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Background: Psychosocial variables are known to play an important role in musculoskeletal pain. Recent efforts incorporating psychological theory into rehabilitative medicine, as part of patient‐centred care or psychologically informed physical therapy, have gained broader acceptance. The fear‐avoidance model is the dominant psychosocial model and has introduced a variety of phenomena which assess psychological distress (i.e., yellow flags). Yellow flags, such as fear, anxiety and catastrophizing, are useful concepts for musculoskeletal providers but reflect a narrow range of psychological responses to pain. Objective: Clinicians lack a more comprehensive framework to understand psychological profiles of each patient and provide individualised care. This narrative review presents the case for applying personality psychology and the Big‐Five trait model (extraversion, agreeableness, conscientiousness, neuroticism and openness to experience) to musculoskeletal medicine. These traits have strong associations with various health outcomes and provide a robust framework to understand patient emotion, motivation, cognition and behaviour. Key Results: High conscientiousness is associated with positive health outcomes and health promoting behaviours. High neuroticism with low conscientiousness increases the odds of negative health outcomes. Extraversion, agreeableness and openness have less direct effects but have positive correlations with important health behaviours, including active coping, positive affect, rehabilitation compliance, social connection and education level. Clinical Application: The Big‐Five model offers an evidence‐based way for MSK providers to better understand the personality of their patients and how it relates to health. These traits offer the potential for additional prognostic factors, tailored treatments and psychological intervention. [ABSTRACT FROM AUTHOR]

Myotonometry is a relatively novel method used to quantify the biomechanical and viscoelastic properties (stiffness, compliance, tone, elasticity, creep, and mechanical relaxation) of palpable musculotendinous structures with portable mechanical devices called myotonometers. Myotonometers obtain these measures by recording the magnitude of radial tissue deformation that occurs in response to the amount of force that is perpendicularly applied to the tissue through a device's probe. Myotonometric parameters such as stiffness and compliance have repeatedly demonstrated strong correlations with force production and muscle activation. Paradoxically, individual muscle stiffness measures have been associated with both superior athletic performance and a higher incidence of injury. This indicates optimal stiffness levels may promote athletic performance, whereas too much or too little may lead to an increased risk of injury. Authors of numerous studies suggested that myotonometry may assist practitioners in the development of performance and rehabilitation programs that improve athletic performance, mitigate injury risk, guide therapeutic interventions, and optimize return-to-activity decision-making. Thus, the purpose of our narrative review was to summarize the potential utility of myotonometry as a clinical tool that assists musculoskeletal clinicians with the diagnosis, rehabilitation, and prevention of athletic injuries. [ABSTRACT FROM AUTHOR]

Background: Evidence suggests that tibialis posterior muscle plays an important role in equinovarus foot deformity in patients who had suffered a stroke and it is one of the most frequently injected lower-extremity muscles for the management of spasticity. Our aim was to assess if a needle accurately and safely penetrates the tibialis posterior muscle during the application of dry needling.  METHODS : We conducted a cadaveric descriptive study. Needling insertion of the tibialis posterior was conducted in 11 cryopreserved cadavers with a 70 mm needle. The needle was inserted using two common approaches, at midpoint (posterior/medial approach) and at upper third (anterior approach) of the leg towards the tibialis posterior. The needle was advanced into the tibialis posterior based upon clinician judgement. Cross-sectional anatomical dissections were photographed and analyzed by photometry. Safety was assessed by calculating the distances from the tip and the path of the needle to proximate neurovascular structures.Results: Accurate needle penetration of the tibialis posterior muscle was observed in all cadavers with both approaches. In general, distances from the needle to the neurovascular bundles were larger with the posterior/medial approach than with the anterior approach, reaching statistically significance for needle tip to nerve (mean difference: 0.6 cm, 95%CI 0.35 to 0.85 cm) and vascular bundle (mean difference: 0.55 cm, 95%CI 0.3 to 0.8 cm) distances (P < 0.001) and needle path to vascular bundle distance (difference: 0.25 cm, 95%CI 0.1 to 0.4 cm, P = 0.045). Age and gender did not influence the main results.Conclusions: This cadaveric study suggests that needling of the tibialis posterior muscle can be accurately and safely conducted. Safety seems to be larger with the posterior/medial approach when compared with the anterior approach. [ABSTRACT FROM AUTHOR]

