Journal of Orthopaedic & Sports Physical Therapy - February 2008 Volume 38, No. 2

Preserving the Quality of the Patient-Therapist Relationship: An Important Consideration for Value-Centered Physical Therapy Care

Current best evidence suggest that, when adjusting for risk, a substantial number of patients receiving outpatient physical therapy report good outcomes and have lower cost of care or frequency of adverse events when compared to pharmacologic or invasive procedures. In other words, physical therapy care, supported by the best available research evidence, is often a bargain when compared to other treatment approaches. However, a question that must be asked is, "How much do patients value their physical therapy care?"

J Orthop Sports Phys Ther 2008;38(2):34-35. doi:10.2519/jospt.2008.0113

KEY WORDS: patient-therapist relationship, value-based care

Influence of Age, Gender, and Injury Mechanism on the Development of Dynamic Knee Stability After Acute ACL Rupture

Wendy J. Hurd, Michael J. Axe, Lynn Snyder-Mackler
STUDY DESIGN: Cross-sectional study. OBJECTIVES: To determine whether the distribution of those with and without dynamic knee stability after anterior cruciate ligament (ACL) rupture differs by age, gender, and contact versus non-contact injury mechanisms. BACKGROUND: There is a differential return to preinjury activities after ACL rupture. It is unknown if there are specific patient groups who are more or less likely to experience good dynamic knee stability after ACL rupture. METHODS AND MEASURES: The study sample consisted of 345 consecutive, highly active patients with complete, isolated ACL insufficiency. Based on the results of a screening examination, patients were categorized as having either good (potential coper) or poor (noncoper) dynamic knee stability. Descriptive and chi-square statistics were calculated to describe patient characteristics and identify the proportion of potential copers and noncopers based on age, gender, and injury mechanism. RESULTS: The groups with the greatest proportion of noncopers were women (P=0.002), mid-aged adults (35-44 years old) (P<0.001), and individuals who sustained a noncontact ACL injury (P=0.011). CONCLUSIONS: Women who sustain an ACL rupture, and those who sustain an ACL rupture via a noncontact mechanism frequently experience dynamic knee instability. A profile of demographic characteristics of those most likely to experience knee instability after ACL rupture may facilitate improved patient outcomes. LEVEL OF EVIDENCE: Prognosis, Level 2b.

J Orthop Sports Phys Ther. 2008;38(2):36-41, published online 7 September 2007. doi:10.2519/jospt.2008.2609

KEY WORDS: clinical research, joint instability, knee

Diffusion-Weighted Magnetic Resonance Imaging of Normal and Degenerative Lumbar Intervertebral Discs: A New Method to Potentially Quantify the Physiologic Effect of Physical Therapy Intervention

Paul F. Beattie, Paul S. Morgan, Denise Peters

STUDY DESIGN: Observational, repeated measures design. OBJECTIVES: To determine the reliability of the apparent diffusion coefficient (ADC) calculated from diffusion-weighted magnetic resonance images (MRI) of the nuclear region of lumbar intervertebral discs (IVDs), to investigate the differences in the ADC based upon T₂-signal intensity, and to examine the test-retest variation in these measures obtained from subjects undergoing serial, diffusion-weighted MRI scans. BACKGROUND: Impaired diffusion of water within the lumbar IVD is a central characteristic of degenerative disc disease. Diffusion-weighted MRI scans can provide quantitative estimates of water diffusion and may be useful to evaluate the physiologic effects of healing or the change in hydration related to interventions such as traction, manual therapy, or exercise on normal and degenerative lumbar IVDs. METHODS AND MEASURES: Thirty subjects underwent T₂-weighted and diffusion-weighted lumbar MRI scans. Twenty-one of these subjects underwent a second diffusion-weighted MRI scan 4 to 7 weeks after the initial scan. The ADC was calculated from midsagittal diffusion-weighted images for the IVDs of L1-2 to L5-S1. To assess reliability, repeated measures of the ADC were performed on the first 16 scans. The T₂-signal of the nuclear region of each disc was classified as hyperintense, intermediate, or hypointense, and its relationship to the mean ADC of the nuclear region was determined. Test-retest variation in the ADC was described using the coefficient of variation (CV), plus or minus the width of the 95% confidence interval of the standard error of measurement (SEM). RESULTS: Intraclass correlation coefficients for estimates of intrarater and interrater reliability ranged from 0.95 to 0.99 and the SEM ranged from 0.006 to 0.026 X 10^-3 mm²/s. The mean ADC was significantly greater for hyperintense IVDs compared to intermediate and hypointense IVDs. The CV plus or minus the 95% CI of the SEM between scans ranged from 9.0% to 13.6% for all discs, 6.1% to 10.1% for hyperintense discs, and 13.1% to 23.7% for intermediate discs. The prevalence of hypointense discs was too low to make meaningful judgments about their normal degree of variation over time. CONCLUSION: The ADC of the nuclear region of the lumbar IVDs may be reliably measured from diffusion-weighted images. Degenerative discs had lower mean ADC values than normal discs but demonstrated greater variation between scans. Diffusion-weighted imaging may be a useful procedure to assess change in diffusion of water in lumbar discs that occurs over time.

