In December of 2006, the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) convened a task force to create a framework for standardizing manual physical therapy procedures. The impetus came from many years of frustration with our ability to precisely communicate to each other, as well as to stakeholders outside our profession. To this end, a contribution titled "A Model for Standardizing Manipulation Terminology In Physical Therapy Practice" is published in this issue of the Journal.

J Orthop Sports Phys Ther. 2008;38(3):97-98. doi:10.2519/jospt.2008.0103

KEY WORDS: guidelines, manual physical therapy, terminology

During APTA's Combined Sections Meeting in Nashville last month, the Journal of Orthopaedic & Sports Physical Therapy recognized for the fourth time the most outstanding research manuscript and clinical practice paper published in the JOSPT within a calendar year. The JOSPT Excellence in Research Award is given to the best article published within the category of research reports. The George J. Davies-James A. Gould Excellence in Clinical Inquiry Award is presented to the best article among the categories of case reports, resident's case problems, clinical commentaries, and literature reviews. An award committee consisting of the JOSPT editor-in-chief, 2 JOSPT associate editors, and the research chairs of the Orthopaedic and Sports Physical Therapy Sections selected the recipients.

J Orthop Sports Phys Ther. 2008;38(3):99-100. doi:10.2519/jospt.2008.0104

KEY WORDS: JOSPT awards

STUDY DESIGN: A single-blinded, pretreatment-posttreatment assessment. OBJECTIVES: To investigate, using ultrasound imaging, the cross-sectional area (CSA) of the lumbar multifidus muscle at 4 vertebral levels (L2, L3, L4, L5) in elite cricketers with and without low back pain (LBP) and (2) to document the effect of a staged stabilization training program on multifidus muscle CSA. BACKGROUND: Despite high fitness levels and often intensive strength training programs, athletes still suffer LBP. The incidence of LBP among Australian cricketers is 8% and as high as 14% among fast bowlers. Previous researchers have found that the multifidus muscle contributes to segmental stability of the lumbopelvic region; however, the CSA of this muscle has not been previously assessed in elite cricketers. METHODS AND MEASURES: CSAs of the multifidus muscles were assessed at rest on the left and right sides for 4 vertebral levels at the start and completion of a 13-week cricket training camp. Participants who reported current or previous LBP were placed in a rehabilitation group. The stabilization program involved voluntary contraction of the multifidus, transversus abdominis, and pelvic floor muscles, with real-time feedback from rehabilitative ultrasound imaging (RUSI), progressed from non-weight-bearing to weight-bearing positions and movement training. Pain scores (using a visual analogue scale) were also collected from those with LBP. RESULTS: The CSAs of the multifidus muscles at the L5 vertebral level increased for the 7 cricketers with LBP who received the stabilization training, compared with the 14 cricketers without LBP who did not receive rehabilitation (P = .004). In addition, the amount of muscle asymmetry among those with LBP significantly decreased (P = .029) and became comparable to cricketers without LBP. These effects were not evident for the L2, L3, and L4 vertebral levels. There was also a 50% decrease in the mean reported pain level among the cricketers with LBP. CONCLUSION: Multifidus muscle atrophy can exist in highly active, elite athletes with LBP. Specific retraining resulted in an improvement in multifidus muscle CSA and this was concomitant with a decrease in pain. LEVEL OF EVIDENCE: Therapy, level 2b.

J Orthop Sports Phys Ther. 2008;38(3):101-108, published online 7 December 2007. doi:10.2519/jospt.2008.2658

KEY WORDS: asymmetry, low back/lumbar spine rehabilitation, rehabilitative ultrasound imaging, therapeutic exercise, ultrasound imaging