Background: The popliteus muscle attaches posteriorly to the joint capsule of the knee. Although it is an important rotational stabiliser and has been implicated in various knee pathologies, research on its treatment with dry needling is scarce.Objective: To determine if a needle accurately and safely penetrates the popliteus muscle during the clinical application of dry needling.Methods: A cadaveric descriptive study was conducted. Needling insertion of the popliteus muscle was conducted in 11 cryopreserved cadavers with a 50-mm needle. The needle was inserted at upper third of the posterior part of the tibia closest to the knee towards the popliteus. The needle was advanced into the muscle based upon clinician judgement. Cross-sectional anatomical dissections were photographed and analysed by photometry. Safety of the intervention was assessed by calculating the distance from the tip of the needle to the proximate neurovascular structures.Results: Accurate needle penetration of the popliteus muscle was observed in 10 out of 11 (91%) of the cadavers (mean needle penetration: 25.7 ± 6.7mm, 95% CI 21.3-30.3 mm). The distances from the tip of the needle were 17±6mm (95% CI 13-21 mm) to the tibial nerve and 15 ± 0.7mm (95% CI 10-20 mm) to the popliteus vascular bundle.Conclusion: The results from this cadaveric study support the notion that needling of the popliteus can be accurately and safely conducted by an experienced clinician. Future studies investigating the clinical effectiveness of these interventions are needed. [ABSTRACT FROM AUTHOR]

Purpose: Investigate the construct validity of prognostic factors purported to predict clinical success with stabilization exercise for low back pain by exploring their associations with lumbar multifidus composition. Methods: Patients with low back pain were recruited from a hospital imaging department. The presence of fivepredictors (age <40 years, positive prone instability test, aberrant trunk flexion movements, straight leg raise range of motion >91°, spinal hypermobility) were identified by standardized physical examination. Predictors were grouped by total positive findings and status on a clinical prediction rule. The proportion of lower lumbar multifidus intramuscular adipose tissue was measured with 3.0 T magnetic resonance imaging. Univariate and multivariate associations were examined with linear regression and reported with standardized beta coefficients (β) and 95% confidence intervals. Results: Data from 62 patients (11 female) with mean (SD) age of 45.2 (11.8) years were included. Total number of predictors (β[95% CI] = −0.37[−0.61,−0.12]; R2 = 0.12), positive prediction rule status (β[95% CI] = −0.57[−0.79,−0.35]; R2 = 0.30), and age <40 years were associated with lower intramuscular adipose tissue (β[95% CI] = −0.55[−0.77,−0.33]; R2 = 0.27). No other individual factors were associated with lumbar multifidus intramuscular adipose tissue. Conclusions: These findings support the construct validity of the grouped prognostic criteria. Future research should examine the clinical utility of these criteria. Low back pain is the single largest cause of disability worldwide and exercise therapy is recommended by international low back pain treatment guidelines. Lower levels of lumbar multifidus intramuscular adipose tissue were associated with predictors of clinical success with stabilization exercise. Higher proportions of lumbar multifidus intramuscular adipose tissue may help identify patients who require longer duration exercise training, or those who are unlikely to respond to stabilization exercise. [ABSTRACT FROM AUTHOR]

* BACKGROUND: Patients with surgical fixation ankle and/or hindfoot fractures often experience decreased range of motion and loss of function following surgery and postsurgical immobilization, yet there is minimal evidence to guide care for these patients. * OBJECTIVES: To assess whether manual therapy may provide short-term improvements in range of motion, muscle stiffness, gait, and balance in patients who undergo operative fixation of an ankle and/or hindfoot fracture. * METHODS: In this multisite, double-blind randomized clinical trial, 72 consecutive patients who underwent open reduction internal fixation an ankle and/or hindfoot fracture and were receiving physical therapy treatment of exercise and gait training were randomized to receive either impairment-based manual therapy (manual therapy group) or a sham manual therapy treatment of light soft tissue mobilization and proximal tibiofibular joint mobilizations (control group). Participants in both groups received 3 treatment sessions over 7 to 10 days, and outcomes were assessed immediately post intervention. Outcomes included ankle joint range of motion, muscle stiffness, gait characteristics, and balance measures. Group-by-time effects were compared using linear mixed modeling. * RESULTS: There were no significant differences between the manual therapy and control groups for range of motion, gait, or balance outcomes. There was a significant difference from baseline to the final follow-up in resting gastrocnemius muscle stiffness between the manual therapy and control groups (-47.9 N/m; 95% confidence interval: -85.1, -9.8; P = .01). There was no change in muscle stiffness for the manual therapy group between baseline and final follow-up, whereas muscle stiffness increased in the control group by 5.4%. * CONCLUSION: A brief course of manual therapy consisting of 3 treatment sessions over 7 to 10 days did not lead to better short-term improvement than the application of sham manual therapy for most clinical outcomes in patients after ankle and/or hindfoot fracture who were already being treated with exercise and gait training. Our results, however, suggest that manual therapy might decrease aberrant resting muscle stiffness after ankle and/or hindfoot surgical fixation. [ABSTRACT FROM AUTHOR]

