFS is a valid, reliable, and responsive outcome measure for patients with upper extremity problems.

J Orthop Sports Phys Ther 2012;42(2):56-65. doi:10.2519/jospt.2012.3953

KEY WORDS: clinical measurement, instrument validation, outcome measure, upper limb

The convex-concave rules purportedly help describe the roll-and-slide relationships that naturally occur between moving articular surfaces. There are 2 components of this rule, depending on whether the convex or concave articular member of the joint is considered the moving segment. As a teacher of kinesiology and a physical therapist, I have always respected these rules, primarily because of their ability to assist with the mental imaging of joint motion. Recently, I have been perplexed by questions from experienced physical therapists as to why the convex-concave rules are still being taught in college or continuing education venues, when research has shown that they are flawed. Perhaps I am so hopelessly infatuated with, and blinded by, the educational charm and utility of the convex-concave rules that I fail to realize they are flawed. Are they? I don’t think so, which is the topic of this editorial.

J Orthop Sports Phys Ther 2012;42(2):53-55. doi:10.2519/jospt.2012.0103

KEY WORDS: arthrology, articular surfaces, kinesiology, morphology

The patient was a 72-year-old woman who presented to an emergency department with a chief complaint of severe right thigh pain following a fall. Prior to the fall, the patient reported an 8-month history of worsening right thigh pain. The patient had a 4-year history of alendronate and calcium use to manage her osteoporosis. Dual X-ray absorptiometry (DXA) hip images taken 1 month prior to the patient’s fracture demonstrated lateral cortical thickening in the subtrochanteric region of the femur. In retrospect, this finding was concerning for impending complete fracture.

J Orthop Sports Phys Ther 2012;42(1):44. doi:10.2519/jospt.2012.0402

KEY WORDS: bisphosphonates, bone mineral density, dual X-ray absorptiometry, DXA, radiography, thigh pain

The patient was a 21-year-old man, currently serving in the military, who was referred to a physical therapist for a chief complaint of left lateral ankle pain of 2 months in duration, after an inversion ankle injury sustained while hiking. At the time of the initial evaluation, the physical therapist reviewed computed tomography images and the radiologist’s report, which noted a cystic lesion in the anterior calcaneus, with a small area of communication with the subtalar joint, which was concerning for a pathologic fracture. The patient was diagnosed with a unicameral bone cyst of the calcaneus and subsequently underwent curettage and packing with a multipotential cellular bone matrix containing adult stem cells.

J Orthop Sports Phys Ther 2012;42(1):43. doi:10.2519/jospt.2012.0401

KEY WORDS: computed tomography, multi-potential cellular bone matrix, radiography, stem cells

J Orthop Sports Phys Ther 2012;42(1):21. doi:10.2519/jospt.2012.0501

KEY WORDS: cervical spine, mobilization, spinal manipulation, thoracic spine

Last Fall, JOSPT conducted an extensive environmental survey that attracted 560 respondents. The survey represented the Journal’s many stakeholder groups, including authors, reviewers, editors, Orthopaedic and Sports Sections members, individual and institutional subscribers, and international partners. The Journal also held a strategic planning meeting and adopted a plan for the next 2 years. Among other findings, the survey showed that journals remain the most important means by which professionals stay current in the field of musculoskeletal rehabilitation. The survey also highlighted the technological sea change in publishing today. The expansion of JOSPT’s online features in recent years, the need to select the “right” technologies, the plethora of content delivery options already available, and the growing demand to read and access the Journal anytime, anywhere, dominated the survey’s results. Based on this survey, existing initiatives, and discussion at the planning meeting, JOSPT’s plan for the future has at its heart technology as means of developing and disseminating clinically relevant information to improve patient care. KEY WORDS: media, technology

In Memoriam: Former JOSPT Editor, Dr Richard Paul Di Fabio

Richard Paul Di Fabio, PT, PhD, editor-in-chief of the Journal of Orthopaedic & Sports Physical Therapy from 1999 to 2001, died Friday, December 9, 2011, following a prolonged and private battle with a progressive illness.

J Orthop Sports Phys Ther 2012:42(1):3-4. doi:10.2519/jospt.2012.0102

Musculoskeletal conditions are important contributors to United States healthcare spending and are certain to play an important role in the future as the population continues to age. Almost half of the population of the United States experiences a musculoskeletal condition annually. Meeting the needs of these individuals within a changing healthcare delivery and reimbursement environment prompted a recent Summit sponsored by the United States Bone and Joint Initiative (USBJI). The Summit dealt with a topic critical to the future of healthcare for clinicians, consumers, and payers alike: value. We do not operate within a value-based healthcare system. Our current delivery system continues to reward volumes, not value. Failure to focus on value has had devastating consequences. The challenge of shifting from a volume-based to a value-based system is central to the future of healthcare. Discussion and action will be critical for the physical therapy profession moving into the future.