J Orthop Sports Phys Ther. 2008;38(2):42-49, published online 21 September 2007. doi:10.2519/jospt.2008.2631

KEY WORDS: back pain, degenerative disc disease, lumbar spine, MRI

Investigation of Elevated Fear-Avoidance Beliefs for Patients With Low Back Pain: A Secondary Analysis Involving Patients Enrolled in Physical Therapy Clinical Trials

Steven Z. George, Julie M. Fritz, Maj John D. Childs

STUDY DESIGN: Secondary analysis. OBJECTIVE: To investigate the Fear-Avoidance Beliefs Questionnaire (FABQ) for its ability to predict 6-month outcomes for patients with low back pain (LBP) participating in physical therapy clinical trials. BACKGROUND: Consistent evidence suggests that fear-avoidance beliefs are predictive of short-term outcomes for patients with LBP. However, proposed cut-off scores have not been widely investigated for longer-term outcomes in samples of patients receiving physical therapy. METHODS AND MEASURES: Subjects (n = 160) were participants in 2 separate randomized trials that used standard methodology and investigated the efficacy of physical therapy interventions for LBP. Subjects completed baseline measures of pain, disability, fear-avoidance beliefs, and physical impairment. They completed 4 weeks of randomly assigned physical therapy and were reassessed at 6 months with standard examination techniques. The accuracy of previously proposed cut-offs for elevated FABQ scores were determined by independent t tests and chi-square analysis on raw 6-month Oswestry Disability Questionnaire (ODQ) scores, 6-month ODQ change scores, and minimally clinical important difference (MCID) in ODQ scores (6 points). Next, a hierarchical regression model determined which FABQ scale better predicted 6-month ODQ scores after controlling for previously reported prognostic factors and relevant treatment parameters. Last, receiver operating characteristic curve analyses were planned to generate a range of FABQ cut-off scores that predicted 6-month MCID in the ODQ. RESULTS: The previously reported cut-off score for the FABQ physical activity scale (>14) resulted in 111 (69.4%) of 160 patients being classified as having elevated baseline scores, while the previously reported cut-off score for the FABQ work scale (>29) resulted in 19 (11.9%) of 160 patients being classified as having elevated baseline scores. Patients with elevated FABQ physical activity scale scores (>14) had no significant differences in 6-month ODQ outcomes. Patients with elevated FABQ work scale (>29) scores reported higher 6-month ODQ scores and were more likely to have reported no improvement in ODQ score. The final regression model explained 24.4% of the variance in 6-month ODQ scores, with only manipulation and exercise and the FABQ work scale as unique predictors. Fifteen of the subjects (12.7%) had a 6-month change in ODQ that indicated no improvement. The area under the receiver operating characteristic curve for the FABQ physical activity scale predicting this outcome was 0.562 (95% CI: 0.415-0.710) and for the FABQ work scale was 0.694 (95% CI: 0.542-0.846). Cut-off scores were explored for the FABQ work scale only, with positive likelihood ratios that ranged from 1.19 to 5.15 and negative likelihood ratios that ranged from 0.30 to 0.83. CONCLUSIONS: The FABQ work scale was the better predictor of self-report of disability in this sample of patients participating in physical therapy clinical trials. Future studies are necessary to further test and refine the FABQ work scale as a screening tool alone, and in combination with other examination findings. LEVEL OF EVIDENCE: Prognosis, Level 2b.

