STUDY DESIGN: Case report. BACKGROUND: Contemporary low back pain (LBP) models propose that the experience and responses to pain result from a complex interaction of bio-psycho-social factors, supporting the need for a management approach that addresses the biological, psychological and social components that may be related to the pain disorder. This case report demonstrates the application and outcomes associated with a cognitive functional intervention, which considers neurophysiological, physical, psychosocial, cognitive and lifestyle dimensions, for the management of a rower with non-specific chronic low back pain (NSCLBP). CASE DESCRIPTION: A male club-level rower with NSCLBP was classified as having a motor control impairment with a lower lumbar compressive loading pattern in flexion. Evaluation of this patient included ergometer rowing analysis (clinical and laboratory) pre and post an 8-week intervention, and 12 weeks outcome measure follow up. The intervention consisted of a cognitive functional approach which targeted optimisation of movement behaviour, providing the rower with alternative movement strategies to minimise sustained flexion loading. OUTCOMES: Reduction in temporal summation of pain while ergometer rowing, reduced disability - changes in scores from pre to post (12 weeks) intervention (Roland Morris Disability Questionaire 12/24 to 1/24; Patient Specific Functional Scale 4/30 to 26/30), and associated improvement in lower limb and back muscle endurance and changes in hip and spino-pelvic kinematics during ergometer rowing. In particular, there was greater use of his available range of movement in the lumbar spine post intervention. DISCUSSION: The cognitive functional intervention for this patient resulted in reduced pain and functional disability related to ergometer rowing, which was associated with a change in lumbar kinematics and improved lower limb and back muscle endurance. The results suggest that providing the rower with greater use of his available range may enhance load distribution during the drive phase of rowing. LEVEL OF EVIDENCE: Therapy, Level 4.

J Orthop Sports Phys Ther, Epub 11 June 2013. doi:10.2519/jospt.2013.4699

KEY WORDS: low back pain in sports, motor control impairment, spino-pelvic kinematics

STUDY DESIGN: Systematic review and meta-analysis. BACKGROUND: Myofascial pain syndrome (MPS) is associated with hyperalgesic zones in muscle called myofascial trigger points (MTrPs). When palpated, active MTrPs cause local or referred symptoms including pain. Dry needling involves inserting an acupuncture-like needle into a MTrP with the goal of reducing pain and restoring range of motion. OBJECTIVE: To explore the evidence regarding the effectiveness of DN in reducing pain for patients with MPS of the upper quarter. METHODS: An electronic literature search was performed using the keyword "dry needling."  Articles identified with the search were screened for the following inclusion criteria: human subjects, randomized controlled trials (RCTs), dry needling intervention group, and MPS involving the upper quarter. The RCTs that met our criteria were assessed and scored for internal validity with the MacDermid Quality Checklist.  Four separate meta-analyses were performed: (1) dry needling compared to sham or control, immediate effects; (2) dry needling compared to sham or control, 4 weeks; (3) dry needling compared to other treatments, immediate effects; (4) dry needling compared to other treatments, 4 weeks. RESULTS: The initial search yielded 246 articles. Twelve RCTs were ultimately selected. The methodological quality scores ranged from 23 to 40 points, with a mean of 34 points (scale range 0-48, best possible score-48). Findings of 3 studies that compared dry needling to sham or placebo treatment provide evidence that dry needling can immediately decrease pain in patients with upper quarter MPS, with an overall effect favoring dry needling. Findings of 2 studies that compared dry needling to sham or placebo treatment provide evidence that dry needling can decrease pain after 4 weeks in patients with upper quarter MPS, although a wide confidence interval for the overall effect limits the impact of the effect. Findings of studies that compared dry needling to other treatments were highly heterogeneous, most likely due to variance in the comparison treatments. There is evidence from 2 studies that lidocaine injection may be more effective in reducing pain than dry needling at 4 weeks. CONCLUSIONS: Based on the best current available evidence, we recommend (Grade A) dry needling, compared to sham or placebo, for decreasing pain (immediately after treatment and at 4 weeks) in patients with upper quarter MPS.  Due to the small number of high quality RCTs published to date, additional well-designed studies are needed to inform future evolution of this recommendation. LEVEL OF EVIDENCE: Therapy, level 1a-.