J Orthop Sports Phys Ther 2012;42(1):1-2. doi:10.2519/jospt.2012.0101

KEY WORDS: cost, musculoskeletal conditions, outcomes, United States healthcare

Letters to the Editor-in-Chief of JOSPT as follows:

• "Early Prognostic Factors in Patients With Whiplash" and Author's Response
• "Staying Current in the Use of Ultrasound Imaging" and Author's Response
• "Differentiating the Soleus From the Gastrocnemius With the Heel Raise Test" and Author's Response

J Orthop Sports Phys Ther 2011;41(12):983-987. doi:10.2519/jospt.2011.0202

The patient was a 17-year-old female who was referred to a physical therapist by her primary-care physician with a chief complaint of bilateral hip and groin pain. The patient was treated by the physical therapist for 8 weeks, but she was unable to successfully return to playing soccer. The patient was subsequently referred to an orthopaedic surgeon, who ordered a magnetic resonance arthrogram that did not reveal intra-articular pathology. To further evaluate bony morphology, computed tomography with 3-dimensional reconstructions was ordered, which demonstrated findings consistent with cam-type femoroacetabular impingement.

J Orthop Sports Phys Ther 2011;41(12):982. doi:10.2519/jospt.2011.0425

KEY WORDS: computed tomography, hip pain, groin pain, magnetic resonance imaging, radiography

The patient was a 79-year-old man with a chief complaint of neck pain after a fall. Three days following the fall, the patient was seen in the emergency department, where computed tomography imaging of the head and radiographs of the cervical spine were completed. The patient was subsequently referred to a physical therapist. Due to concern for a possible undetected cervical spine fracture, the patient was immediately referred to his physician. Magnetic resonance imaging demonstrated a type II fracture of the odontoid.

J Orthop Sports Phys Ther 2011;41(12):981. doi:10.2519/jospt.2011.0424

KEY WORDS: cervical spine, computed tomography, magnetic resonance imaging, radiography

STUDY DESIGN: Prospective, longitudinal, observational cohort design. OBJECTIVE: The primary aim was to examine the association between changes in psychosocial distress (PD), and functional status (FS) and pain intensity at discharge from physical therapy. BACKGROUND: Patients with lumbar impairments seeking physical therapy commonly demonstrate elevated PD. However, it is not clear if PD changes that occur during physical therapy management are associated with improved clinical outcomes. METHODS: Data from adults (n = 692) with lumbar impairment were analyzed. Patients were screened using the Symptom Checklist Back Pain Prediction Model questionnaire (SCL BPPM) to identify patients at intake and discharge into 3 levels of risk for persistent disability (high, intermediate, or low). SCL BPPM classifications allowed for 5 patterns of change in PD during therapy (decreased, stable low, stable intermediate, stable high, or increased). Associations between PD change patterns and discharge FS and pain intensity were assessed using multivariable linear regression models, controlling for selected risk-adjustment variables. RESULTS: Proportions of patients classified by patterns of PD change for decreased, stable low, stable intermediate, stable high, and increased were 0.34, 0.52, 0.05, 0.06, and 0.03, respectively. Compared to the decreased PD group, (1) increased, stable high, and stable intermediate PD patterns were associated with worse discharge FS scores (–7.9 [95% CI: –13.5, –2.21], –10.9 [95% CI: –15.25, –6.49], and –8.9 [95% CI: –13.65, –4.21] units, respectively), and (2) stable high and stable intermediate PD patterns were associated with higher pain intensity (2.59 [95% CI: 1.81, 3.56] and 2.14 [95% CI: 1.25, 3.04] units, respectively). CONCLUSIONS: Lower FS and higher pain intensity outcomes were associated in similar but not identical patterns with patients whose SCL BPPM classification of PD increased, or remained at high or intermediate levels during physical therapy. Serial assessments of change in PD during rehabilitation are recommended as a possible treatment-monitoring tool.

J Orthop Sports Phys Ther 2011;41(12):969-980. doi:10.2519/jospt.2011.3814

KEY WORDS: computerized adaptive testing, depression, functional and pain outcomes, lumbar spine, psychosocial distress, somatization