J Orthop Sports Phys Ther. 2008;38(2):50-58, published online 22 January 2008. doi:10.2519/jospt.2008.2647

KEY WORDS: disability, FABQ, Owestry, prognosis

The Difference in a Clinical Measure of Patella Lateral Position Between Individuals With Patellofemoral Pain and Matched Controls

Lee Herrington

STUDY DESIGN: Cross-sectional matched-pairs design. OBJECTIVE: To investigate if differences existed in the medio-lateral position of the patella between subjects with patellofemoral pain (PFP) and matched controls. BACKGROUND: The assessment of patella position is often proposed as an essential aspect of clinical examination of individuals with PFP. To date, only 1 clinical method of assessing lateral patella position has been intensively investigated. Although there is a growing body of evidence on the reliability and validity of this method, no studies have investigated differences in patella position between patients with PFP and controls. METHODS AND MEASURES: Twelve female patients with PFP and 12 matched controls (mean ± SD age, 21.9 ± 2.6) had their medio-lateral patella position assessed in 20º of flexion. Differences between groups were investiged with independent-groups t tests. RESULTS: All subjects were found to have a laterally located patella. The mean ± SD lateral position for the individuals in the PFP group was 7.5 ± 2.6 mm compared to 3.8 ± 2.4 mm for the control group. This difference was statistically significant (P = .019). Intratester reliability of the measurement of patellar position, calculated using intraclass correlation model 3,1, was 0.86. CONCLUSION: Using this method of assessing patella position, the patella of individuals with PFP was significantly more laterally located than the patella of those in a matched control group.

J Orthop Sports Phys Ther. 2008;38(2):59-62, published online 16 October 2007. doi:10.2519/jospt.2008.2660

KEY WORDS: anterior knee pain, knee, patella, patellofemoral joint

Differential Diagnosis of a Sports Hernia in a High-School Athlete

Casey A. Unverzagt, Teresa Schuemann, Jeffrey Mathisen
STUDY DESIGN: Resident's case problem. BACKGROUND: Chronic anterior hip and groin pain is a growing concern among high-performance athletes. This manuscript enforces the need for physical therapists to remain current with its complex differential diagnosis, as it can be debilitating for the athlete and equally frustrating for the sports medicine team. This resident's case problem details the account of an 18-year-old high-school wrestler who presented to the high-school sports medicine team without physician referral. His chief complaint was chronic right anterior hip and groin pain, which had been variable in frequency and intensity for 3 years. DIAGNOSIS: A screening examination for serious underlying pathology was negative. After physical examination, it was determined that this individual had signs and symptoms consistent with a sports hernia. He was referred to a general surgeon who diagnosed him with a symptomatic inguinal hernia and later performed laparoscopic evaluation and treatment. The patient had a moderate-size indirect inguinal hernia sac, which was carefully dissected away from the remaining contents of the spermatic cord and was repaired with a Parietex mesh. At a 2-week postoperation follow-up, the patient was asymptomatic and cleared to return to wrestling and baseball without limitations. DISCUSSION: This resident's case problem demonstrates the debilitating and often elusive nature of a sports hernia. It suggests that the diagnosis is not well understood and emphasizes the importance of a robust medical foundation for each member of the sports medicine team conducting athletic evaluations. LEVEL OF EVIDENCE: Diagnosis, Level 4.

J Orthop Sports Phys Ther. 2008;38(2):63-70, published online 7 September 2007. doi:10.2519/jospt.2008.2626

KEY WORDS: abdomen, abdominal, athletic pubalgia, groin

The Interrater Reliability of 4 Clinical Tests Used to Assess Individuals With Musculoskeletal Hip Pain

