STUDY DESIGN: Reliability study. OBJECTIVES: To determine intrarater test-retest and interrater reliability of the Functional Movement Screen (FMS) among novice raters. BACKGROUND: The FMS is used by various examiners to assess movement and predict time loss injuries in diverse populations (eg, youth to professional athletes, firefighters, military service members) of active participants. Unfortunately, critical analysis of the reliability of the FMS is currently limited to 1 sample of active college age participants. METHODS: Sixty-four active duty service members (mean ± SD age and body mass index: 25.2 ± 3.8 years, 25.1 ± 3.1 kg/m²) without a history of injury were enrolled. Participants completed the 7 component tests of the FMS in a counterbalanced order. Each component test was scored on an ordinal scale (0 to 3 points) resulting in a composite score from 0 to 21 points. Intrarater test-retest reliability was assessed between baseline scores and those obtained with repeated testing performed 48 to 72 hours later. Interrater reliability was assessed based on the assessment from 2 raters, selected from a pool of 8 novice raters, which assessed the same movements on day 2 simultaneously. Descriptive statistics, weighted Kappa (k_w), and percent agreement were calculated on component scores. Intraclass correlation coefficients (ICC), standard error of the measurements (SEM), minimal detectable chance (MDC₉₅), and associated 95% confidence intervals were calculated on composite scores. RESULTS: The average ± SD score on the FMS was 15.7 ± 0.2 points with 15.6% (n=10) of the participants scoring less than or equal to 14 points, the recommended cutoff for predicting time-loss injuries. The intrarater test-retest and interrater reliability of the FMS composite score resulted in an ICC_3,1  of 0.76 (95% CI: 0.63-0.85) and an ICC_2,1 of 0.74 (95% CI: 0.60-0.83) respectively. The SEM of the composite test was within 1 point and the MDC₉₅ was 2.1 and 2.5 points on the 21 point scale for inter- and intrarater reliability, respectively. The interrater agreement of the component scores ranged from moderate to excellent (k_w: 0.45 to 0.82). CONCLUSIONS: Among novice raters, the FMS composite score demonstrated moderate to good interrater and intrarater reliability with acceptable levels of measurement error. The measures of reliability and measurement error were similar for both intrarater reliability that repeated the assessment of the movement patterns over a 48 to 72 hour period and interrater reliability that had 2 raters assess the same movement pattern simultaneously.  The interrater agreement of the FMS component scores were good to excellent for the pushup, quadruped, shoulder mobility, straight leg raise, squat, hurdle, and lunge. Only 15.6% (n=10) of the participants were identified at-risk for injury based on previously published cut-off values.

J Orthop Sports Phys Ther, Epub 14 May 2012. doi:10.2519/jospt.2012.3838

KEY WORDS: injury prediction, injury prevention, injury risk, interrater, intrarater

STUDY DESIGN: Prospective cohort/predictive validity study. OBJECTIVE: To determine the predictive validity of selected clinical examination items and to develop a clinical prediction rule to determine which patients with neck pain may benefit from cervical thrust joint manipulation (TJM) and exercise. BACKGROUND: TJM to the cervical spine has been shown to be effective for some patients presenting with a primary report of neck pain. It would be useful for clinicians to have a decision making tool, such as a clinical prediction rule, that could accurately identify which subgroup of patients would respond positively to cervical TJM. METHODS: Consecutive patients presenting to physical therapy with a primary complaint of neck pain completed a series of self-report measures, and then received a detailed standardized history and physical examination. After the clinical examination, all patients received a standardized treatment regimen consisting of cervical TJM and range of motion (ROM) exercise. Depending on response to treatment, patients were treated for 1 or 2 sessions over approximately 1 week. At the end of their participation in the study, patients were classified as having experienced a successful outcome based on a score of +5 ("quite a bit better") or higher on the Global Rating of Change Scale. Sensitivity, specificity, and positive and negative likelihood ratios were calculated for all potential predictor variables. Univariate techniques and step-wise logistic regression were used to determine the most parsimonious set of variables for prediction of treatment success. Variables retained in the regression model were used to develop a multivariate clinical prediction rule. RESULTS: Eighty-two patients were included in data analysis of which 32 (39%) achieved a successful outcome. A clinical prediction rule with 4 attributes (symptom duration less than 38 days, positive expectation that manipulation will help, side-to-side difference in cervical rotation ROM of 10 degrees or greater, and pain with posterior-anterior (PA) spring testing of the middle cervical spine) was identified. If 3 or more of the 4 attributes (positive likelihood ratio of 13.5) were present the probability of experiencing a successful outcome improved from 39% to 90%. CONCLUSION: The clinical prediction rule may improve decision-making by providing the ability to a priori identify patients with neck pain who are likely to benefit from cervical TJM and ROM exercise. However, this is only the first step in the process of developing and testing a clinical prediction rule as future studies are necessary to validate the results and should also include long-term follow-up and a comparison group. LEVEL OF EVIDENCE: Therapy, Level 1b.