STUDY DESIGN: Controlled laboratory testing using a single-group, prospective, repeated-measures design. OBJECTIVES: To compare the material properties of a hyperelastic athletic tape to a conventional tape and to compare the passive ankle support of these tapes before and after exercise. BACKGROUND: The near-linear material properties of conventional athletic tape may interfere with ankle motion, resulting in reduced athletic performance. Conventional athletic tape is also known to lose much of its initial support during exercise. It was assumed that a tape constructed of Kevlar fibers embedded in a silicon matrix would possess hyperelastic material properties that would improve ankle support. METHODS: A tensile testing machine was used to determine the tensile material properties of 11 samples of conventional and hyperelastic tape. The ankles of 11 young, healthy athletes were taped, one ankle with conventional tape and the other ankle with hyperelastic tape. The passive ankle support of each tape was measured with an instrumented linkage (the ankle flexibility tester) before and after 30 minutes of exercise. RESULTS: The composite tape had a significantly higher load to failure than the conventional tape. It had significantly lower initial stiffness and higher late stiffness than conventional tape, thus demonstrating highly hyperelastic behavior. The hyperelastic tape maintained a significantly higher portion of its support during the 30 minutes of exercise than the conventional tape. CONCLUSIONS: Composite athletic tape with highly hyperelastic properties can be constructed and maintains a larger portion of its support during short-duration exercises (less than 30 minutes) than conventional athletic tape.

J Orthop Sports Phys Ther 2011;41(12):961-968. doi:10.2519/jospt.2011.3476

KEY WORDS: anterior talofibular ligament, brace, calcaneofibular ligament, inversion sprain, ligament

STUDY DESIGN: Resident’s case problem. BACKGROUND: A 21-year-old athletic male college student presented to a direct-access physical therapy clinic with complaints of left calf pain 4 days in duration. After initial examination, a working diagnosis of calf strain was formulated. Three days following initial examination, the patient reported 80% improvement in symptoms and was performing activities of daily living pain free. Four weeks later, the patient returned with complaints of reoccurring calf pain. The patient’s signs, symptoms, and history at subsequent follow-up no longer presented a consistent clinical picture of calf strain; therefore, a D-dimer assay was ordered to rule out a deep vein thrombosis (DVT). DIAGNOSIS: The D-dimer was elevated so the patient was admitted to the hospital and started on low-molecular-weight heparin. A compression ultrasound revealed an extensive left superficial femoral and popliteal DVT in this otherwise healthy athlete. DISCUSSION: Lower extremity DVT is a serious and potentially fatal disorder. Physical therapists need to be diagnostically vigilant for vascular pathology in all patients with extremity pain and swelling. Employing the best current evidenced-based screening tools to rule out vascular pathology, such as deep and superficial vein pathology, should be the goal of every clinician. The Wells score is one such screening tool that has proven to be beneficial in this area. This case report presents a dilemma in diagnosis and illustrates the importance of revisiting differential diagnoses with each patient encounter. Clinicians must consider the possibility of a DVT with every patient seen with posterior leg pain. LEVEL OF EVIDENCE: Diagnosis, level 4.

J Orthop Sports Phys Ther 2011;41(12):942-947. doi:10.2519/jospt.2011.3823

KEY WORDS: clinical prediction rule, D-dimer assay, DVT

STUDY DESIGN: Descriptive bibliometric analysis. BACKGROUND: Content and bibliometric studies are useful for describing the publication patterns of a given profession, such as physical therapy, within the medical and allied health fields. However, few studies have conducted these analyses on specialty physical therapy journals. OBJECTIVES: To conduct a content and bibliometric assessment of publications within the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) and report publication and citation trends over multiple years. METHODS: All available JOSPT manuscripts published from 1980 through 2009 were reviewed. Only research reports, topical reviews, and case reports were included in the current analysis. Articles were coded by 2 independent reviewers based on type, participant characteristics, research design, purpose, clinical condition, and intervention. We obtained additional citation information (eg, authors and institutions) from a subset of articles published from 1992 through 2009 using bibliometric software. RESULTS: Of the 2233 available JOSPT publications, 1732 (77.6%) met criteria for inclusion. Of these, 1172 (67.7%) were research reports, 351 (20.3%) topical reviews, and 209 (12.1%) case reports. Over the last 30 years there has been a significant increase in the number of articles published and the percentage of research reports, systematic reviews, articles focused on prognosis, and articles including symptomatic participants. Percentage decreases were observed for topical or nonsystematic reviews and articles focused on anatomy/physiology. Top institutions, authors, and cited papers from 1992 through 2009 were identified in the bibliometric analyses. CONCLUSION: JOSPT has shown publication trends for increased percentage of experimental and clinically relevant research. However, there may be a need for increased publication of randomized controlled trials and studies focused on diagnosis, prognosis, and treatment, if goals of evidence-based practice are to be met.

J Orthop Sports Phys Ther 2011;41(12):920-931. doi:10.2519/jospt.2011.3808

KEY WORDS: citation analysis, publication trends, research

Editor-in-Chief Dr. Guy Simoneau recognizes the authors, associate editors, International Editorial Review Board members, and manuscript and musculoskeletal imaging reviewers who contributed to the various aspects of the Journal over the past 12 months.