Objective To evaluate the cost-effectiveness of the inclusion of trigger point–dry needling (TrP-DN) into an exercise program for the management of subacromial pain syndrome. Methods Fifty patients with unilateral subacromial pain syndrome were randomized with concealed allocation to exercise alone or exercise plus TrP-DN. Both groups were asked to perform an exercise program targeting the rotator cuff musculature twice daily for five weeks. Patients allocated to the exercise plus TrP-DN group also received dry needling during the second and fourth sessions. Societal costs and health-related quality of life (estimated by EuroQol-5D-5L) over a one-year follow-up were used to generate incremental cost per quality-adjusted life-year (QALY) ratios for each intervention. Results Intention-to-treat analysis was possible for 48 (96%) of the participants. Those in the exercise group made more visits to medical doctors and received a greater number of other treatments (P  < 0.001). The major contributor to societal costs (77%) was the absenteeism paid labor in favor of the exercise plus TrP-DN group (P  = 0.03). The combination of exercise plus TrP-DN was less costly (mean difference cost/patient = €517.34, P  = 0.003) than exercise alone. Incremental QALYs showed greater benefit for exercise plus TrP-DN (difference = 2.87, 95% confidence interval = 2.85–2.89). Therefore, the inclusion of TrP-DN into an exercise program was more likely to be cost-effective than an exercise program alone, with 99.5% of the iterations falling in the dominant area. Conclusions The inclusion of TrP-DN into an exercise program was more cost-effective for individuals with subacromial pain syndrome than exercise alone. From a cost-benefit perspective, the inclusion of TrP-DN into multimodal management of patients with subacromial pain syndrome should be considered. [ABSTRACT FROM AUTHOR]

Objective: To examine the prognostic value of the Fear Avoidance Model (FAM) variables when predicting pain intensity and disability 10-weeks postoperative following lumbar disc surgery. Methods: We recruited patients scheduled for first-time, single level lumbar disc surgery. The following aspects of the FAM were assessed at preoperative baseline and after 10 postoperative weeks: numeric pain rating scale (0–10) for leg and back pain intensity separately, Pain Catastrophizing Scale (PCS), Fear Avoidance Beliefs Questionnaire (FABQ), Beck Depression Inventory (BDI), Oswestry Disability Questionnaire (ODI), and the International Physical Activity Questionnaire (IPAQ). Multivariate regression models were used to examine the best combination of baseline FAM variables to predict the 10-week leg pain, back pain, and disability. All multivariate models were adjusted for age and sex. Results: 60 patients (30 females, mean [SD] age = 40.4 [9.5]) were enrolled. All FAM measures correlated with disability at baseline. Adding FAM variables to each of the stepwise multiple linear regression model explained a significant amount of the variance in disability (Adj. R2 = .38, p < .001), leg pain intensity (Adj. R2 = .25, p = .001), and back pain intensity Adj. R2 = .32, p < .001 at 10-weeks). After adjusting for age and gender, BDI and FABQ-work subscale were the only significant predictors added to each of the prediction models for the 10-week clinical outcome (leg pain, back pain, and ODI). Conclusion: BDI and FABQ-work subscale variables are associated with baseline pain intensity and disability and predict short-term pain and disability following lumbar disc surgery. Measuring these variables in patients being considered for lumbar disc surgery may improve patient outcome. [ABSTRACT FROM AUTHOR]