J Orthop Sports Phys Ther, Epub 14 May 2012. doi:10.2519/jospt.2012.4243

KEY WORDS: clinical decision rule, clinical prediction guide, manual therapy, mobilization, prognosis

STUDY DESIGN: Prospective Cohort OBJECTIVES: To identify the prevalence of neurocognitive and balance deficits in collegiate football players 48 hours following competition. BACKGROUND: Neurocognitive testing, balance assessments, and subjective report of symptoms are a commonly used test battery in examining athletes when concussion is suspected. Previous literature suggests many concussions go unreported.  Little research exists examining the prevalence of neurocognitive or balance deficits in athletes who do not report concussion-like symptoms to a health care provider. METHODS: Forty-five Division IA Collegiate football players participated in this study.  Preseason baseline scores using the Balance Error Scoring System (BESS), the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), and the Post Concussion Symptom Score were compared to  posttest results obtained 48 hours following a game.  Prevalence of symptoms were analyzed and reported. RESULTS: Thirty-Two of the 45 (71%) athletes tested demonstrated at least one deficit in either the Post Concussion Symptom Score, BESS, or at least one composite score of the ImPACT.   Nineteen of the 32 subjects demonstrated a change in two or more categories of neurocognitive and balance function. CONCLUSION: In a cohort of subjects who were tested 48 hours following the last game of the season and did not seek medical attention related to a concussion, a significant number of football players demonstrated limitations in neurocognitive and balance performance suggesting further research needs to be performed to improve recognition of an athlete's deficits and improve the ability to assess concussion. LEVEL OF EVIDENCE: Therapy, level 2b.

J Orthop Sports Phys Ther, Epub 24 April 2012. doi:10.2519/jospt.2012.3798

KEY WORDS: BESS, ImPACT, test battery, traumatic brain injury

STUDY DESIGN: Single cohort laboratory based study. OBJECTIVES: To measure thoracic spine extension motion during bilateral arm elevation using functional radiography and photographic image analysis. BACKGROUND: Impairment of thoracic spine extension motion may impact on shoulder girdle function. Motion of the thoracic spine during arm movement has not been directly measured using functional radiographic analysis. METHODS: In 21 asymptomatic males, the thoracic kyphosis was measured in neutral standing and in end-range bilateral arm elevation using lateral radiographs and photographic image analysis. Using both measurement techniques, the difference between the two body positions was used to quantify the range of extension motion of the thoracic spine. Bland and Altman plots were used to examine the agreement between measurement techniques. The relationship between the amount of thoracic kyphosis in neutral standing and kyphosis in full bilateral arm elevation was also examined. RESULTS: The mean±SD increase in thoracic extension with bilateral arm elevation was 12.8±7.6° and 10.5±4.4 when measured from the radiographs and photographs, respectively. There was a significant correlation between the radiographic and photographic measurements of the amount of neutral thoracic kyphosis measured in neutral posture (r=0.71, p<0.01) and for the kyphosis measured while in full bilateral arm elevation (r=0.82, p<0.001). The mean difference between the 2 measurement techniques was 2.1 degrees for kyphosis measured in neutral posture, and 0.5 degrees when measured in full bilateral arm elevation. The thoracic kyphosis angle measured in neutral posture was strongly correlated with the thoracic kyphosis angle measured in full bilateral arm elevation when measured with both radiographic (r=0.78, p<0.001) and photographic (r=0.84, p<0.001) techniques. CONCLUSION: In asymptomatic men, bilateral arm elevation is associated with movement of the thoracic spine towards extension but the amount of movement is variable among individuals.

J Orthop Sports Phys Ther, Epub 20 April 2012. doi:10.2519/jospt.2012.4164

KEY WORDS: biomechanics, kyphosis, movement analysis, range of motion, shoulder elevation

STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To compare the effectiveness of cervical spine thrust manipulation and Kinesiotaping® applied to the neck on self-reported pain and disability, and cervical range of motion in individuals with mechanical neck pain. BACKGROUND: The effectiveness of cervical manipulation has received considerable attention in the literature. However, because some patients cannot tolerate cervical thrust manipulations, alternative therapeutic options should be investigated. METHODS: Eighty patients (36 females) were randomly assigned to 1 of 2 groups: the manipulative group received 2 cervical thrust manipulations, whereas the tape group received Kinesiotaping® applied to the neck. Neck pain (11-point numeric pain rating scale), disability (Neck Disability Index), and cervical range of motion data were collected at baseline and 1 week after the intervention by an assessor blinded to the treatment allocation of the patients. Mixed-model ANOVAs were used to examine the effects of the treatment on each outcome variable with group as the between-subject variable and time as the within-subject variable. The primary analysis was the Group by Time interaction. RESULTS: No significant Group by Time interactions were found for pain (F=1.892; P=0.447) or disability (F=0.115; P=0.736). The Group by Time interaction was statistically significant for right (F = 7.317, P=0.008) and left (F=9.525, P=0.003) cervical rotation range of motion with the patients receiving the cervical thrust manipulation experiencing greater improvement in cervical rotation than those treated with Kinesiotape (P < 0.01). No significant Group by Time interactions were found for cervical spine range of motion for flexion (F=0.944; P= 0.334), extension (F=0.122; P=0.728), and right (F=0.220; P=0.650) and left (F=0.389, P= 0.535) lateral-flexion. CONCLUSIONS: Patients with mechanical neck pain receiving cervical thrust manipulation or treated with Kinesiotaping® exhibited similar reductions in neck pain intensity and disability and similar changes in active cervical range of motion except for rotation. Changes in neck pain surpassed the minimal clinically important difference (MCID), whereas changes in disability did not. Changes in cervical range of motion were small and not clinically meaningful. Because we did not include a control or placebo group in this study, we cannot rule out placebo effect or natural changes over time as potential reasons for the improvements measured in both groups. LEVEL OF EVIDENCE: Therapy, Level 1b.