J Orthop Sports Phys Ther, Epub 11 June 2013. doi:10.2519/jospt.2013.4668

KEY WORDS: dry needling, myofascial pain syndrome, randomized controlled trial

SYNOPSIS: Altered knee joint biomechanics and excessive joint loading have long been considered as important contributors to the development and progression of knee osteoarthritis (OA). Therefore, a better understanding of how various treatment options influence the loading environment of the knee joint could have practical implications for devising more effective physical therapy management strategies. The aim of this clinical commentary is to review the pertinent biomechanical evidence supporting the use of treatment options intended to provide protection against excessive joint loading while offering symptomatic relief and functional improvements for better long-term management of patients with knee OA. The biomechanical and clinical evidence regarding the effectiveness of knee joint offloading strategies including contralateral cane use, laterally wedged shoe insoles, variable stiffness shoes, valgus knee bracing, and gait modification strategies within the context of effective disease management are discussed. In addition, the potential role of therapeutic exercise and neuromuscular training in improving the mechanical environment of the knee joint are considered. Management strategies for treatment of joint instability and patellofemoral compartment disease are also mentioned. Based on the evidence presented as part of this clinical commentary, it is argued that special considerations for the role of knee joint biomechanics and excessive joint loading are necessary in designing effective short and long-term management strategies for treatment of patients with knee OA. LEVEL OF EVIDENCE: Therapy, level 5.

J Orthop Sports Phys Ther, Epub 11 June 2013. doi:10.2519/jospt.2013.4121

KEY WORDS: arthritis, biomechanics, excessive loading, joint mechanics, patellofemoral joint, tibiofemoral joint

STUDY DESIGN: A retrospective chart review. OBJECTIVES: To evaluate and compare the relationship between patients' age and the change in Oxford Knee Score from pre- to post-operative assessments, and to investigate whether there is a relationship between pre-operative Oxford Knee Scores and the indication for total knee replacement surgery, and if age affects this relationship. BACKGROUND: There are an increasing number of younger patients receiving knee joint replacement; yet it is unknown how this cohort functions after surgery, warranting the investigation for potential age-related differences in joint function with surgery. In addition, the Oxford Knee Score has been validated as a clinical tool, but has yet to be accepted in the decision-making process regarding the need for, or appropriateness of total knee replacement. METHODS: In a retrospective chart review, 240 patients completed the Oxford Knee Score questionnaire within the context of evaluation for chronic pain and/or dysfunction associated with their knee. RESULTS: The largest improvement with joint replacement was observed to occur in the youngest patient group (50-59 years old). Moreover, the Oxford Knee Score was shown to be the strongest predictor (OR; 0.61) for the indicated intervention, when compared to other predictors. The youngest patient group reported a significantly (p>0.03) higher Oxford Knee Score when indicated for surgery, compared to the oldest patient group (80-89 years old). CONCLUSION: The results provide insight to how age influences self-perceived joint function before and after joint replacement surgery and to the clinical decision to provide the surgical option to younger patients.  Moreover, the observed relationship between the Oxford Knee Score and the indicated treatment gives merit to the use of the questionnaire as a pre-operative tool when considering treatment options for knee Osteoarthritic patients.

J Orthop Sports Phys Ther, Epub 11 June 2013. doi:10.2519/jospt.2013.4540

KEY WORDS: age-related differences, Oxford Knee score, self-reported function, total knee replacement