STUDY DESIGN: Retrospective review of medical records. OBJECTIVES: To describe characteristics of patients with lumbar spine dysfunction, and to compare functional outcome and number of visits to physical therapy according to type of physician referral. BACKGROUND: The type of referral, characterized as prescriptive or open, has been associated with the perceived amount of supervision that is required for the provision of physical therapy care.  The rationale for prescriptive referrals is not consistent with autonomous physical therapy practice, and may be deemed unnecessary if such referrals are associated with equivalent outcomes. METHODS AND MEASURES:  Medical records of patients treated within a rehabilitation provider network between October 2002 and December 2003 were reviewed retrospectively for administrative and clinical variables. Subjects were selected if they completed the Roland Morris Questionnaire (RMQ) on admission and discharge from physical therapy care.  Associations between referral type and discharge RMQ scores, and number of visits were determined using independent t tests and were further examined using stepwise multiple regression analysis. RESULTS:  Ninety-six records met inclusion criteria, of which 54 (56.2%) had open referrals and 42 (43.8%) had prescriptive referrals.  Type of referral was not associated with number of visits in bivariate or in multivariate analyses. Prescriptive referrals were associated with higher discharge RMQ scores, representing greater disability, in bivariate analysis (t test, P = .03); however, this association was attenuated in multivariate analyses after adjustment for physician status as primary care practitioner or specialist. CONCLUSION:  Prescriptive referrals were not associated with enhanced outcomes of physical therapy care. LEVEL OF EVIDENCE: Prognosis, level 2b.

J Orthop Sports Phys Ther. 2008;38(3):109-115, published online 9 November 2007. doi:10.2519/jospt.2008.2591

KEY WORDS: autonomous practice, outcomes, physician referrals

J Orthop Sports Phys Ther. 2008;38(3):116-125, published online 9 November 2007. doi:10.2519/jospt.2008.2596

STUDY DESIGN: Retrospective descriptive cohort study. OBJECTIVES: To describe the distribution and rate of injuries in elite adolescent ballet dancers, and to examine the utility of screening data to distinguish between injured and noninjured dancers. BACKGROUND:  Adolescent dancers account for most ballet injuries. Limited information exists, however, regarding the distribution, rate of, and risk factors for adolescent dance injuries. METHODS AND MEASURES: Two hundred and four dancers (age, 9–20 years) were screened over 5 years. Screening data were collected at the beginning and injury data were collected at the end of each training year.  Descriptive statistics were used to characterize distribution and rate of injuries. Inference statistics were used to examine differences between injured and noninjured dancers. RESULTS: Fifty-three percent of injuries occurred in the foot/ankle, 21.6% in the hip, 16.1% in the knee, and 9.4% in the back. Thirty-two to fifty-one percent of the dancers were injured each year, and, over the 5 years, there were 1.09 injuries per 1000 athletic exposures, and 0.77 injuries per 1000 hours of dance. Significant differences between injured and noninjured dancers were limited to current disability scores (P = .007), history of low back pain (P = .017), right foot pronation (P = .005), insufficient right-ankle plantar flexion (P = .037), and lower extremity strength (P = .045). CONCLUSION: Distribution of injuries was similar to that of other studies. Injury rates were lower than most reported rates, except when expressed per 1000 hours of dance. Few differences were found between injured and noninjured dancers. These findings should be considered when designing and implementing screening programs. LEVEL OF EVIDENCE: Prognosis, level 2b.

J Orthop Sports Phys Ther. 2008;38(3):126-136, published online 21 September 2007. doi:10.2519/jospt.2008.2390 

KEY WORDS: injury prevention, injury surveillance, musculoskeletal characteristics, performing arts

STUDY DESIGN: Descriptive, cross-sectional. OBJECTIVES: We compared lower extremity anatomical characteristics in males and females between different maturation groups. BACKGROUND: Sex differences have been observed in lower extremity anatomical characteristics. While the reasons contributing to these sex differences in adults are unknown, there is evidence that anatomy and posture change considerably during growth and development. METHODS AND MEASURES: One hundred seventy-three young athletes (age range, 9–18 years) were assessed for stage of maturation and placed into 1 of 3 groups, according to Tanners stages 1 and 2 (MatGrp₁), 3 and 4 ( MatGrp₂), and 5 (MatGrp₃). Participants were measured for pelvic angle, hip anteversion, quadriceps angle, tibiofemoral angle, femur length, tibial length, genu recurvatum, tibial torsion, navicular drop, general joint laxity, and anterior knee laxity. Data were compared by sex and maturation group. RESULTS: When comparing maturation groups, limb length, pelvic angle, and tibial torsion increased with maturation, and anterior knee laxity, genu recurvatum, tibiofemoral angle, and foot pronation decreased with maturation. Females had greater general joint laxity, hip anteversion, and tibiofemoral angles, and shorter femur and tibial lengths than males, regardless of maturation group. Maturational changes in knee laxity and quadriceps angles were sex dependent. CONCLUSIONS: We observed a general change in posture with maturation that began with greater knee valgus, knee recurvatum, and foot pronation in MatGrp₁, then moved toward a relative straightening and external rotation of the knee, and supination of the foot in later maturation groups. While the majority of the measures changed similarly in males and females across maturation groups, decreases in quadriceps angles and anterior knee laxity were greater in males compared to females, and females were observed to have a more inwardly rotated hip and valgus knee posture, compared to males, particularly in later maturation groups. LEVEL OF EVIDENCE: Diagnosis, level 4.