J Orthop Sports Phys Ther, Epub 20 April 2012. doi:10.2519/jospt.2012.4086

KEY WORDS: cervical spine, manual therapy, mobilization

STUDY DESIGN: Resident's case problem. BACKGROUND: A 56 year-old male was referred to physical therapy for analysis of unusual gait first noticed 3 years previously when running. Prior to this evaluation, the patient had seen multiple orthopaedic, sports medicine, and neurological specialists while undergoing repeated and extensive testing. Ten months of testing and treatment including conservative and surgical management did not provide an explanation for the gait abnormality or result in improvement of the patient's condition. DIAGNOSIS: The patient's physical examination was relatively unremarkable considering the severity of the gait abnormality. Distinct abnormalities were apparent with computerized gait analysis and dynamic electromyography, that when combined with the physical examination findings led to a suspicion of the task-specific disorder, runner's dystonia. The patient was referred to a neurologist specializing in movement-related disorders, with a final confirmed diagnosis of primary task-specific dystonia with first onset during running, ie, runner's dystonia. DISCUSSION:  Idiopathic, task-specific dystonia of the lower extremity is documented as a very rare occurrence, yet increasing trends in running participation may result in a higher incidence of this condition.  Improved awareness of runner's dystonia in the present case may have enhanced the clinical decision making process and resulted in more timely and effective treatment solutions. Clinical examination findings including computerized gait analysis and electromyography can aid in the diagnosis of runner's dystonia in conjunction with imaging, blood, and genetic testing. LEVEL OF EVIDENCE: Diagnosis, level 4.

J Orthop Sports Phys Ther, Epub 20 April 2012. doi:10.2519/jospt.2012.3892

KEY WORDS: differential diagnosis, electromyography, gait analysis, runner's dystonia

STUDY DESIGN: Descriptive prospective cohort study. OBJECTIVES: To investigate the relationships between knee joint effusion, quadriceps activation, and quadriceps strength.  These relationships may help clinicians better identify impaired quadriceps activation. BACKGROUND: After anterior cruciate ligament (ACL) injury, the involved quadriceps can demonstrate weakness. Experimental data have shown that quadriceps activation and strength may be directly mediated by intracapsular joint pressure created by saline injection.  An inverse relationship between quadriceps activation and the amount of saline injected has been reported.  This association has not been demonstrated for traumatic effusion.  We hypothesized that traumatic joint effusion due to ACL rupture and post-injury quadriceps strength would correlate well with quadriceps activation, allowing clinicians to use effusion and strength measurement as a surrogate for electrophysiological assessment of quadriceps activation. METHODS:  Prospective data were collected on 188 patients within 100 days of ACL injury (average 27 days) referred from a single surgeon.  A complete clinical evaluation of the knee was performed including ligamentous assessment and assessment of range of motion and effusion.  Quadriceps function was electrophysiologically assessed using maximum volitional isometric contraction and burst superimposition techniques to quantify both strength and activation. RESULTS: Effusion grade did not correlate with quadriceps central activation ratio (CAR) [Zero effusion: mean ± SD CAR = 93.5% ±5.8%; Trace effusion: CAR = 93.8% ±9.5%; 1+ effusion: CAR = 94.0% ±7.5%; 2+/3+ effusion: CAR = 90.6% ±11.1%]. These values are lower than normative data from healthy subjects (CAR = 98% ±3%). CONCLUSIONS: Joint effusion after ACL injury does not directly mediate quadriceps activation failure seen after injury.  Therefore, it should not be used as a clinical substitute for electrophysiological assessment of quadriceps activation.  Patients presenting to physical therapy after ACL injury should be treated with high intensity neuromuscular electrical stimulation to help normalize this activation.

J Orthop Sports Phys Ther, Epub 20 April 2012. doi:10.2519/jospt.2012.3793

KEY WORDS: ACL, effusion, electrophysiological assessment, swelling

STUDY DESIGN: Repeated measures. OBJECTIVES: The purpose of this study was to quantify the changes in the transverse abdominis (TrA), internal oblique (IO), and external oblique (EO) muscle thickness induced by different inward pressures of the transducer during ultrasound imaging (USI). BACKGROUND: USI of the lateral abdominal muscles is increasingly being used in the management of conditions involving musculoskeletal dysfunctions. However, to the best of our knowledge, no study has evaluated the influence of different inward pressures of the transducer on the lateral abdominal muscle thickness during USI. METHODS: Thirty healthy male volunteers participated in this study. The thickness of the TrA, IO, and EO muscles were measured by USI in the following 4 conditions, where inward pressures of 0.5 N, 1.0 N, 2.0 N, and 4.0 N. A repeated measures ANOVA was utilized to determine the influence of inward pressure on thickness of the lateral abdominal muscles. RESULTS: The thickness of TrA, IO, and EO muscles were significantly different among the 4 conditions (P < 0.038). The mean differences between the 0.5-N and 4.0-N conditions were greater than the minimal detectable change of the 0.5-N condition in the lateral abdominal muscles. CONCLUSIONS: The difference in magnitude produced by the forces under different conditions was meaningful. When using a technique that involves a handheld transducer, the examiner should attempt to maintain consistent inward pressure of the transducer during USI to quantify the minimal change of lateral abdominal muscles.