STUDY DESIGN: Cross-sectional. OBJECTIVE: To investigate the interrater reliability of movement quality ratings for the forward step-down (FSD) and compare hip muscle strength and lower extremity joint range-of-motion and muscle flexibility among asymptomatic women with different level of movement quality. BACKGROUND: The interrater reliability of the FSD test has not yet been investigated. Additionally, it is not known whether differences in musculoskeletal measures exist among individuals with different level of movement quality during the FSD test. METHODS: Two physical therapists assessed the movement quality during the FSD test in 26 asymptomatic women (mean ± SD age: 22.7 ± 0.9 years). Hip muscle strength, lower extremity joint range-of-motion and muscle flexibility were also assessed. The interrater reliability of the FSD test was estimated by using the kappa coefficient and percent agreement. Differences in musculoskeletal measures based on movement quality were assessed by independent t-tests. RESULTS: Kappa coefficient and percent agreement for rating of the FSD test were 0.80 (95% CI: 0.57, 1.01) and 85%, respectively. The subjects with moderate movement quality had significantly less strength of the hip abductors, less knee flexion range of motion measured in prone (quadriceps flexibility) and less hip adduction range of motion measured in side-lying (iliotibial band/tensor fascia latae flexibility), compared to those with good movement quality. CONCLUSION: There was good agreement for the rating of movement quality during the FSD test, and there were physical attributes that distinguished those with moderate versus good quality of movement.

J Orthop Sports Phys Ther, Epub 11 June 2013. doi:10.2519/jospt.2013.4073

KEY WORDS: hip, knee, reliability, strengths

STUDY DESIGN: Experimental laboratory study. OBJECTIVE: To compare how the design of 2 balance platforms affect ankle musculature activation for various weight bearing exercises. BACKGROUND: Balance platforms are widely used in both training and rehabilitation and a better understanding of how platform design and type of exercise modify the demands on the ankle musculature may be helpful in staging exercise progression. METHODS: Surface electromyography was used to measure the activation level of the fibularis longus, tibialis anterior, and medial gastrocnemius while performing 4 exercises on 2 different balance platforms (compliant and rigid). Twenty four (12 females, 12 males) healthy sedentary subjects participated in the study. Analysis of variance was used for statistical analysis. RESULTS: There was no significant interaction between balance platforms and exercises (P > .05) and the type of platform did not influence muscle activation for the 3 muscles monitored (P > .05).  The highest activation level for the fibularis longus and medial gastrocnemius was obtained during single leg stance and for the tibialis anterior during the single leg squat (P < .05). CONCLUSION: In this study, while the demands on the ankle musculature were similar for selected exercises performed on a compliant versus a rigid balance platform, muscle activation level varied based on the exercise.

J Orthop Sports Phys Ther, Epub 11 June 2013. doi:10.2519/jospt.2013.4456

KEY WORDS: electromyography, EMG, posture

STUDY DESIGN: Experimental laboratory study. OBJECTIVES: To measure the activation patterns (onset and magnitude) of the abdominal muscles during a standing long jump using wire and surface electromyography. BACKGROUND: Activation patterns of the abdominal muscles, especially the deep muscles such as the transversus abdominis (TrA), have yet to be examined during full body movements such as jumping. METHODS: Thirteen healthy men participated. Wire electrodes were inserted into the TrA with the guidance of ultrasonography imaging, and surface electrodes were attached to the rectus abdominis (RA) and external oblique (EO). Electromyographic signals and video images were recorded while each subject performed a standing long jump. The jump task was divided into 3 phases: preparation, push-off, and float. For each muscle, muscle onset relative to the onset of the RA and normalized muscle activation levels (% maximum voluntary contraction) were analyzed during each phase. Comparisons between muscles and phases were assessed using 2-way ANOVA's. RESULTS: The onset of the TrA and EO relative to the onset of the RA were -0.13 ± 0.17, -0.02 ± 0.07 s, respectively. Onset of TrA activation was earlier than that of EO. The activation levels of all 3 muscles were significantly greater during the push-off phase than during the preparation and float phases. CONCLUSIONS: Consistent with previously published trunk perturbation studies in healthy persons, TrA was activated prior to RA and EO. Additionally, the highest muscle activation levels were observed during the push-off phase.