J Orthop Sports Phys Ther 2011;41(12):911-913. doi:10.2519/jospt.2011.0112

KEY WORDS: authors, editorial board, reviewers

For physical therapists, modifying technique is not a novel concept; however, our motives are typically focused on symptom and injury reduction rather than purely performance. These specific modifications are based on minimizing tissue load, while still enabling successful completion of the task. Applying this same rationale to running, an activity in which up to 80% of participants are injured annually, would seem to be a good thing. Yet the idea of using gait retraining in patients without neurological injury/pathology is rather uncommon. However, a few researchers have investigated specific walking retraining strategies to reduce knee joint loading, with the goal of applying these techniques to individuals with knee osteoarthritis. This has led some to use the same concept on runners with patellofemoral pain, with a corresponding improvement in gait and symptoms.

J Orthop Sports Phys Ther 2011;41(12):909-910. doi:10.2519/jospt.2011.0111

KEY WORDS: 2012 Olympic Games, running

This month’s issue of JOSPT contains a bibliometric analysis of the publishing history of the Journal of Orthopaedic & Sports Physical Therapy. The results provide an opportunity to reflect on trends at JOSPT and, more generally, in the evidence base of orthopaedic and sports physical therapy practice. Results of the bibliometric review by Coronado and colleagues are encouraging for JOSPT and the profession of physical therapy as a whole. The results indicate an increase in the publication of research articles involving symptomatic subjects, with fewer narrative and nonsystematic review papers. The results also raise an interesting issue about whether we have a sufficient number of randomized controlled trials in our literature and to what extent our future progress should be based on the publication of more randomized trials.

J Orthop Sports Phys Ther 2011;41(12):907-908. doi:10.2519/jospt.2011.0110

KEY WORDS: evidence-based medicine, physical therapy, profession, randomized controlled trials

The patient was a 34-year-old male recreational marathon runner referred to a physical therapist with a chief complaint of worsening right lateral hip pain of 3 months duration that was insidious in nature. Following a physical examination, the physical therapist discussed his suspicions with the referring physician. Magnetic resonance imaging revealed findings consistent with a stress fracture at the inferomedial right femoral neck, a mild cam-type deformity of the right femoral neck, and a mild degree of heterogeneity of the right superior anterior labrum, representing a possible tear.

J Orthop Sports Phys Ther 2011;41(11):905. doi:10.2519/jospt.2011.0423

KEY WORDS: hip, magnetic resonance imaging

The patient was a 45-year-old man who was referred to a physical therapist with a chief complaint of posterior right ankle pain for the past 2 weeks. The physical therapist requested radiographs, which demonstrated obliteration of Kager's fat pad, a finding highly suspicious for an Achilles tendon rupture. Based upon history, physical examination, and radiographic findings, the physical therapist ordered magnetic resonance imaging which confirmed the diagnosis of Achilles tendon rupture.

J Orthop Sports Phys Ther 2011;41(11):904. doi:10.2519/jospt.2011.0422

KEY WORDS: ankle, Kager's fat pad, magnetic resonance imaging, radiography

SYNOPSIS: This article is intended for the clinician charged with either diagnosing or treating patients with lower extremity symptoms thought to be of musculoskeletal etiology. It gives a brief overview of the imaging techniques that can be utilized, common pathology, and certain pearls and pitfalls that may be encountered in both ordering and interpreting lower extremity magnetic resonance imaging. While we cannot present a comprehensive discussion of all of the known disorders in the lower extremity, we will choose common disorders to illustrate the diagnostic benefits and limitations of magnetic resonance imaging and provide reasons for choosing certain magnetic resonance imaging techniques.

J Orthop Sports Phys Ther 2011;41(11):873-886. doi:10.2519/jospt.2011.3713

KEY WORDS: diagnosis, medical imaging, MRI

SYNOPSIS: Magnetic resonance imaging (MRI) is capable of producing images in any anatomical plane, visualizing and analyzing a variety of tissue characteristics, as well as quantifying blood flow and metabolic functions. Although MRI details of compact bone and calcium are poor when compared to those taken with plain radiography or computed tomography, its high soft tissue contrast discrimination and multiplanar imaging capabilities are significant advantages. Musculoskeletal anatomy and neurovascular bundles are well delineated. The advent of MRI has revolutionized the clinicianís ability to confirm a proper diagnosis for musculoskeletal problems, which has led to more directed, specific rehabilitative protocols. However, the value of MRI to rehabilitative professionals has been even greater in its ability to identify serious, more uncommon pathologies, such as in those with underlying infection, fracture, or tumor, that require immediate care and are considered to be beyond their scope of practice. Furthermore, MRI, with its precise delineation of fat, muscle, and bone, is an ideal candidate for imaging of muscle disease or injury and has emerged as the method of choice for the detection of early cartilage wear in young patients, such as osteoarthritis. Finally, this imaging modality can avoid radiation exposure in a predominantly younger patient cohort commonly affected by musculoskeletal diseases. The aim of this paper is to consider how physical therapists may take advantage of the diagnostic value of MRI of the upper limb, while avoiding the pitfalls of misinterpretation of images as a result of technical issues, pathological changes, or normal variants.