J Orthop Sports Phys Ther, Epub 19 April 2012. doi:10.2519/jospt.2012.4064

KEY WORDS: muscle thickness, transverse abdominis, ultrasound imaging

STUDY DESIGN: Retrospective analyses of longitudinal, observational cohort data. OBJECTIVES: To compare discriminating ability and minimal clinically important improvement (MCII) calculated using functional status (FS) measures estimated from the Lumbar Computerized Adaptive Test (LCAT) and Modified Oswestry Low Back Pain Disability Questionnaire (ODI). BACKGROUND: LCAT and ODI are commonly used to estimate FS in patients seeking outpatient therapy but have not been compared directly. METHODS: Data from 8,198 adults were analyzed from patients who completed LCAT and ODI at intake: 3,379 (41%) completed both surveys at discharge. Global ratings of change data were available from 980 patients. Discriminating ability of FS estimates from LCAT and ODI was estimated using Relative Validity (RV) calculated by dividing F values from LCAT and ODI ANCOVAs for important risk-adjustment variables. MCII was estimated using receiver operating characteristic (ROC) analyses by quartiles of intake FS values, and areas under the curves (AUC) were compared. RESULTS: RV ratios favored LCAT for age (3.7, 95% CI 2.0-8.9), acuity (1.3, 95% CI 1.1-1.6), comorbidities (1.8, 95% CI 1.3-2.6), and surgical history (1.8, 95% CI 1.2-2.9). MCII cut-scores per quartile favored LCAT. ROC AUCs were not different. CONCLUSIONS: FS measures estimated by both questionnaires had similar psychometric characteristics. The LCAT FS estimates tended to be more discriminating than ODI FS estimates. MCII cut-scores by quartile of intake FS favored the LCAT. Given the need to be efficient and precise estimating measures of FS, particularly for older patients, results favor the LCAT in busy, automated outpatient therapy clinics increasingly serving an aging population.

J Orthop Sports Phys Ther, Epub 19 April 2012. doi:10.2519/jospt.2012.3942

KEY WORDS: computerized adaptive testing, lumbar spine, minimal clinically important difference, Oswestry, relative validity

STUDY DESIGN: Crossover. OBJECTIVES: To compare the time required to decrease intramuscular temperature 8°C below baseline temperature, and compare intramuscular temperature 90 minutes post-treatment between two cryotherapy modalities. BACKGROUND: Cryotherapy is used to treat pain from muscle injuries.  Cooler intramuscular temperatures may reduce cellular metabolism and secondary hypoxic injury to attenuate acute injury response, specifically the rate of chemical mediator activity.  Modalities that decrease intramuscular temperature quickly may be beneficial in the treatment of muscle injuries. METHODS: 18 healthy subjects received 2 cryotherapy conditions: crushed ice bag (CIB) and cold water immersion (CWI) in a randomly allocated order separated by 72 hours, applied until intramuscular temperature decreased 8°C below baseline.  Intramuscular temperature was monitored in the gastrocnemius 1cm below subcutaneous adipose tissue.  The primary outcome was time to decrease intramuscular temperature 8°C below baseline. A secondary outcome was intramuscular temperature at the end of a 90 minute rewarming period.  Paired t-tests were used to examine outcomes. RESULTS: Time to reach an 8°C reduction in intramuscular temperature was not significantly different between CIB and CWI (mean difference (95% CI) = 2.6 minutes (-3.10, 8.30)).  Intramuscular temperature remained significantly colder 90 minutes post-cold water immersion compared to crushed ice bag (mean difference (95% CI) = 2.8°C (2.07, 3.52)). CONCLUSION: There was no difference in time required to reduce intramuscular temperature 8°C 1cm below adipose tissue using CIB and CWI.  However, intramuscular temperature remained significantly colder 90 minutes following CWI.  These results provide clinicians with information that may guide treatment modality decisions.