J Orthop Sports Phys Ther. 2008;38(3):137-149, published online 16 October 2007. doi:10.2519/jospt.2008.2645

KEY WORDS:  alignment, development, growth, joint laxity, posture

STUDY DESIGN: Case control study. OBJECTIVES: To classify individuals with functional ankle instability (FAI) into deficit and no-deficit categories based on the evaluation of the most common factors that have been proposed to be related to FAI. BACKGROUND: Recent studies have suggested that FAI may be secondary to a combination of factors including ankle proprioceptive deficit, muscular weakness, impaired balance, delayed neuromuscular reaction time, and joint laxity. However, only a few authors have investigated the prevalence and association among these factors in a single group of individuals. METHODS AND MEASURES: The above 5 factors were tested bilaterally in 21 individuals with FAI and in 16 healthy control subjects. Data were analyzed for (1) within- and between-group comparison, (2) classification of subjects with FAI into deficit and no-deficit categories, and (3) magnitude of association between factors in the subjects with FAI using Pearson's bivariate correlation. RESULTS: Balance control and evertors strength were significantly less on the affected side in comparison to the unaffected side in subjects with FAI. The evertors' strength was also significantly different between the side difference of the FAI group and the side difference of the control group. Passive ankle stiffness was significantly correlated to balance control, ankle proprioception, and evertor peak torque. Individuals with FAI demonstrated a large variation in the deficit categories ranging from multiple to no noticeable deficits. CONCLUSION: Mechanical alterations in the ankle joint may influence several aspects of the ankle's functional ability. Alterations in the afferent processes, represented in this study by ankle proprioception, may affect the evertors' strength or vice versa. More importantly, individuals with FAI might exhibit high variability in ankle deficits. LEVEL OF EVIDENCE: Symptom prevalence, level 4.

J Orthop Sports Phys Ther. 2008;38(3):150-157, published online 16 October 2007. doi:10.2519/jospt.2008.2524

KEY WORDS: ankle sprains, proprioception, strength, unstable ankle

The patient was a 26-year-old female with a 14-year history of right-sided patellofemoral pain and frequent episodes of patellar subluxation/dislocation. Because of her longstanding history of patellofemoral pain and failure to respond to conservative management, magnetic resonance imaging was ordered. Axial and sagittal images of the patellofemoral joint revealed a bone spur on the anterior-medial surface of the femoral trochlear groove. After further consultation with an orthopedic surgeon, an arthroscopic surgical procedure was scheduled to remove the bone spur. At the time of publication, the subject was 1 month postsurgery and symptom free.

J Orthop Sports Phys Ther. 2008;38(3):158. doi:10.2519/jospt.2008.0403

KEY WORDS: magnetic resonance imaging, patellar subluxation/dislocation

SYNOPSIS: We propose describing a manipulative technique using 6 characteristics:

1. Rate of force application: Describe the rate at which the force was applied.
2. Location in range of available movement: Describe whether motion was intended to occur only at the beginning of the available range of movement, towards the middle of the available range of movement, or at the end point of the available range of movement.
3. Direction of force: Describe the direction in which the therapist imparts the force.
4. Target of force: Describe the location to which the therapist intended to apply the force.
5. Relative structural movement: Describe which structure or region was intended to remain stable and which structure or region was intended to move, with the moving structure or region being named first and the stable segment named second, separated by the word "on."
6. Patient position: Describe the position of the patient, for example, supine, prone, recumbent. This would include any premanipulative positioning of a region of the body, such as being positioned in rotation or side bending.

J Orthop Sports Phys Ther. 2008;38(3):A1-A6. doi:10.2519/jospt.2008.0301