J Orthop Sports Phys Ther 2011;41(11):861-872. doi:10.2519/jospt.2011.3833

KEY WORDS: MRI, musculoskeletal, radiology

SYNOPSIS: Musculoskeletal imaging of the spine can be an invaluable tool to inform clinical decision making in patients with spinal pain. An understanding of the technology involved in producing and interpreting high-resolution images produced from magnetic resonance imaging (MRI) of the human spine is necessary to better appreciate which sequences can be used for, or tailored to, individual patients and their conditions. However, there is substantial variability in the clinical meaningfulness of some MRI findings of spinal tissues. For example, normal variants can often mimic significant musculoskeletal pathology, which could increase the risk of misinformed clinical decisions and, even worse, poor or adverse outcomes. This clinical commentary will highlight some of the pearls and pitfalls of MRI for the cervical, thoracic, and lumbar regions, and include cases to illustrate some of the common imaging artifacts and normal variants for MRI of the spine.

J Orthop Sports Phys Ther 2011;41(11):848-860. doi:10.2519/jospt.2011.3636

KEY WORDS: MRI, medical imaging, radiology, spinal pain, whiplash

J Orthop Sports Phys Ther 2011;41(11):847. doi:10.2519/jospt.2011.0507

KEY WORDS: magnetic resonance imaging, physical therapy

SYNOPSIS: For healthcare providers involved in the management of patients with musculoskeletal disorders, the ability to order diagnostic imaging is a beneficial adjunct to screening for medical referral and differential diagnosis. A trial of conservative treatment, such as physical therapy, is often recommended prior to the use of imaging in many treatment guidelines for the management of musculoskeletal conditions. In the United States, physical therapists are becoming more autonomous and can practice some degree of direct access in 48 states and Washington, DC. Referral for imaging privileges could increase the effectiveness and efficiency of healthcare delivery, particularly in combination with direct access management. This clinical commentary proposes that, given the American Physical Therapy Association's goal to have physical therapists as primary care musculoskeletal specialists of choice, it would be beneficial for physical therapists to have imaging privileges in their practice. The purpose of this commentary is 3-fold: (1) to make a case for the use of imaging privileges by physical therapists, using a historical perspective; (2) to discuss the barriers preventing physical therapists from having this privilege; and (3) to offer suggestions on strategies and guidelines to facilitate the appropriate inclusion of referral for imaging privileges in physical therapist practice.

J Orthop Sports Phys Ther 2011;41(11):829-837. doi:10.2519/jospt.2011.3556

KEY WORDS: diagnosis, direct access, MRI, radiology, x-ray

SYNOPSIS: Medical practitioners have a variety of imaging modalities at their disposal. The exquisite soft tissue delineation available with magnetic resonance imaging (MRI) has resulted in the rising utilization of this particular modality. Increasingly, physical therapists around the world are actively involved in not only referring patients with musculoskeletal conditions for MRI but also in the acquisition of MRI data in both the clinical and research arenas. The MRI process involves the use of a very strong static magnetic field, time-varying (gradient) fields, and radiofrequency energy. To ensure the well-being of patients, staff, and visitors, an understanding of the primary hazards of this environment and the rigorous safety procedures that must be followed is imperative to the clinician. This paper describes the basic components of an MRI system, discusses various MRI safety issues, and presents the screening procedure necessary prior to using MRI. Primary hazards associated with the imaging process are also reviewed.

J Orthop Sports Phys Ther 2011;41(11):820-828. doi:10.2519/jospt.2011.3906

KEY WORDS: metal, MRI hazards, musculoskeletal imaging, pregnancy, projectile effect

The ability to refer for diagnostic tests is particularly relevant to the topic of this special issue on magnetic resonance imaging (MRI). As a doctoring profession, one could argue that the ability to refer a patient for MRI (and other imaging applications) must be available to the direct-access physical therapist. Though the prescription for and use of MRI has not typically been considered within the scope of physical therapist practice, this may be the perfect time to challenge the obstacles precluding the obtainment of such diagnostic privileges and to specifically provide perspective on why and how such a specialized privilege could positively impact the provision of physical therapy services and patient outcomes. An expected obligation of such autonomy, however, is accountability. Is our entire profession adequately prepared to accept the role of, or the responsibilities associated with, referral for imaging privileges?