J Orthop Sports Phys Ther, Epub 23 March 2012. doi:10.2519/jospt.2012.4200

KEY WORDS: adipose tissue, cold water immersion, ice bag

STUDY DESIGN: Case report. BACKGROUND: Postpartum low back and hip dysfunction may be caused by an incomplete recovery of abdominal musculature and impaired neuromuscular control. The purpose of this report is to describe the management of a postpartum runner with hip and low back pain (LBP) through exercise training via ultrasound imaging (USI) biofeedback combined with running form modification. CASE DESCRIPTION: A postpartum runner with hip and LBP underwent dynamic lumbar stabilization (DLS) training with USI biofeedback, and running form modification to reduce mechanical loading. Muscle thickness of transversus abdominus (TrA) and internal oblique (IO) was measured with USI pre-intervention and 7wks after completion of the intervention. Additionally, three-dimensional lower extremity joint motions, moments and powers were calculated during treadmill running. OUTCOMES: The patient's pain with running decreased from a constant 9/10 (0, no pain; 10, worst pain) to an occasional 3/10 post-treatment. TrA muscle thickness increased 6.3% during the abdominal drawing in maneuver (ADIM) and 27.0% during the ADIM with straight leg raise (SLR); changes were also noted in the IO. These findings corresponded to improved lumbopelvic control; pelvic list and axial rotation during running decreased 38% and 36%, respectively. The patient's running volume returned to pre-injury levels (8.1-9.7 km, 3 d/wk) with no hip pain and minimal LBP; she successfully completed her goal of running a half marathon. DISCUSSION: The successful outcomes of this case support the consideration of DLS exercises, USI biofeedback and running form modification in postpartum runners with lumbopelvic dysfunction. LEVEL OF EVIDENCE: Therapy, Level 4.

J Orthop Sports Phys Ther, Epub 23 March 2012. doi:10.2519/jospt.2012.3941

KEY WORDS: abdominal drawing in maneuver, running mechanics, transversus abdominus 

STUDY DESIGN: Cross-sectional. OBJECTIVE: To use stress ultrasonography to measure the change in anterior talofibular ligament length during the anterior drawer and ankle inversion stress tests. BACKGROUND: In approximately 30% of individuals, ankle sprains may eventually develop into chronic ankle instability (CAI) with recurrent symptoms. Individuals with CAI and those who have a history of ankle sprain (greater than 1 year prior) without chronic instability (copers), may or may not have mechanical laxity. METHODS: Sixty subjects (n=60 ankles) were divided into 3 groups: 1) Control subjects without ankle injury history (n=20, mean ± SD age, 24.8 ± 4.8years, height, 173.7 ± 9.4cm, weight, 77.2 ± 19.5 kg), ankle sprain copers (n=20, 22.3±2.9yrs, 172.8±11.3cm, 72.4±14.3kg), and subjects with CAI (n=20, 23.5±4.2yrs, 174.6±9.6cm, 74.8±17.3kg). Ligament length change with the anterior drawer and end-range ankle inversion was calculated from ultrasound images. The Foot and Ankle Ability Measure (FAAM) was used to quantify self-reported function on activities-of-daily living (ADL) and sports. RESULTS: The anterior drawer test resulted in length changes that were greater (F_2,57=6.2, p=.004) in the CAI (mean ± SD length change, 15.6 ± 15.1%, p=.006) and the coper groups (14.0 ± 15.9%, p=.016) compared to the control group (1.3 ± 10.7%); however the length change for the CAI and coper groups were not different (p=.93). Ankle inversion similarly resulted in greater ligament length change (F_2,57=6.5, p=.003) in the CAI (25.3 ± 15.5%, p=.003) and coper groups (20.2 ± 19.6%, p=.039) compared to the control group (7.4 ± 12.9%); with no difference in length change between the copers and CAI groups (p=.59). The CAI group had a lower score on the FAAM-ADL (87.4 ± 13.4%) and FAAM-Sports (74.2 ± 17.8%)  when compared to the control (98.8 ± 2.9% and 98.9 ± 3.1%, p<.0001) and coper groups (99.4 ± 1.8% and 94.6 ± 8.8%, p<.0001). CONCLUSION: Stress ultrasonography identified greater length changes of the anterior talofibular ligament in both the coper and CAI groups compared to the control group. Only subjects with CAI had reductions in self-reported function.

J Orthop Sports Phys Ther, Epub 23 March 2012. doi:10.2519/jospt.2012.3923

KEY WORDS: anterior talofibular ligament, CAI, FAAM

STUDY DESIGN: Secondary analysis, pre-treatment:post-treatment observational study. OBJECTIVE: Compare the reliability and responsiveness of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Knee Outcome Survey-Activities of Daily Living Scale (ADLS), and the Lower Extremity Functional Scale (LEFS) in individuals with knee osteoarthritis (OA). BACKGROUND: The WOMAC is the current standard in patient-reported measures of function in patients with knee OA. The ADLS and LEFS have been designed for potential use in patients with knee OA.  If the ADLS and/or LEFS are to be considered viable alternatives to the WOMAC in measuring patient-reported function in individuals with knee OA, then they should have measurement properties that are comparable to the WOMAC.  It would also be important to determine whether either of these instruments may be superior to the WOMAC in terms of reliability or responsiveness in this population. METHODS: Data from 168 subjects with knee OA who participated in a rehabilitation program were used in the analyses. Reliability and responsiveness of each outcome measure were estimated at 2, 6, and 12 month follow-up time points. Reliability was estimated by calculating the intraclass correlation coefficient (2,1) for subjects who were unchanged in status from baseline at each follow-up time point, based on a global rating of change score. To examine responsiveness, the standard error of the measure (SEM), minimum detectable change (MDC), minimum clinically important difference (MCID), and the Guyatt responsiveness index (GRI) were calculated for each outcome measure at each follow-up time point. RESULTS: All 3 outcome measures demonstrated reasonable reliability and responsiveness to change. Reliability and responsiveness tended to decrease somewhat with increasing follow up time. There were no substantial differences between outcome measures for reliability or any of the 3 measures of responsiveness at any follow-up time point. CONCLUSIONS: The results do not indicate that one outcome measure is superior to another with regards to reliability and responsiveness when applied to subjects with knee OA.  We believe all 3 instruments are appropriate outcome measures to examine change in functional status of patients with knee OA.