Background: The application of dry needling usually is associated with postneedling-induced pain. A postneedling intervention to reduce this adverse event is needed.Objective: To determine the effectiveness of low-load exercise on reducing postneedling-induced pain after dry needling of active trigger points (TrPs) in the infraspinatus muscle in subacromial pain syndrome.Design: A 72-hour follow-up, single-blind randomized controlled trial.Setting: Urban hospitals.Participants: Individuals with subacromial pain syndrome (n = 90, 52% female, mean age: 35 ± 13 years) with active TrPs in the infraspinatus muscle.Interventions: All individuals received dry needling into the infraspinatus active TrP. Then, they were divided randomly into an experimental group, which received a single bout of low-load exercise of shoulder muscles; a placebo group, which received inactive ultrasound for 10 minutes; and a control group, which did not receive any intervention.Outcome Measures: Numerical Pain Rating Scale (0-10 point) was administered postneedling, immediately postintervention (2 minutes), and 24, 48, and 72 hours after needling. Shoulder pain (Numerical Pain Rating Scale, 0-10) and disability (Disabilities of the Arm, Shoulder and Hand; Shoulder Pain and Disability Index) were assessed before and 72 hour after needling.Results: The 5 × 3 analysis of covariance showed that the exercise group demonstrated a larger decrease in postneedling-induced pain immediately after (P = .001), 24 hours (P = .001), and 48 hours after (P = .006) than placebo or control groups. No differences were found at 72 hours (P = .03). Similar improvements in shoulder pain (P < .001) and related disability (Disabilities of the Arm, Shoulder and Hand: P < .001; Shoulder Pain and Disability Index: P < .001) were observed 72 hours after needling, irrespective of the treatment group.Conclusions: Low-load exercise was effective for reducing postneedling-induced pain on active TrPs in the infraspinatus muscle 24 and 48 hours after needling. The application of a postneedling intervention did not influence short-term pain and disability changes.Level Of Evidence: I. [ABSTRACT FROM AUTHOR]

The Army Physical Fitness Test (APFT) is a semiannual requirement. While conducting physical readiness training (PRT) is a requirement for all Soldiers, there is no requirement to train Soldiers on techniques that may help to optimize their performance on the APFT. A cohort of 34 officers that attended the Army Medical Department Basic Officer Leadership Course completed a technique-focused training program in conjunction with their required PRT program subsequent to failing one or more events on their initial APFT. The training consisted of a 30-minute video lesson and an individualized performance assessment completed by an Army physical therapist. Upon retest 10 days after the initial test, 27 (79.4%) participants passed the APFT with a mean improvement of 22.3 points on their overall APFT score. When evaluating change in performance by event based on failing the event initially, the observed improvement was an increase of over 9 push-ups, over 11 situps, and nearly 2 minutes on the run event. The addition of a technique-focused training program to an existing PRT program can result in significant short-term improvement for those with substandard APFT performance. [ABSTRACT FROM AUTHOR]

Military service members receive regular screenings for a variety of health conditions, but a field-expedient and military-specific screening tool that identifies an individual's risk for injury has not yet been identified. The purpose of this study is to describe the conduct of a novel musculoskeletal readiness screening tool (MRST) and evaluate the real-time interrater reliability of the MRST when scored by raters with differing levels of medical experience. Materials/Methods: This study included a convenience sample of 40 active duty military participants (30 male, 10 female, mean age 29.3±6.9 years) without any current musculoskeletal injury or pain at the time of enrollment. The MRST consisted of 5 physical performance tests and one self-report question as follows: (1) weightbearing lunge (WBL), (2) overhead squat, (3) closed kinetic chain upper extremity stability test (CKCUEST), (4) eyes closed forward step down, (5) repeated tuck jump, and (6) individual perceived level of risk for MSK injury. Three raters (a board certified physical therapist with 15 years of experience, a physical therapy student with less than one year didactic training, and a physical therapy technician with approximately 10 years of experience) independently scored each event as 0, 1, or 2 based on the quality of the participant's performance. This scoring system allows for a cumulative score ranging from 0 to 12, with lower scores thought to indicate higher risk for future injury. Descriptive, reliability, and chance-corrected agreement statistics were calculated using IBM SPSS. This study was approved by the Brooke Army Medical Center Institutional Review Board at Fort Sam Houston, Texas. Results: The mean composite MRST score for all graders was 7.79±1.41. Among all 3 raters the overall reliability was moderate (ICC (2,1)=0.75 (0.62, 0.85)). Chance-corrected agreement values for the individual events ranged from slight to almost perfect as follows: WBL (k=0.33-0.44), overhead squat (k=0.57-0.65), CKCUEST (k=0.89-1.0), eyes-closed forward step down (k=0.10-0.42), repeated tuck jump (k=0.39-0.61), individual perceived level of risk for MSK injury (k=1.0). Conclusions: The MRST showed moderate interrater reliability for the overall composite score with varied levels of agreement for individual events scores. Future research should investigate test-retest reliability and interrater reliability among medical personnel from different disciplines. [ABSTRACT FROM AUTHOR]