J Orthop Sports Phys Ther 2011;41(11):803-805. doi:10.2519/jospt.2011.0109

KEY WORDS: autonomy, direct access, MRI

STUDY DESIGN: Controlled laboratory study, longitudinal. OBJECTIVES: To investigate the effects of frequency and self-control of feedback on physiotherapy students learning lumbar spinal mobilization. BACKGROUND: Posterior-to-anterior mobilization is included in most physiotherapy curricula. However, force application varies between therapists and the optimal feedback for learning is unknown. METHODS: Sixty-two physiotherapy students were randomized to 3 feedback groups: constant (100% of practice trials), intermittent (33%), and self-controlled (varied according to student choice) feedback. Students performed 12 practice trials of grade II posterior-to-anterior mobilization to the third lumbar vertebra while receiving real-time feedback. The differences between students’ force parameters (mean peak force [N], force amplitude [N], and oscillation frequency [Hz]) and those of a physiotherapist expert were compared between groups posttest and at a follow-up of 5 to 7 days using analysis of covariance. Students completed a survey regarding their perceptions of feedback. RESULTS: Students in the self-controlled group applied mean peak force (mean difference between student and expert, 6.7 N; 95% confidence interval [CI]: 4.4, 9.0) and force amplitude (6.3 N; 95% CI: 4.2, 8.4) that more closely matched the expert’s than those applied by the constant group (13.7 N; 95% CI: 8.7, 18.6; P = .021, and 13.1 N; 95% CI: 8.9, 17.4; P = .028) at posttest, with similar results at follow-up for force amplitude only (self-controlled, 9.5 N; 95% CI: 5.8, 18.1; constant, 21.0 N; 95% CI: 13.3, 28.7; P = .018). There were no other significant differences. All students reported a better understanding of manual force application, but feedback preferences varied. CONCLUSION: Self-controlled feedback appears to be more beneficial than constant feedback for students learning to apply forces during lumbar mobilization.

J Orthop Sports Phys Ther 2012;42(2):114-124, Epub 25 October 2011. doi:10.2519/jospt.2012.3691

KEY WORDS: motor skills, musculoskeletal manipulations, physical therapy techniques, spinal manipulation, students

STUDY DESIGN: Clinical measurement. OBJECTIVES: To determine the interrater and intrarater reliability of the active hip abduction (AHAbd) test. BACKGROUND: The AHAbd test is used to assess lumbopelvic movement during a dynamic lower limb activity. The test has previously been shown to predict low back pain development during a prolonged standing exposure in previously asymptomatic individuals. As an observation-based assessment for which rater reliability has not been established, similar scoring on the test between clinicians is essential. METHODS: One hundred twenty-eight video clips of participants performing the AHAbd test were recorded. Sixteen practicing physical therapists scored test performance by viewing 20 preselected videos to establish interrater reliability. Fourteen of the 16 raters rescored the videos after a 3-week period to establish intrarater reliability. Demographic data were collected for all raters. Intraclass correlation coefficients (ICCs) were calculated for reliability statistics. Correlations were performed between demographic data and ICCs. RESULTS: Interrater reliability (ICC_2,1) for the test using the 4-point scale was 0.70 (95% confidence interval [CI]: 0.56, 0.84) and 0.59 (95% CI: 0.43, 0.76) when the scale was dichotomized into positive/negative scores. Intrarater reliability (ICC_3,1) was 0.74 on average. Demographic characteristics were not significantly associated with reliability scores. CONCLUSION: Interrater and intrarater reliability for scoring of the AHAbd test by practicing clinicians was similar, regardless of experience level or practice setting. The AHAbd test can be considered to be a reliable observational tool.

J Orthop Sports Phys Ther 2011;41(12):953-960, Epub 25 October 2011. doi:10.2519/jospt.2011.3684

KEY WORDS: low back pain, lumbar region, lumbopelvic control, stabilization

STUDY DESIGN: Single cohort study. OBJECTIVES: To investigate the efficacy of real-time biofeedback provided during treadmill gait training to correct knee hyperextension in asymptomatic females while walking. BACKGROUND: Knee hyperextension is associated with increased stress to the posterior capsule of the knee joint, anterior cruciate ligament, and the anterior compartment of the tibiofemoral joint. Previous methods aimed at correcting knee hyperextension have shown limited success. METHODS: Ten women, ages 18 to 39 years, with asymptomatic knee hyperextension during ambulation, were provided with 6 sessions of real-time feedback of kinematic data (Visual 3D) during treadmill training. Gait evaluations were performed pretraining, posttraining, and 1 month after the last training session. RESULTS: Participants showed improved control of knee hyperextension during overground walking at 1.3 m/s at posttraining and at 1 month posttraining. CONCLUSION: The present study demonstrated that knee sagittal plane kinematics may be influenced by gait retraining using real-time biofeedback.