J Orthop Sports Phys Ther, Epub 11 June 2013. doi:10.2519/jospt.2013.4420

KEY WORDS: electromyography, muscle onset, transversus abdominis, trunk stability

STUDY DESIGN: Systematic review with meta-analysis. OBJECTIVES: To evaluate the effectiveness of post-operative physical therapy treatment for patients who have undergone arthroscopic partial meniscectomy. BACKGROUND: There is no consensus on which treatment is best for meniscectomized patients. METHODS: The search was done in the following databases: Medline; Embase; Cinahl; Lilacs; Scielo; IBECS; Scopus; Web of Science; PEDro; Academic Search Premier and the Cochrane Central Register of Controlled Trials and the search range was from 1950 to March 2013.  The keywords were: physiotherapy, physical therapy modalities, exercise therapy, rehabilitation, knee, placebo, groups, tibial meniscus, meniscus, arthroscopy, meniscectomy, partial meniscectomy, randomized controlled trial, controlled clinical trial, randomized, systematic review and meta-analysis. RESULTS: Eighteen randomized controlled trials (RCTs) were included. Only 6 studies participated in the meta-analysis. Outpatient PT with a home exercise program improved function compared to a home program alone (Mean Difference (MD) = 10.3, 95% Confidence Interval (CI) [1.3, 19.3], P = 0.02) and knee flexion ROM (MD= 9.1; 95% CI [3.7; 14.5], P= 0.0009). For the comparison of inpatient PT to inpatient and outpatient PT, inpatient PT alone reduced the likelihood of effusion (Odds Ratio (OR) = 0.25; 95% CI [0.10; 0.61], P = 0.003). CONCLUSION: Physical therapy associated with home exercises seems to be effective to improve patient-reported knee function and range of motion in patients post- arthroscopic meniscectomy, although the RCTs were classified from moderate to high risk of bias and should be interpreted with caution. LEVEL OF EVIDENCE: Therapy, II B.

J Orthop Sports Phys Ther, Epub 11 June 2013. doi:10.2519/jospt.2013.4255

KEY WORDS: arthroscopy, knee joint, menisci tibial, physical therapy, systematic review

STUDY DESIGN: Systematic review with Meta-analysis. OBJECTIVES: Identify risk factors for osteoarthritis (OA) of the knee, hip and ankle including joint injury, sport, physical activity, overweight/obesity, and occupational activity in all age groups. BACKGROUND: OA is a significant health problem worldwide, affecting up to 10% of men and 18% of women over 60 years. There has not been a comprehensive review examining modifiable physical risk factors associated with the onset of OA. This evidence is important to inform the physiotherapy management of individuals following onset of OA. METHODS: Twelve electronic databases were systematically reviewed. Studies selected met the following criteria; a) original data, b) joint injury, sport activity, physical activity, overweight/obesity, and/or occupational activity investigated as risk factors, c) outcome included OA (hip, knee, and/or ankle), and d) analytic component of study design. The data extracted included study design, years follow-up, study population, OA definition, risk factors, and results (effect estimates reported or calculated where available). The quality of evidence was assessed based on a modified version of the Downs and Black checklist. RESULTS: Joint injury, obesity, and occupational activity were associated with an increased risk of OA of the knee and hip. Sport and physical activity produced inconsistent findings. Joint injury was identified as a significant risk factor for knee OA (Combined Odds Ratio (OR) = 3.8, 95% CI; 2.0- 7.2) hip OA (Combined OR= 5.0, 95% CI; 1.4 - 18.2) and previous meniscectomy with or without ACL injury (Combined OR= 7.4, 95% CI; 4.0 - 13.7). There is a paucity of research examining risk factors associated with ankle OA, where this review identified only 2 studies with this outcome. CONCLUSIONS: Joint injury, obesity, and occupational activity are associated with an increased risk of knee and hip OA.  Some findings remain inconclusive including levels of physical activity and sport-specificity in individuals that do not suffer an injury. Early identification of individuals at risk for OA provides an opportunity for physiotherapy management or other interventions to modify risk-related behaviour. There is a need in the literature for additional high quality studies, such as prospective cohort studies that minimize potential bias, in examining the relationship with physical risk factors and OA.