Purpose: Explore the relationships between preoperative findings and clinical outcome following lumbar disc surgery, and investigate the prognostic value of physical examination findings after accounting for information acquired from the clinical history.Methods: We recruited 55 adult patients scheduled for first time, single-level lumbar discectomy. Participants underwent a standardized preoperative evaluation including real-time ultrasound imaging assessment of lumbar multifidus function, and an 8-week postoperative rehabilitation programme. Clinical outcome was defined by change in disability, and leg and low back pain (LBP) intensity at 10 weeks. Linear regression models were used to identify univariate and multivariate predictors of outcome.Results: Univariate predictors of better outcome varied depending on the outcome measure. Clinical history predictors included a greater proportion of leg pain to LBP, pain medication use, greater time to surgery, and no history of previous physical or injection therapy. Physical examination predictors were a positive straight or cross straight leg raise test, diminished lower extremity strength, sensation or reflexes, and the presence of postural abnormality or pain peripheralization. Preoperative pain peripheralization remained a significant predictor of improved disability (p = 0.04) and LBP (p = 0.02) after accounting for information from the clinical history. Preoperative lumbar multifidus function was not associated with clinical outcome.Conclusions: Information gleaned from the clinical history and physical examination helps to identify patients more likely to succeed with lumbar disc surgery. While this study helps to inform clinical practice, additional research confirming these results is required prior to confident clinical implementation. [ABSTRACT FROM AUTHOR]

Purpose/Hypothesis: Lower extremity and low back injuries represent a significant financial burden on the military healthcare system. Subsequent injuries often occur during the recuperation period or in the period directly after physical therapy ends when the patient returns to full duty. Medical providers have relatively few objective tools with which to determine if someone is ready for return to duty (RTD). The purpose of this study is to assess interrater and test-retest reliability of a novel gender-neutral RTD screening tool that requires minimal training, equipment, and time. Subjects: This study included 34 active duty military participants (male=22, female=12, age=28.5±5.9). 23 subjects (male=14, female=9, age=28.7±6.3) returned for follow-up testing within one week. Materials/Methods: After answering a medical questionnaire, all participants completed the RTD screening tool consisting of: (1) modified anterior reach, (2) modified deep squat, (3) modified trunk stability push-up, (4) modified hip abduction test, (5) forward step-down under low-light conditions, (6) modified Feagin hop test, and (7) perceived risk of future injury. Each individual event was qualitatively scored from 0 to 2 or 3. The composite score ranged from 0 to 16 with higher scores indicating better performance. Results: For the primary rater, the mean score was 11.26±2.35 during the first trial session and 12.43±1.47 during the second trial session. For the secondary rater, the mean score during the first trial session was 11.38±2.51 and 12.61±1.73 during the second session. There was good interrater reliability for the composite score (intraclass correlation coefficient [ICC] (2,1)=0.88 (0.78, 0.94)). The test-retest reliability was moderate (ICC (3,1)=0.57, (0.21, 0.79)). The chance-corrected agreement was acceptable for all individual events except the modified hip abduction test. There were no significant differences between male and female composite scores. Conclusions: This novel RTD screening tool showed good overall interrater reliability, suggesting that entrylevel clinicians trained on the grading requirements are able to reliably administer the tool. In addition, the screen showed gender-neutrality with no significant differences between men and women. However, the RTD screening tool had only moderate test-retest reliability, suggesting the possible presence of a learning effect. The modified hip abduction test demonstrated poor chance-corrected agreement. Future research should consider including a longer practice session to ameliorate any possible learning effect and to modify the hip abduction test to improve reliability. Clinical Relevance: This study has demonstrated that a novel RTD screening tool can reliably be administered to an active duty population to assist clinicians in making RTD decisions. However, at this time, it cannot be determined if a certain composite or individual event score will indicate increased risk for injury. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To explore for associations between demographic, patient history, and physical examination variables and short-term improvement in self-reported disability following dry needling therapy performed on individuals with low back pain (LBP). BACKGROUND: Dry needling is an intervention used with increasing frequency in patients with LBP; however, the characteristics of patients who are most likely to respond are not known. METHODS: Seventy-two volunteers with mechanical LBP participated in the study. Potential prognostic factors were collected from baseline questionnaires, patient history, and physical examination tests. Treatment consisted of dry needling to the lumbar multifidus muscles bilaterally, administered during a single treatment session. Improvement was based on percent change on the Oswestry Disability Index at 1 week. The univariate and multivariate associations between 33 potential prognostic factors and improved disability were assessed with correlation coefficients and multivariate linear regression. RESULTS: Increased LBP with the multifidus lift test (rpb = 0.31, P = .01) or during passive hip flexion performed with the patient supine (rpb = 0.23, P = .06), as well as positive beliefs about acupuncture/dry needling (rho = 0.22, P = .07), demonstrated univariate associations with Oswestry Disability Index improvement. Aggravation of LBP with standing (rpb = -0.27, P = .03), presence of leg pain (rpb = -0.29, P = .02), and any perception of hypermobility in the lumbar spine (rpb = -0.21, P = .09) were associated with less improvement. The multivariate model identified 2 predictors of improved disability with dry needling: pain with the multifidus lift test and no aggravation with standing (R2 = 0.16, P = .01). CONCLUSION: Increased LBP with the multifidus lift test was the strongest predictor of improved disability after dry needling, suggesting that the finding of pain during muscle contraction should be studied in future dry needling studies. [ABSTRACT FROM AUTHOR]