J Orthop Sports Phys Ther, Epub 8 March 2012. doi:10.2519/jospt.2012.4038

KEY WORDS: clinimetrics, function, measurement, physical therapy, psychometrics

STUDY DESIGN: Controlled laboratory study using a cross-sectional design. OBJECTIVES: To determine if there is any sex difference in trunk, pelvis, hip, and knee kinematics, hip strength, and gluteal muscle activation during the performance of a single leg squat in individuals with patellofemoral pain syndrome (PFPS) and controls. BACKGROUND: Although of greater incidence in females, PFPS is also quite common in males. Trunk kinematics have the potential to affect hip and knee function, however there is a lack of studies considering the influence of the trunk in individuals with PFPS. METHODS: Eighty subjects were distributed into 4 groups: females with PFPS, female controls, males with PFPS, and male controls. Trunk, pelvis, hip, and knee kinematics and gluteal muscle activation were evaluated during a single leg squat. Hip abduction and external rotation eccentric strength was measured on an isokinetic dynamometer.  Group differences were assessed using 2-way MANOVA (sex x group). RESULTS: Compared to controls, subjects with PFPS had greater ipsilateral trunk lean (mean ±, SD, 9.3˚ ± 5.3˚ versus 6.7˚ ± 3.0˚, P=.012), contralateral pelvic drop (10.3˚ ± 4.7˚ versus 7.4˚ ± 3.8˚, P=.003), hip adduction (14.8˚ ± 7.8˚ versus 10.8˚ ± 5.6˚, P<.0001), and knee abduction (9.2˚ ± 5.0˚ versus 5.8˚ ± 3.4˚, P<.0001) when performing a single leg squat. Subjects with PFPS also had 18% less hip abduction and 17% less hip external rotation strength. Compared to the female controls, the females with PFPS had more hip internal rotation (P<.05) and less muscle activation of the gluteus medius (P=.017) during the single leg squat. CONCLUSION: Therefore, despite many similarities in findings for males and females with PFPS, there are some specific sex differences that may warrant consideration in future studies and clinically when evaluating and treating females with PFPS.

J Orthop Sports Phys Ther, Epub 8 March 2012. doi:10.2519/jospt.2012.3987

KEY WORDS: anterior knee pain, biomechanics, electromyography, patella

STUDY DESIGN: Case Series. BACKGROUND: It has been shown in rodent and canine models that cartilage composition is significantly altered in response to long-term unloading. To date, however, no in vivo human studies have investigated this topic. The objective of this case series was to determine the influence of unloading and reloading on T_1ρ and T₂ relaxation times of articular cartilage in healthy young joints. CASE DESCRIPTION: Ten patients who required 6 to 8 weeks of non-weight-bearing for injuries affecting the distal lower extremity participated in the study. Quantitative T_1ρ and T₂ imaging of the ipsilateral knee joint was performed at 3 time points: 1) prior to surgery (baseline); 2) immediately after a period of non-weight-bearing (post-NWB); and 3) after 4 weeks of full-weight-bearing (post-FWB). Cartilage regions-of-interest were segmented and overlaid on T_1ρ and T₂ relaxation time maps for quantification. Descriptive statistics are provided for all changes. OUTCOMES: Increases of 5 to 10% in T_1ρ times of all femoral and tibial compartments were noted post-NWB. All values returned to near-baseline levels post-FWB. Increases in medial tibia T₂ times were noted post-NWB and remained elevated post-FWB. The load-bearing regions showed the most significant changes in response to unloading (up to 12% increases). DISCUSSION: The observation of a transient shift in relaxation times confirms that cartilage composition is subject to alterations based on loading conditions. These changes appear to be mostly related to proteoglycan content and more localized to the load-bearing regions. However, following 4 weeks of full-weight-bearing, relaxation times of nearly all regions had returned to baseline levels demonstrating reversibility in compositional fluctuations. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther, Epub 8 March 2012. doi:10.2519/jospt.2012.3975

KEY TERMS: biomechanics, knee, medical imaging, MRI

STUDY DESIGN: Retrospective longitudinal cohort. OBJECTIVES: To describe the clinical characteristics of patients with low back pain (LBP) according to physician referral source, and to identify associations between referral source and discharge functional status as well as number of physical therapy (PT) visits. BACKGROUND: Little is known about associations between physician referral source and outcomes of PT care for patients with LBP. Exploring these associations can contribute to better understanding of physician-PT relationships and may lead to improved referral patterns. METHODS: Data from a proprietary clinical database was examined retrospectively. Physician referral source was classified as primary care, specialist, or occupational medicine. Outcomes were overall health status (OHS) at discharge and number of PT visits. Descriptive statistics and bivariate associations between referral source and each outcome were assessed by calculating differences and 95% confidence intervals in means and proportions. In order to account for potential confounding, multi-level linear regression was used to adjust for baseline clinical covariates, and for effects related to clustering of patients treated by individual clinicians, and of clinicians working within individual clinics. RESULTS: Bivariate and multi-level analyses revealed significant associations between referral source and OHS and visits. Compared to specialist physician referral, referral from occupational medicine and primary care physicians was associated with higher discharge OHS scores and lower number of visits. CONCLUSIONS: After accounting for important clinical covariates and clustering, patients with LBP who were referred by occupational medicine and primary care physicians tended to have better functional outcomes and required fewer PT visits per episode of care. LEVEL OF EVIDENCE: Prognosis, level 2c.