J Orthop Sports Phys Ther, Epub 11 June 2013. doi:10.2519/jospt.2013.4796

KEY WORDS: arthritis, athletic injury, risk factors

STUDY DESIGN: Systematic literature review with meta-analysis. OBJECTIVES: To investigate the association between non-neutral foot types (high arch and flat foot) and lower extremity and low back injuries, and to identify the most appropriate methods to use for foot classification. METHODS: A search of 5 electronic databases (PubMed, EMBASE, CINAHL, SPORTDiscus, and ProQuest Dissertation and Thesis), Google Scholar, and reference lists of included studies was conducted to identify relevant articles. The review included comparative cross-sectional, case control, and prospective studies that reported qualitative/quantitative associations between foot types and lower extremity and back injuries. Quality of the selected studies was evaluated and data synthesis for the level of association between foot types and injuries was conducted. A random-effects model was used to pool odds ratios (OR) and standardized mean differences (SMD) results for meta-analysis. RESULTS: Twenty-nine studies were selected and included for meta-analysis. A significant association between non-neutral foot types and lower extremity injuries was determined [OR (95% confidence intervals (CI) = 1.23 (1.11, 1.37); p < .001]. Foot posture index (FPI) [OR = 2.58 (1.33, 5.02); p < .01] and visual/physical examination [OR = 1.17 (1.06, 1.28); p < .01] were 2 assessment methods using distinct foot type categories that displayed significant association with lower extremity injuries. For foot assessment methods using a continuous scale, measurements of Lateral Calcaneal Pitch Angle [SMD = 1.92 (1.44, 2.39); p < .00001], Lateral Talo-Calcaneal Angle [SMD = 1.36 (0.93, 1.80); p < .00001], and Navicular Height (NH) [SMD = 0.34 (0.16, 0.52); p < .001] displayed significant effect sizes in identifying high arch foot, while Navicular Drop Test [SMD = 0.45 (0.03, 0.87); p < .05] and Relaxed Calcaneal Stance Position [SMD = 0.49 (0.01, 0.97); p < .05] for flat foot. Subgroup analyses revealed no significant associations for children with flat foot, cross-sectional studies, or prospective studies on high arch. CONCLUSION: High arch and flat-foot foot types are associated with lower extremity injuries but the strength of this relationship is low. Although FPI and visual/physical examination are methods that displayed significance, they are qualitative measures. Radiographic and NH measurements can delineate high arch foot effectively, with only anthropometric measures accurately classifying flat foot. LEVEL OF EVIDENCE: Prognosis, level 1b.

J Orthop Sports Phys Ther, Epub 11 June 2013. doi:10.2519/jospt.2013.4225

KEY WORDS: flat foot, high arch, injuries

STUDY DESIGN: Cross sectional, observational study. OBJECTIVES: To investigate the cross sectional area (CSA) of trunk muscles in professional ballet dancers with and without LBP (low back pain). BACKGROUND: LBP is the most prevalent chronic injury in classical ballet dancers. Research on non-dancers has found changes in trunk muscle size and symmetry in association with LBP. There are no studies which examine these changes in ballet dancers. METHODS: Magnetic resonance imaging was performed in 14 male and 17 female dancers. The CSA of 4 muscles (multifidus, lumbar erector spinae, psoas and quadratus lumborum) were measured and compared among 3 groups of dancers; without LBP or hip pain (n=8), with LBP only (n=13) and with both hip region and LBP (n=10). RESULTS: Dancers with no pain had larger multifidus muscles compared to those with LBP at L3-L5 (P<0.024) and larger than those with both hip region and LBP at L3 and L4 on the right (P<0.027). Multifidus CSA was larger on the left side at L4 and L5 in dancers with hip region and LBP compared to those with LBP only (P< 0.033). Changes in CSA were not related to the side of pain (all: P>0.05). The CSAs of the other muscles did not differ between groups. The psoas (P<0.0001) and quadratus lumborum (P<0.01) muscles were larger in male dancers compared to female dancers. There was a positive correlation between the size of the psoas muscles and the number of years of professional dancing (P=0.03). CONCLUSION: In classical ballet dancers, LBP and hip region and LBP are associated with smaller CSA of multifidus but not erector spinae, psoas or quadratus lumborum muscles.