Introduction. Manual therapists commonly use assessments of intervertebral motion to determine the need for spinal manipulation, but the reliability of these procedures demonstrates conflicting results. The objectives of this study were to investigate the interrater reliability of thoracic spine motion palpation for perceived joint restriction and pain. Methods. Twenty-five participants between the ages of 18 and 70, with or without mid-back pain, were enrolled. Two raters motion palpated marked T5–T12 levels using two methods (standardised and pragmatic) and noted any restricted or painful segments. We calculated agreement between two raters by generating raw agreement percentages and Kappa coefficients with 95% confidence intervals. Results. There was poor to low level of agreement between the raters for both joint stiffness and pain localization using both pragmatic and standardized approaches. The results did not improve significantly when we conducted a post hoc analysis where three spinal levels were collapsed as one and right and left sides were also combined. Conclusions. The results for interrater reliability were poor for motion restriction and pain. These findings may have unfavourable implications for all manual therapists who use motion palpation to select patients appropriate for spinal manipulation. [ABSTRACT FROM AUTHOR]

Introduction. Manual therapists commonly use assessments of intervertebral motion to determine the need for spinal manipulation, but the reliability of these procedures demonstrates conflicting results. The objectives of this study were to investigate the interrater reliability of thoracic spine motion palpation for perceived joint restriction and pain. Methods. Twenty-five participants between the ages of 18 and 70, with or without mid-back pain, were enrolled. Two raters motion palpated marked T5-T12 levels using two methods (standardised and pragmatic) and noted any restricted or painful segments. We calculated agreement between two raters by generating raw agreement percentages and Kappa coefficients with 95% confidence intervals. Results. There was poor to low level of agreement between the raters for both joint stiffness and pain localization using both pragmatic and standardized approaches. The results did not improve significantly when we conducted a post hoc analysis where three spinal levels were collapsed as one and right and left sides were also combined. Conclusions. The results for interrater reliability were poor for motion restriction and pain. These findings may have unfavourable implications for all manual therapists who use motion palpation to select patients appropriate for spinal manipulation. [ABSTRACT FROM AUTHOR]

Context: Low back pain (LBP) is a prevalent condition imposing a large socioeconomic burden. Despite intensive research aimed at the efficacy of various therapies for patients with LBP, most evidence has failed to identify a superior treatment approach. One proposed solution to this dilemma is to identify subgroups of patients with LBP and match them with targeted therapies. Among the subgrouping approaches, the system of treatment-based classification (TBC) is promoted as a means of increasing the effectiveness of conservative interventions for patients with LBP.Evidence Acquisition: MEDLINE and PubMed databases were searched from 1985 through 2010, along with the references of selected articles.Results: TBC uses a standardized approach to categorize patients into 1 of 4 subgroups: spinal manipulation, stabilization exercise, end-range loading exercise, and traction. Although the TBC subgroups are in various stages of development, recent research lends support to the effectiveness of this approach.Conclusions: While additional research is required to better elucidate this method, the TBC approach enhances clinical decision making, as evidenced by the improved clinical outcomes experienced by patients with LBP. [ABSTRACT FROM AUTHOR]

The article presents a report on a 22-year old man who was revealed with an intra-articular fracture, the fracture involves the radial head and extended through the neck. The patient is endorsed by the physical therapist to a radiography test of the elbow and was then recommended to an orthopedic surgeon and advised for conservative management. Radiographic view of the fracture from anterior-to-posterior is presented.