J Orthop Sports Phys Ther, Epub 8 March 2012. doi:10.2519/jospt.2012.3957

KEY WORDS: lumbar spine, physician referral, practice-based evidence

SYNOPSIS: The management of patients after anterior cruciate ligament (ACL) reconstruction should be evidence based. Since our original published guidelines in 1996, successful outcomes have been consistently achieved with the rehabilitation principles of early weight bearing, using a combination of weight bearing and non-weight bearing exercise focused on quadriceps and lower extremity strength, and meeting specific objective requirements for return to activity. As rehabilitative evidence and surgical technology and procedures have progressed, the original guidelines should be revisited to ensure the most up to date evidence is guiding rehabilitative care. Emerging evidence on rehabilitative interventions and advancements in concomitant surgeries, including those addressing chondral and meniscal injuries, is continuing to grow and greatly affects the rehabilitative care of patients with ACL reconstruction.  The aim of this article is to update our previously published rehabilitation guidelines using the most recent research to reflect the most current evidence for management of patients after ACL reconstruction. The focus will be on current concepts in rehabilitation interventions and modifications needed for concomitant surgery and pathology.

J Orthop Sports Phys Ther, Epub 8 March 2012. doi:10.2519/jospt.2012.3871

KEY WORDS: ACL, graft, surgery

STUDY DESIGN: Clinical measurement study. OBJECTIVES: To translate and cross-culturally adapt the Western Ontario Shoulder Instability Index (WOSI) into Italian, and to evaluate its measurement properties in patients with shoulder instability secondary to a first traumatic anterior dislocation. BACKGROUND: The WOSI was developed for English-speaking patients. To date, no Italian version of the WOSI exists. METHODS: The WOSI was cross-culturally adapted to Italian according to established guidelines. Sixty-four (16 women, 48 men) patients with unilateral shoulder anterior instability were prospectively recruited for the purposes of this study. Internal consistency, test-retest reliability, construct validity, and responsiveness of the WOSI were evaluated. RESULTS: The Italian version of the WOSI showed a high degree of internal consistency, with a Cronbach's alpha of 0.93 (95% CI, 0.91 to 0.96). The test-retest reliability was high for both short-term (3 days, 64 patients) and medium-term (14 weeks, 20 patients) test-retest, with intraclass correlation coefficients of 0.95 (95% CI, 0.90 to 0.97) and 0.92 (95% CI, 0.89 to 0.95), respectively. The WOSI was more closely correlated to the DASH than the SF-36 (r = 0.794 and 0.113, respectively). The receiver-operating characteristic curve analysis revealed that the WOSI was more responsive than the DASH (P = 0.03), with an area under the curve of 0.90 (95% CI, 0.78 to 0.97) for the WOSI and 0.76 (95% CI, 0.61 to 0.88) for the DASH. CONCLUSION: The Italian version of the WOSI is a valid, reliable, and responsive tool that can be used to measure function in Italian speaking patients with shoulder instability due to a first traumatic anterior dislocation.

J Orthop Sports Phys Ther, Epub 8 March 2012. doi:10.2519/jospt.2012.3827

KEY WORDS: outcome measures, shoulder dislocation, shoulder questionnaire

STUDY DESIGN: Controlled laboratory study using a single cohort design. OBJECTIVES: To determine if balance in older adults could be significantly improved with foot orthotic intervention. BACKGROUND:  Poor balance has been associated with risk for falls. Limited evidence exists indicating that foot orthoses influence balance. METHODS: Thirteen individuals older than 65 who reported at least 1 unexplained fall during the past year and who demonstrated poor balance participated in the study.  Subjects were tested for one-leg stance, tandem stance, tandem gait, and alternating step tests during the first (SCREEN) and second (PRE) sessions prior to foot orthotic intervention. Tests were repeated during the second testing session immediately after custom foot orthotic intervention (POST), and 2 weeks following foot orthotic use (FU).  SCREEN and PRE measures were compared for stability using absolute difference computations and Friedman's rank test.  PRE, POST, and FU data were analyzed using the Friedman's rank test (alpha = 0.05) with Bonferroni correction for multiple post-hoc comparisons. RESULTS: Each balance measure was statistically equivalent between the SCREEN and PRE measurements.  One-leg stance times for PRE were significantly less than POST (P = .002) and FU (P = .013) measurements.  Tandem stance times for PRE were significantly less than POST (P = .013) and FU (P = .013) measurements.  Steps taken for the tandem gait test during the PRE measurements were significantly fewer than steps taken for the FU test (P = .007).  Steps taken during the alternating step test for the PRE test were significantly fewer than steps taken during the POST (P = .002) and FU (P =.001) tests.  POST and FU measurements were not significantly different for any of the 4 outcome measures. CONCLUSIONS: The results provide preliminary evidence that foot orthoses can effect improvement in balance measures for older adults.