J Orthop Sports Phys Ther, Epub 30 April 2013. doi:10.2519/jospt.2013.4523

KEY WORDS: dance, lumbar, MRI, muscle cross sectional area

STUDY DESIGN: Clinical measurement, concurrent validity criterion standard. OBJECTIVE: To determine the concurrent validity of digital nylon calipers in comparison to ultrasound imaging (USI) for the measurement of inter-recti distance (IRD). BACKGROUND: Diastasis rectus abdominis (DRA) is the abnormal increase in the width of the linea alba measured as IRD. A DRA can compromise mechanical trunk function in both genders. IRD has been accurately measured with USI, however, requires costly equipment and extensive examiner training. Digital nylon calipers are inexpensive and easy to use, but their use to measure IRD has not been validated. METHODS: A sample of convenience of 56 males and females were measured. A single examiner was assigned to each tool, calipers or USI, and IRD was measured at 2 locations under 2 conditions; with abdominal muscles at rest and with abdominal muscles contracted.  All measurements were made during a single session and examiners were blinded to measurements with the other tool. RESULTS: Above the umbilicus, the measurements of IRD with the calipers were similar to those made with USI with an intraclass correlation coefficient (ICC_3,2) of 0.79 with abdominal muscles at rest and 0.71 with abdominal muscles contracted. The absolute mean difference between the calipers and USI techniques for measurements of IRD above the umbilicus was 0.03 cm larger with the calipers when the abdominal muscles were at rest and 0.03 cm smaller when the abdominal muscles were contracted. The values of IRD obtained with the calipers and USI techniques were not comparable when obtained below the umbilicus. CONCLUSIONS: The calipers area valid tool for measuring IRD above the umbilicus in males and females. Measuring IRD with calipers below the umbilicus should not be considered valid, using USI as the criterion standard.  This may reflect anatomical variation of the linea alba or a limitation of the calipers to assess IRD at the same depth as USI.

J Orthop Sports Phys Ther, Epub 30 April 2013. doi:10.2519/jospt.2013.4449

KEY WORDS: diastasis recti, linea alba, rectus abdominis

STUDY DESIGN: Validation study. OBJECTIVES: To investigate the association between changes in electromyographic (EMG) signal amplitude and sonographic measures of muscle thickness of 4 abdominal muscles, during 2 clinical tests, in adults with and without lumbopelvic pain (LPP). BACKGROUND: There is a trend in rehabilitation to use ultrasound imaging (USI) to determine the extent of abdominal muscle contraction. However the literature investigating the relationship between abdominal muscle thickness change and level of activation is inconclusive, and has not included clinically relevant tasks. METHODS: Simultaneous recording from fine-wire EMG and USI was performed for 4 abdominal muscles in 7 adults (mean ± SD age, 29.7±12.0 years) with and 7 adults (32.0±10.6 years) without LPP, during an active straight leg raise  (ASLR) test and an abdominal drawing in manoeuvre (ADIM). Cross-correlation functions and linear regression analyses were used to describe the relationship between the 2 measures. Analyses of variance (ANOVA) were used to compare individuals with and without LPP, with a set at 0.05. RESULTS: Across all muscles, peak cross-correlation values were low (ASLR; r=0.28±0.09, ADIM; r=0.35±0.11) and there was large variability in associated time lags (ASLR; τ=0.69s±2.56s, ADIM; τ=0.53s±3.75s). Regression analyses did not detect a systematic pattern of association between EMG signal amplitude and RUSI measurements and ANOVAs revealed no differences between cohorts. CONCLUSION: These results suggest a weak relationship between EMG amplitude and abdominal muscle thickness change measured with USI during the ADIM and ASLR, and raises question about using thickness change derived from USI as a measure of muscular activity for the abdominal musculature.