J Orthop Sports Phys Ther 2011;41(12):948-952, Epub 25 October 2011. doi:10.2519/jospt.2011.3660

KEY WORDS: gait retraining, knee alignment, knee kinematics, physical therapy

STUDY DESIGN: Controlled laboratory study. OBJECTIVES: To measure superior/inferior translation and external rotation of the humerus relative to the scapula during scapular plane abduction using 3-D/2-D model image registration techniques. BACKGROUND: Kinematic changes in the glenohumeral joint, including excessive superior translation of the humeral head and inadequate external rotation of the humerus, are believed to be a possible cause of shoulder impingement. Although many researchers have analyzed glenohumeral kinematics with various methods, few articles have assessed dynamic in vivo glenohumeral motion. METHODS: Twelve healthy males with a mean age of 32 years (range, 27-36 years) were enrolled in this study. Fluoroscopic images of the dominant shoulder during scapular plane elevation were taken, and computed tomography-derived 3-D bone models were matched with the silhouette of the bones in the fluoroscopic images using 3-D/2-D model image registration techniques. The kinematics of the humerus relative to the scapula were determined using Euler angles. RESULTS: On average, there was 2.1 mm of initial humeral translation in the superior direction from the starting position to 105° of humeral elevation. Subsequently, an average of 0.9 mm of translation in the inferior direction occurred between 105° and maximum arm elevation. The average amount of external rotation of the humerus was 14° from the starting position to 60° of humeral elevation. The humerus then rotated internally an average 9° by the time the shoulder reached maximum elevation. These changes in superior/inferior translation and external/internal rotation were statistically significant (P<.001 and P = .001, respectively), based on 1-way repeated-measures analysis of variance. CONCLUSION: The observed glenohumeral translations and rotations characterize healthy shoulder function and serve as a preliminary foundation for quantifying pathomechanics in the presence of glenohumeral joint disorders.

J Orthop Sports Phys Ther 2012;42(2):96-104, Epub 25 October 2011. doi:10.2519/jospt.2012.3584

KEY WORDS: 3-D/2-D registration, arthrokinematics, computed tomography, imaging, impingement

STUDY DESIGN: Prospective single-cohort study. OBJECTIVES: To determine and document changes in pain and disability in patients with primary, nonacute acromioclavicular joint (ACJ) pain treated with a manual therapy approach. BACKGROUND: To our knowledge, there are no published studies on the physical therapy management of nonacute ACJ pain. Manual physical therapy has been successful in the treatment of other shoulder conditions. METHODS: The chief inclusion criterion was greater than 50% pain relief with an ACJ diagnostic injection. Patients were excluded if they had sustained an ACJ injury within the previous 12 months. Treatment was conducted utilizing a manual physical therapy approach that addressed all associated impairments in the shoulder girdle and cervicothoracic spine. The primary outcome measure was the Shoulder Pain and Disability Index. Secondary measures were the American Shoulder and Elbow Surgeon and global rating of change scales. Outcomes were collected at baseline, 4 weeks, and 6 months. The Shoulder Pain and Disability Index and American Shoulder and Elbow Surgeon scale values were analyzed with a repeated-measures analysis of variance. RESULTS: Thirteen patients (11 male; mean ± SD age, 41.1 ± 9.6 years) completed treatment consisting of an average of 6.4 sessions. Compared to baseline, there was a statistically significant and clinically meaningful improvement for the Shoulder Pain and Disability Index at 4 weeks (P = .001; mean, 25.9 points; 95% confidence interval [CI]: 11.9, 39.8) and 6 months (P<.001; mean, 29.8 points; 95% CI: 16.5, 43.0), and the American Shoulder and Elbow Surgeon scale at 4 weeks (P<.001; mean, 27.9 points; 95% CI: 14.7, 41.1) and 6 months (P<.001; mean, 32.6 points; 95% CI: 21.2, 43.9). CONCLUSION: Statistically significant and clinically meaningful improvements were observed in all outcome measures at 4 weeks and 6 months, following a short series of manual therapy interventions. These results, in a small cohort of patients, suggest the efficacy of this treatment approach but need to be verified by a randomized controlled trial. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2012:42(2):66-80, Epub 25 October 2011. doi:10.2519/jospt.2012.3866

KEY WORDS: distal clavicle excision, manipulation, mobilization, Mumford, shoulder

