Journal of Orthopaedic & Sports Physical Therapy - January 2003 Volume 33, No. 1

Literature Reviews and Case Reports

Literature reviews and case reports contribute uniquely to the body of knowledgein physical therapy and are essential to evidence-based practice. This editorial highlights an example of each of these types of papers, published in this month’s Journal: a literature review on patellofemoral joint pain syndrome by Bizzini et al and a case report by Peterson on the treatment of a patient with cervicogenic headache.

J Orthop Sports Phys Ther. 2003; 33(2):70-72.

Systematic Review of the Quality of Randomized Controlled Trials for Patellofemoral Pain Syndrome

Mario Bizzini, Maj John D. Childs, Sara R. Piva, Anthony Delitto
Study Design: Systematic review of the literature. Objectives: To develop a grading scale to judge the quality of randomized clinical trials (RCTs) and conduct a systematic review of the published RCTs that assess nonoperative treatments for patellofemoral pain syndrome (PFPS). Background: Systematic reviews of the quality and usefulness of clinical trials allow for efficient synthesis and dissemination of the literature, which should facilitate clinicians’ efforts to incorporate principles of evidence-based practice in the clinical decision-making process. Methods and Measures: Using a scale based on criteria in the Cochrane Collaboration Handbook, we sought to critically appraise the methodology used in RCTs related to the nonoperative management of PFPS, synthesize and interpret our results, and report our findings in a user-friendly fashion. A scale to assess the methodological quality of trials was designed and pilot tested for its content and reliability. Published RCTs identified during a literature search were then selected and rated by 6 raters. We used predefined cutoff scores to identify specific weaknesses in the clinical research process that need to be improved in future clinical trials. Results: The quality scale we developed was demonstrated to be sufficiently reliable to warrant interpretation of the reviewers’ findings. The percentage of trials that met a minimum level of quality for each specific criterion ranged from a low of 25% for the adequacy of the description of the randomization procedure to a high of 95% for the description and standardization of the intervention. Conclusions: Based on the results of trials exhibiting a sufficient level of quality, treatments that were effective in decreasing pain and improving function in patients with PFPS were acupuncture, quadriceps strengthening, the use of a resistive brace, and the combination of exercises with patellar taping and biofeedback. The use of soft foot Orthotics in patients with excessive foot pronation appeared useful in decreasing pain. In addition, at a short-term follow-up, patients who received exercise programs were discharged earlier from physical therapy. Unfortunately, most RCTs reviewed contained qualitative flaws that bring the validity of the results into question, thus diminishing the ability to generalize the results to clinical practice. These flaws were primarily in the areas of randomization procedures, duration of follow-up, control of cointerventions, assurance of blinding, accountability and proper analysis of dropouts, number of subjects, and the relevance of outcomes. Also, given the limited number of high-quality clinical trials, recommendations about supporting or refuting specific treatment approaches may be premature and can only be made with caution.

J Ortho Sports Phys Ther. 2003;33(1):4-20.

Keywords: bias, decision making, evidence, grading, methodology

Articular and Muscular Impairments in Cervicogenic Headache: A Case Report

Shannon M. Petersen
Study Design: Case report. Objectives: To describe the use of manual therapy and muscle re-education for an individual with suspected cervicogenic headache. Background: This patient was a 27-year-old woman with complaint of headache. She was functionally limited with prolonged postures and lifting. She also demonstrated impairments in cervical mobility and muscular performance. Methods and Measures: This patient was treated 8 times over an 8-week period. Intervention included manual upper cervical spine mobilization techniques, muscle re-education for the deep neck flexor muscles, and scapular stabilization exercises. Results: Following treatment, the patient demonstrated an increase in cervical mobility, improved muscular performance, a decrease in headaches, and complete resolution of functional limitations. Conclusion: The combination of manual therapy and muscle re-education was successful in relieving headaches and improving function in this patient.

J Ortho Sport Phys Ther. 2003:33(1):21-30.