J Orthop Sports Phys Ther, Epub 25 January 2012. doi:10.2519/jospt.2012.3944

KEY WORDS: falls, geriatrics, orthoses, postural control, stability

STUDY DESIGN: Case report. BACKGROUND: The Achilles tendon is the most frequently ruptured tendon, with the incidence increasing in the last decades. The rupture generally occurs without any preceding warning signs and therefore pre-injury data are seldom available. This case represents a unique opportunity to compare pre-injury running mechanics with post-injury evaluation in a patient with an Achilles tendon rupture. CASE DESCRIPTION: A 23-year-old female sustained a right total Achilles tendon rupture while playing soccer. Running mechanics data were collected pre-injury, as she was a healthy participant in a study on running analysis. In addition, patient reported symptoms, physical activity level, strength, ankle range of motion, heel-rise ability, Achilles tendon length, and running kinetics were evaluated 1 year after surgical repair. OUTCOMES: During running greater ankle dorsiflexion and eversion and rearfoot abduction were noted on the involved side post injury when compared to pre-injury data. In addition, post-injury, the magnitude of all kinetics data were lower on the involved limb when compared to the uninvolved limb. The involved side displayed differences in strength, ankle range of motion, heel-rise, and tendon length when compared to the uninvolved side 1 year after injury. DISCUSSION: Despite a return to normal running routine and reports of only minor limitations with running, considerable changes were noted in running biomechanics 1 year after injury. Calf muscle weakness and Achilles tendon elongation were also found when comparing the involved and uninvolved side.

J Orthop Sports Phys Ther, Epub 25 January 2012. doi:10.2519/jospt.2012.3913

KEY WORDS: Achilles tendon total rupture score (ATRS), biomechanics, heel-rise test

STUDY DESIGN: Cross sectional cohort study. OBJECTIVE: To investigate the differences in the level of activation of neck-shoulder muscles between elite swimmers with and without shoulder pain during a functional upper limb task. BACKGROUND: Previous studies have reported altered motor control of the neck-shoulder muscles in patients with chronic neck-shoulder pain. Whether the activation of neck-shoulder muscles is altered among elite swimmers suffering from shoulder pain is unknown. METHODS: Surface electromyography (SEMG) from the sternocleidomastoid (SCM), upper trapezius (UT), and anterior scalene (SCL) muscles was recorded bilaterally in 17 elite swimmers (9 men, 8 women; mean ± SD age: 21±3 years) with unilateral shoulder pain, and 17 age- and sex matched elite swimmers without pain. Root mean square (RMS) values were calculated and normalized to assess the level of muscular activation 5 seconds before, 120 seconds and 150 seconds into, and 10 seconds after a functional upper limb task. RESULTS: The repeated measures revealed significant differences between both groups for RMS of both SCL (F=3.733; P=0.016), but not for the SCM and UT muscles. Swimmers with shoulder pain had higher normalised RMS in both SCL muscles at 120s (78% on average) and 150s (86% on average) into and 10s post-task (40% on average) as compared with swimmers without shoulder pain (P<0.05). CONCLUSIONS: The elite swimmers with shoulder pain demonstrated greater activation of the SCL muscles during a functional task and a lower ability to relax the SCL muscles after completion of the task than elite swimmers without shoulder pain. The present findings suggest altered pattern of cervical muscle activation on elite swimmers with shoulder pain during performance of a functional task.

J Orthop Sports Phys Ther, Epub 25 January 2012. doi:10.2519/jospt.2012.3875

KEY WORDS: electromyography, neck, scalene

STUDY DESIGN: Controlled laboratory study. OBJECTIVES: To investigate the reliability and concurrent validity of photographic measurements of hallux valgus angle compared to radiographs as the criterion standard. BACKGROUND: Clinical assessment of hallux valgus involves measuring alignment between the first toe and metatarsal on weight-bearing radiographs or grading the severity of deformity visually using categorical scales. Digital photographs offer a non-invasive method of measuring deformity on an exact scale; however, the validity of this technique has not previously been established. METHODS: Thirty-eight subjects (30 female, 8 male) were examined (76 feet; 54 with hallux valgus). Computer software was used to measure hallux valgus angle from digital records of bilateral weight-bearing dorsoplantar foot radiographs and photographs. One examiner measured 76 feet on 2 occasions 2 weeks apart, and a second examiner measured 40 feet on a single occasion. Reliability was investigated by intraclass correlation coefficients (ICCs) and validity by 95% limits of agreement (LA). Pearson's correlation coefficient was also calculated. RESULTS: Intrarater and interrater reliability were very high (ICCs > 0.96) and 95% LA between photographic and radiographic measurements were acceptable. Measurements from photographs and radiographs were also highly correlated (Pearson's r = 0.96). CONCLUSIONS: Digital photographic measurements of hallux valgus angle are reliable and have acceptable validity compared to weight-bearing radiographs. This method provides a convenient and precise tool in assessment of hallux valgus, while avoiding the cost and radiation exposure associated with x-rays.

J Orthop Sports Phys Ther, Epub 25 January 2012. doi:10.2519/jospt.2012.3841

KEY WORDS: foot deformity, measurement, radiograph