J Orthop Sports Phys Ther, Epub 30 April 2013. doi:10.2519/jospt.2013.4440

KEY WORDS: EMG, external oblique, internal oblique, rectus abdominis, transversus abdominis, ultrasound imaging

STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To compare the effectiveness of a manual therapy and exercise approach (MTEX) to a home exercise program (HEP) in the management of individuals with an inversion ankle sprain. BACKGROUND: An in clinic exercise program has been found to yield similar outcomes as an HEP for individuals with an inversion ankle sprain. However, no studies have compared a MTEX approach to an HEP.  METHODS: Patients with an inversion ankle sprain completed the Foot and Ankle Ability Index Activities of Daily Living subscale (FAAM-ADL), the Foot and Ankle Ability Index Sport subscale (FAAM-SPORT), the Lower Extremity Functional Scale (LEFS), and the Numeric Pain Rating Scale (NPRS). Patients were randomly assigned to either an MTEX or an HEP approach. Outcomes were collected at baseline, 4-weeks, and 6-months.  The primary aim (effects of treatment on pain and disability) was examined with a mixed model ANOVA. The hypothesis of interest was the 2-way interaction (group*time). RESULTS: Seventy-four patients, mean age 35.1 (SD= 11.0) years, (48.6% female), were randomized into the MTEX group (n=37) or HEP group (n=37). The overall group*time interaction for the mixed model ANOVA was statistically significant for the FAAM-ADL (P<.001), FAAM-SPORT (P< .001), LEFS (P<.001), and pain (P=<.001).  Improvements in all functional outcome measures and pain were significantly greater at both the 4-week and 6-month follow-up periods in favor of the MTEX group. CONCLUSION: The results suggest that a MTEX approach is superior to an HEP in the treatment of inversion ankle sprains. Trial Registration: NCT00797368. LEVEL OF EVIDENCE: Therapy, level 1b.

J Orthop Sports Phys Ther, Epub 29 April 2013. doi:10.2519/jospt.2013.4792

KEY WORDS: manipulation, mobilization

STUDY DESIGN: Controlled laboratory study using cadaveric knee specimens and a repeated-measures design. OBJECTIVES: To investigate the effect of increased iliotibial band load (assumed to represent increased tensor fascia latae and gluteus maximus strength) on tibiofemoral kinematics and force distribution on the tibiofemoral articulation. BACKGROUND: Owing to the difficulty in measuring in vivo joint loading, there is limited evidence on the direct relationship between increased iliotibial band load and force distribution in the tibiofemoral articulation. METHODS: Eight fresh-frozen cadaveric knee specimens were used in this study. A robotic testing system tested tibiofemoral kinematics under 3 simulated loading conditions: 1) 300 N quadriceps load, 100 N hamstrings load, 0 N iliotibial band load; 2) 300 N quadriceps load, 100 N hamstrings load, 50 N iliotibial band load; 3) 300 N quadriceps load, 100 N hamstrings load, 100 N iliotibial band load. The load distribution in the medial and lateral tibiofemoral articulation was also measured under these loading conditions by using piezoelectric pressure sensors. Data were collected and analyzed at full extension and at 5°, 10°, 15°, 20°, 25°, and 30° of knee flexion. RESULTS: The loads transmitted through the medial tibiofemoral articulation significantly decreased when the load on the iliotibial band was increased with a concomitant significant increase in lateral tibiofemoral articulation load. Increase in the iliotibial band load also increased lateral and anterior tibial translations as well as external and valgus tibial rotations. CONCLUSION: The present study demonstrated that an increase in iliotibial band load when tested in a non-weight bearing condition in a cadaveric model can significantly decrease the loads transmitted through the medial tibiofemoral articulation.

J Orthop Sports Phys Ther, Epub 18 March 2013. doi:10.2519/jospt.2013.4506

KEY WORDS: gluteus maximus, joint forces, knee osteoarthritis, robotic testing system, tensor fascia latae