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: Case series. BACKGROUND: Patellofemoral pain is a common overuse injury in runners. Recent findings suggest that patellofemoral pain is related to high-impact loading associated with a rearfoot strike pattern. This case series describes the potential training effects of a landing pattern modification program to manage patellofemoral pain in runners. CASE DESCRIPTION: Three female runners with unilateral patellofemoral pain who initially presented with a rearfoot strike pattern underwent 8 sessions of landing pattern modification program using real-time audio feedback from a force sensor placed within the shoe. Ground reaction forces during running were assessed with an instrumented treadmill. Patellofemoral pain symptoms were assessed using 2 validated questionnaires. Finally, running performance was measured by self-reported best time to complete a 10-km run in the previous month. The runners were assessed before, immediately after, and 3 months following training. OUTCOMES: The landing pattern of runners was successfully changed from a rearfoot to a nonrearfoot strike pattern after training. This new pattern was maintained 3 months after the program. The vertical impact peak and rates of loading were shown to be reduced. Likewise, the symptoms related to patellofemoral pain and associated functional limitations were improved. However, only 1 of the participants reported improved running performance after the training. DISCUSSION: This case series provided preliminary data to support further investigation of interventions leading to landing pattern modification in runners with patellofemoral pain. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2011;41(12):914-919, Epub 25 October 2011. doi:10.2519/jospt.2011.3771

KEY WORDS: biofeedback, gait retraining, impact peak, impact rate, landing pattern

STUDY DESIGN: Systematic review of the literature. OBJECTIVE: To summarize peer-reviewed literature on the reliability, validity, and responsiveness of the Patient-Specific Functional Scale (PSFS), and to identify its use as an outcome measure. METHODS: Searches were performed of several electronic databases from 1995 to May 2010. Studies included were published articles containing (1) primary research investigating the psychometric and clinimetrics of the PSFS or (2) the implementation of the PSFS as an outcome measure. We assessed the methodological quality of studies included in the first category. RESULTS: Two hundred forty-two articles published from 1994 to May 2010 were identified. Of these, 66 met the inclusion criteria for this review, with 13 reporting the measurement properties of the PSFS, 55 implementing the PSFS as an outcome measure, and 2 doing both of the above. The PSFS was reported to be valid, reliable, and responsive in populations with knee dysfunction, cervical radiculopathy, acute low back pain, mechanical low back pain, and neck dysfunction. The PSFS was found to be reliable and responsive in populations with chronic low back pain. The PSFS was also reported to be valid, reliable, or responsive in individuals with a limited number of acute, subacute, and chronic conditions. This review found that the PSFS is also being used as an outcome measure in many other conditions, despite a lack of published evidence supporting its validity in these conditions. CONCLUSION: Although the use of the PSFS as an outcome measure is increasing in physiotherapypractice, there are gaps in the research literature regarding its validity, reliability, and responsiveness in many health conditions.

J Orthop Sports Phys Ther 2012;42(1):30-42, Epub 25 October 2011. doi:10.2519/jospt.2012.3727

KEY WORDS: disability evaluation, instrument validation, PSFS, questionnaires, treatment outcomes

STUDY DESIGN: Observational. OBJECTIVE: To assess the effects of spinal decompression procedures performed during a clinical exam on low back pain (LBP) symptoms. BACKGROUND: Not all patients report an immediate or complete improvement in symptoms when the direction of lumbar motion or alignment is corrected according to principles of the movement system impairment (MSI) model. Axial compression of the spine may be responsible for the remaining symptoms. METHODS: Seventy subjects (mean ± SD age, 41.9 ± 11.5 years; 38 females, 32 males) with chronic LBP were evaluated using a standardized MSI exam. Seven tests assessing the effects of spinal decompression on LBP were added to the exam if the subjects’ symptoms were not alleviated with typical standardized corrections of movement and alignment. For each test of decompression, subjects reported their symptoms compared to a reference movement or position. RESULTS: When decompression was performed during lateral bending to the right and left, 21 of 21 (100%) and 16 of 20 (80%) subjects, respectively, reported an improvement. When traction was applied to subjects in right and left sidelying, 6 of 11 (55%) and 7 of 9 (78%), respectively, reported an improvement. When patients performed a push-up in sitting, 36 of 51 (71%) reported an improvement. In subjects who had symptoms in unsupported sitting, 41 of 57 (72%) reported an improvement in supported sitting. In subjects who reported symptoms in standing, 33 of 47 (70%) reported an improvement in hook-lying. CONCLUSION: Patients with chronic LBP consistently reported an improvement in symptoms with tests proposed to decrease the axial load on the spine. These tests are a quick and effective way to assess the contribution of axial decompression to LBP symptoms and potentially could be used as part of the plan of care.

J Orthop Sports Phys Ther 2012;42(2):105-113, Epub 25 October 2011. doi:10.2519/jospt.2012.3724

KEY WORDS: axial loading, distraction, lumbar spine, traction

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

JOSPT offers invited reviews of current titles. The October 2011 column includes 5 reviews of the following books: Athletic and Sports Issues in Musculoskeletal Rehabilitation; Biomechanics of Human Motion: Basics and Beyond for the Health Professions; Nerve and Vascular Injuries in Sports Medicine; Assessment and Treatment of Muscle Imbalance: The Janda Approach; and Ther Ex Notes: Clinical Pocket Guide.

J Orthop Sports Phys Ther 2011;41(10):797-801.