RobRoy L. Martin, Jon K. Sekiya

STUDY DESIGN: Descriptive and reliability study. OBJECTIVES: To evaluate the interrater reliability of the FABER test, flexion-internal rotation-adduction impingement test, log roll test, and the palpation of the greater trochanter for tenderness. BACKGROUND: Clinical examination for individuals with musculoskeletal hip pain is believed to provide critical diagnostic information. However, there is very limited information in the literature on the reproducibility of examination techniques for the hip region. METHODS AND MEASURES: Seventy subjects were evaluated prospectively by an orthopaedic surgeon and physical therapist. Subjects had a mean age of 42 years (range 18-76 years; SD 15.4) and included 32 (46%) females and 38 (54%) males. Subject diagnoses were as follows: degenerative joint disease (n=27 [39% of subjects]), labral tear (n=35 [50% of subjects]), femoroacetabular impingement (n=48 [69% of subjects]), capsular laxity (n=28 [40% of subjects]), trochanteric bursitis (n=29 [41% of subjects]), iliopsoas tendonitis (n=10 [14% of subjects]), and adductor strain (n=2 [3% of subjects)]. Subjects could have more than 1 diagnosis. Kappa, prevalence indexes, bias indexes, and maximal attainable kappa were calculated. RESULTS: Kappa (κ) coefficients with 95% confidence intervals (CI) were as follows: FABER test κ was 0.63 (95% CI: 0.43-0.83); flexion-internal rotation-adduction impingement test κ was 0.58 (95% CI: 0.29-0.87); log roll test κ was 0.61 (95% CI: 0.41-0.81); and greater trochanteric tenderness κ was 0.66 (95% CI: 0.48-0.84). Bias indexes were low (0.06-0.08) for all 4 tests while prevalence indexes were low (0.03-0.37) for 3 of the 4 tests. The flexion-internal rotation-adduction impingement test had a high prevalence index (0.76), with a higher proportion of positive tests. CONCLUSION: The kappa values for the FABER test, log roll test, and assessment of greater trochanteric tenderness were greater than 0.40 (fair level of agreement) at a 95% confidence level. The low reliability obtained for the flexion-internal rotation-adduction impingement test may be related to a prevalence concern.

J Orthop Sports Phys Ther. 2008;38(2):71-77, published online 21 September 2007. doi:10.2519/jospt.2008.2677

KEY WORDS: agreement, examination, kappa, reproducibility

Spinal Accessory Nerve Palsy: Associated Signs and Symptoms

Martin J. Kelley, Thomas E. Kane, Brian G. Leggin

STUDY DESIGN: Retrospective case series. BACKGROUND: Spinal accessory nerve palsy (SANP) is common following neck dissection surgery and can occur with blunt or penetrating trauma to the lateral neck region and cervical stretch injuries. Early detection of SANP remains a clinical challenge and the condition is often misdiagnosed. The purpose of this case series is to describe the associated history, signs, and symptoms related to SANP and increase awareness of the scapular flip sign as a clinical sign associated with SANP. CASE SERIES DESCRIPTION: Twenty subjects (13 male, 7 female) presented with pain and decreased shoulder function following head and neck surgery or posttrauma. All patients were thoroughly examined and the scapular flip sign was assessed. All patients presented with a cluster of signs and symptoms including trapezius atrophy, shoulder girdle depression, limited active shoulder abduction to less than 90°, shoulder pain, and shoulder weakness. A positive scapular flip sign was present in all cases. The middle and lower trapezius were rated as 0/5, based on manual muscle testing, indicating no identifiable muscle activation against resistance. DISCUSSION: A typical history and consistent signs and symptoms were found related to SANP. A strong relationship appeared between the presence of the scapular flip sign and SANP. The suspected mechanism for the scapular flip sign is the unopposed pull of the humeral external rotators by the inactive middle and lower trapezius. Early identification of SANP can assist with the prognosis, explain persistent impairments and functional deficits, motivate appropriate diagnostic testing and interventions, and help maximize outcome. Further research to validate the scapular flip sign and establish a clinical prediction rule for the diagnosis of SANP should be performed. LEVEL OF EVIDENCE: Diagnosis, Level 4.

J Orthop Sports Phys Ther. 2008;38(2):78-86, published online 7 September 2007. doi:10.2519/jospt.2008.2454

KEY WORDS: examination, neck, shoulder, trapezius

Proximal Tibiofibular Dislocation/Sublaxation

Michael J. Axe, Lynn Snyder-Mackler

A 19-year-old male soccer player presented with pain in the right anterolateral proximal leg region 5 days after injury. Despite negative plain radiographs and lack of joint deformity there was suspicion of an anterolateral proximal tibiofibular joint dislocation that spontaneously reduced. Magnetic resonance imaging (MRI) confirmed the diagnosis of a recent dislocation.

J Orthop Sports Phys Ther. 2008;38(2):87. doi:10.2519/jospt.2008.0402

KEY WORDS: proximal tibiofibular dislocation