STUDY DESIGN: Retrospective cohort. OBJECTIVES: The objectives of this study were to 1) examine patients' general expectations for treatment by physical therapists and specific expectations for common interventions in patients with neck pain; and 2) assess the extent to which the patients' general and specific expectations for treatment affect clinical outcomes. BACKGROUND: Patient expectations can have a profound influence on the magnitude of treatment outcome across a broad variety of patient conditions. METHODS: We performed a secondary analysis of data from a clinical trial of interventions for neck pain. Prior to beginning treatment for neck pain, 140 patients were asked their general expectations of benefit as well as their specific expectations for individual interventions. Next we examined how these expectations related to the patients' ratings of the success of treatment at one and six months after treatment. RESULTS: Patients had positive expectations for treatment by a physical therapist with more than 80% of patients expecting to have moderate relief of symptoms, prevention of disability, the ability to do more activity, and to sleep better. The manual therapy interventions of massage (87%) and manipulation (75%) had the highest proportion of patients who expected these interventions to significantly improve neck pain. These were followed by strengthening (70%) and range of motion (54%) exercises. Very few patients thought surgery would improve their neck pain (<1%). At 1-month, patients who were unsure of experiencing complete pain relief had lower odds than patients expecting complete relief (OR 0.33, 95%CI 0.11, 0.99). Believing that manipulation would help and not receiving manipulation lowered the odds of success (OR 0.16, 95%CI 0.04, 0.72) compared to believing manipulation would help and receiving manipulation. Six months after treatment, having unsure expectations for complete pain relief lowered the odds of success 0.19 (95%CI 0.05, 0.7) times while definitely expecting to do more exercise increased odds of success (OR 11.4, 95%CI 1.7, 74.7) times. When considering self-reported disability, patients who believed manipulation would help and received manipulation reported less disability than those who didn't believe manipulation would help and both received manipulation (difference of -3.8, 95%CI -5.9, -1.5; p=0.006) and did not receive manipulation (difference of -5.7, 95%CI -9.3, -2.1; p=0.014).  There was also an interaction between time and the expectation for complete relief. Here, participants who expected complete relief had greater changes in disability at 1-month (20.3% 95%CI 18.1, 22.6) compared to those participants who did not expect complete relief (14.1%, 95%CI 11.1, 17.0; p=0.014). CONCLUSION: General expectations of benefit have a strong influence on clinical outcomes for patients with neck pain. LEVEL OF EVIDENCE: Prognosis, level 2b.

J Orthop Sports Phys Ther, Epub 18 March 2013. doi:10.2519/jospt.2013.4492

KEY WORDS: exercise, manual therapy, neck pain, outcomes

STUDY DESIGN: Randomized controlled trial. OBJECTIVES: To determine the effects of instruction aimed at improving frontal plane knee biomechanics during a jump landing task. BACKGROUND: Technique training is a common component of knee injury prevention programs.  In developing programs that minimize time commitment and increase the likelihood of adoption by target groups, there is a need to evaluate individual program components. METHODS: A total of 26 female recreational athletes (average age: 21.2 yrs) who presented with medial knee displacement during a jump landing task completed the study protocol.  Participants were randomly placed into one of 2 groups:  experimental or control.  The experimental group received instructions aimed at improving knee abduction during jump-landings.  The control group received "sham" training.  Prior to training, baseline kinematics and kinetics (peak knee abduction angle, peak internal knee adductor moment, knee flexion excursion, peak internal knee extensor moment, and peak vertical ground reaction force) were obtained from participants while performing a basketball rebound task.   Immediate (5-minutes post-instruction) and delayed (15-20 minutes post-instruction) retentions tests were performed within the instructional session.  Two additional retention tests were performed following home-based training (1 and 2 weeks following the initial training). RESULTS: The initial instructional session resulted in greater knee flexion excursion (9°) and a 20% reduction in the peak internal knee adductor moment in the experimental group.  Following home-based training, the experimental group continued to exhibit increased knee flexion excursion along with decreased peak vertical ground reaction forces. No biomechanical changes were observed in the control group for any of retention tests when compared to baseline. CONCLUSION: The jump training instructions employed in the current study resulted in kinematic and kinetic changes in the sagittal plane as opposed to the frontal plane. LEVEL OF EVIDENCE: Therapy/Prevention, level 2b.

J Orthop Sports Phys Ther, Epub 18 March 2013. doi:10.2519/jospt.2013.4229

KEY WORDS: ACL, biomechanics, feedback, instruction, training