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The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to nonarthritic heel pain. [ABSTRACT FROM AUTHOR]

Background: Following head and neck trauma, the involvement of the cranio-cervical junction (CCJ) and its contribution to a patients transition to chronic pain, is poorly understood. The detection of hypermobility in this region is dependent on clinical examination and static imaging modalities such as x-ray, CT and MRI. Sagittal plane hypermobility of the CCJ is evaluated using saggital view, flexion-extension cervical radiographs. Frontal plane hypermobility is typically assessed using lateral bending and open mouth cervical radiographs. Unfortunately there is no established reliability surrounding the use of these measures. This study explores the reliability of radiographic measurements of lateral-bending open-mouth cervical radiographs. Methods: Cervical open-mouth lateral-bending X-ray images were collected from 56 different patients between 18 and 60 years of age patients following cervical spine injury. These images were interpreted by two musculoskeletal radiologists and two clinicians (physiatrist and chiropractor), using a standard set of measurements. Measurements included qualitative and quantitative assessments of the amount of asymmetry noted between various osseous landmarks. Reliability statistics were calculated for levels of agreement using kappa coefficients (κ) and Intraclass Correlation Coefficients (ICC) for dichotomous and continuous variables, respectively. Results: Reliability (κ) for qualitative assessments were moderate to substantial for asymmetry of neutral C2 spinous position, dens-lateral mass spacing, and "step off" between the lateral borders of the articular pillars of C2 and C1 lateral mass (κ range =.47–.78). ICC values for the quantitative measurements of dens-lateral mass spacing and "step off" between the lateral borders of the C2 articular pillars and C1 lateral mass were moderate to excellent (ICC range =.56–.97). Conclusions: The qualitative and quantitative measurements used in this study demonstrated good to excellent inter-examiner reliability. Correlation with clinical findings is necessary to establish the utility of these measurements in clinical practice. [ABSTRACT FROM AUTHOR]

Objectives: The scientific literature demonstrates a cost-benefit associated with early access to physical therapy. The purpose of this case study is to report the results of an orthopedic performance improvement initiative (OPII) at a small military treatment facility (approximately 4.5K active duty beneficiaries). The OPII was introduced to (1) limit variation by ensuring that all active duty orthopedic consults were audited ensuring proper timing of appropriate services and (2) establish contractual agreement for shared resources with the U.S. Naval Jacksonville Orthopedic Department.Methods: OPII was accomplished through consensus development and strong leadership support. All orthopedic referrals (n = 260) were audited for 6 months. Appropriate recommendations were provided to either continue with orthopedic care or to redirect to a physical therapy first approach.Results: Orthopedic referrals decreased 27% with concomitant 32% increase in physical therapy referrals producing overall savings of $462K (33%). Meanwhile, surgical throughput improved 45%. Seventy percent of the savings were attributed to improved utilization translating to a relative value unit savings per beneficiary of $17.64 (23.7%).Conclusion: Our results support the value of a conservative physical therapy first approach for musculoskeletal conditions and shared mil-to-mil resourcing agreements. Success requires an iterative audit/feedback process balanced with stakeholder consensus. [ABSTRACT FROM AUTHOR]

Background: The purported relationship between cervical manipulative therapy (CMT) and stroke related to vertebral artery dissection (VAD) has been debated for several decades. A large number of publications, from case reports to case-control studies, have investigated this relationship. A recent article suggested that case misclassification in the case-control studies on this topic resulted in biased odds ratios in those studies. Discussion: Given its rarity, the best epidemiologic research design for investigating the relationship between CMT and VAD is the case-control study. The addition of a case-crossover aspect further strengthens the scientific rigor of such studies by reducing bias. The most recent studies investigating the relationship between CMT and VAD indicate that the relationship is not causal. In fact, a comparable relationship between vertebral artery-related stroke and visits to a primary care physician has been observed. The statistical association between visits to chiropractors and VAD can best be explained as resulting from a patient with early manifestation of VAD (neck pain with or without headache) seeking the services of a chiropractor for relief of this pain. Sometime after the visit the patient experiences VAD-related stroke that would have occurred regardless of the care received. This explanation has been challenged by a recent article putting forth the argument that case misclassification is likely to have biased the odds ratios of the case-control studies that have investigated the association between CMT and vertebral artery related stroke. The challenge particularly focused on one of the case-control studies, which had concluded that the association between CMT and vertebral artery related stroke was not causal. It was suggested by the authors of the recent article that misclassification led to an underestimation of risk. We argue that the information presented in that article does not support the authors' claim for a variety of reasons, including the fact that the assumptions upon which their analysis is based lack substantiation and the fact that any possible misclassification would not have changed the conclusion of the study in question. [ABSTRACT FROM AUTHOR]

Background and Purpose. Our nation's suboptimal health care quality and unsustainable costs can be linked to the failure to implement evidence-based interventions. Implementation is the bridge between the decision to adopt a strategy and its sustained use in practice. The purpose of this case report is threefold: (1) to outline the historical implementation of an evidence-based quality improvement project, (2) to describe the program's future direction using a systems perspective to identify implementation barriers, and (3) to provide implications for the profession as it works toward closing the evidence-to-practice gap. Case Description . The University of Pittsburgh Medical Center (UPMC) Centers for Rehab Services is a large, multicenter physical therapy organization. In 2005, they implemented a Low Back Initiative utilizing evidence-based protocols to guide clinical decision making. Outcomes. The initial implementation strategy used a multifaceted approach. Formative evaluations were used repeatedly to identify barriers to implementation. Barriers may exist outside the organization, they can be created internally, they may result from personnel, or they may be a direct function of the research evidence. Since the program launch, 3 distinct improvement cycles have been utilized to address identified implementation barriers. Discussion. Implementation is an iterative process requiring evaluation, measurement, and refinement. During this period, behavior change is actualized as clinicians become increasingly proficient and committed to their use of new evidence. Successfully incorporating evidence into routine practice requires a systems perspective to account for the complexity of the clinical setting. The value the profession provides can be enhanced by improving the implementation of evidence-based strategies. Achieving this outcome will require a concerted effort in all areas of the profession. New skills will be needed by leaders, researchers, managers, and clinicians. [ABSTRACT FROM AUTHOR]

Background: Swearing deserves attention in the physical therapy setting due to its potential positive effects on pain, physical performance, and therapeutic alliance. The purpose of this case report is to describe the strategic use of swearing in the clinical setting., Case Presentation: A 44-year-old female completed an episode of physical therapy after undergoing patellofemoral arthroplasty. Swearing was formally included into the plan of care, and the patient swore out loud during the most challenging and painful interventions., Results: The patient reported that repeating a swear word was funny, distracted the patient, and made the patient feel more confident. The patient and physical therapist self-reported a strong therapeutic alliance., Conclusion: There is evidence repeating a swear word out loud can strengthen the therapeutic alliance, improve physical performance, and decrease pain. This is, to our knowledge, the first report of a patient swearing during an episode of physical therapy care., Competing Interests: NBW, RS, ADM, BM, CGB, and JD declare no competing interests.