Key Words: cervical spine, deep neck flexors, manual therapy

Treatment of Fabella Syndrome With Manual Therapy: A Case Report

J. Tim Zipple, Roger L. Hammer, Peter V. Loubert
Study Design: Clinical case report. Objectives: To educate clinicians about fabella syndrome as a possible cause for Posterolateral knee pain and dysfunction. Also to describe a physical therapy intervention strategy for Posterolateral knee pain secondary to hypomobility or malposition of a fabella. Background: A 44-year-old, physically fit, Caucasian male with a 10-year history of left posterolateral knee pain and functional limitations during athletic activities, walking, and activities of daily living presented for evaluation and treatment. He had previously experienced relief of symptoms after experimenting with a mechanical maneuver administered by his wife. Methods and Measures: A thorough examination for strength, range of motion, and accessory motions was performed. A fabella was palpable in the lateral head of the gastrocnemius muscle and a provisional diagnosis of fabella syndrome was made. While in a prone position, the patient received soft tissue mobilization of the lateral gastrocnemius, followed by medial, lateral, and inferior glides of the fabella. Results: The patient reported an immediate reduction in posterolateral knee pain and demonstrated a 30° increase in active knee flexion. Conclusions: Physical therapists may be unaware that fabella syndrome is a possible source of posterolateral knee pain and dysfunction. This simple manual therapy intervention was effective in reducing symptoms of pain and increasing tolerance for activities involving knee flexion, extension, and rotation. Physical therapists may wish to add this diagnosis and the corresponding examination and intervention techniques to their management strategy for patients with fabella syndrome.

J Orthop Sports Phys Ther. 2003;33(1):33-39.

Key Words: knee pain, manipulation, mobilization, posterior knee pain

Improvement in Sit-up Performance Associated With 2 Different Training Regimens

Richard E. Baxter, Josef H. Moore, Timothy L. Pendergrass, Todd A. Crowder, Shannon Lynch
Study Design: Factorial experimental design. Objective:To compare the outcomes of 2 different abdominal muscular fitness training regimens on sit-up performance across sex and abdominal muscular fitness level. Background: Researchers suggest that the curl-up, when compared to the sit-up, optimizes the challenge to the abdominal muscles while minimizing shear and compressive forces on the lumbar spine. Although researchers have compared curl-ups and sit-ups in many ways, a comparison of sit-up performance after training programs involving curl-ups and sit-ups has not been investigated. Methods and Measures: One hundred two active, healthy, college-aged subjects participated in this study. After stratification based upon maximal 2-minute sit-up performance during the orientation session, subjects were randomly assigned to either a training group using curl-up exercise, a training group using sit-up exercise, or a control group. Maximal 2-minute sit-up test performance was measured before and after a 6-week training program. Data were analyzed utilizing an ANOVA model. Significant interactions or main effects were analyzed utilizing Tukey’s Honestly Significant Difference Test. Level of significance for all testing was at a = 0.05. Results: The sit-up training group improved significantly (P<0.05). No significant difference in sit-up performance was noted for the curl-up or control groups after the 6-week training program. No statistically significant difference in improvement was noted between sex of subject and level of abdominal muscular fitness of subject. Conclusions: Short-term sit-up training with the Modified Kersey Method in this population significantly improved a maximum 2-minute sit-up test performance. Curl-up training utilizing the same method did not result in improvement in the number of sit-ups performed in 2 minutes. Specificity of training provides the primary explanation for our findings.

J Orthop Sports Phys Ther. 2003;33(1):40-47.

Keywords: abdominal muscular fitness, curl-up, strength training

Bilateral Rearfoot Asymmetry and Anterior Knee Pain Syndrome

Lori A. Livingston, James L. Mandigo
Study Design: Single-session observational study. Objectives: To examine the magnitude and extent of asymmetry between right and left rearfoot angles in individuals who are asymptomatic versus symptomatic for anterior knee pain. Background: Asymmetry in lower limb measures has been linked to the occurrence of knee pathologies, yet the practice of deriving unilateral rather than bilateral data and thereafter averaging the findings may play a role in obscuring the true nature of the rearfoot angle-knee pain relationship. Methods and Measures: A convenience sample of participants was recruited from the local university and business communities and a university-affiliated physiotherapy clinic. Eight-one young adult males and females volunteered to participate in this study. Following an extensive screening process, including mandatory exclusion for a previous history of lower limb dysfunction or injury, data were collected from 75 individuals classified as asymptomatic (n=50), unilaterally symptomatic (n=11), or bilaterally symptomatic (n=14) for anterior knee pain. Right and left rearfoot angles were goniometrically measured under static, weight-bearing conditions. Results: No significant differences in mean right and left rearfoot angles by group or limb were observed. However, these mean values did not always reflect the true variation of data within the sample. Fifty-six percent of the individuals studied demonstrated a minimum of 4° bilateral rearfoot angle difference, while for 20% of the sample this difference exceeded 7°. Only a weak yet statistically significant correlation existed between right and left rearfoot angles (r=0.31, P<0.01). Conclusions: Rearfoot angles in weight bearing are not bilaterally symmetric, and the magnitude and direction of the observed asymmetry does not appear to be indicative of whether an individual is asymptomatic or symptomatic for anterior knee pain.

J Orthop Sports Phys Ther. 2003;33(1):48-55.

Keywords: anterior knee pain, calcaneal eversion, orthoses, foot