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STUDY DESIGN: Resident's case problem. BACKGROUND: Cauda equina syndrome (CES) is a rare, potentially devastating, disorder and is considered a true neurologic emergency. CES often has a rapid clinical progression, making timely recognition and immediate surgical referral essential. DIAGNOSIS: A 32-year-old male presented to a medical aid station in Iraq with a history of 4 weeks of insidious onset and recent worsening of low back, left buttock, and posterior left thigh pain. He denied symptoms distal to the knee, paresthesias, saddle anesthesia, or bowel and bladder function changes. At the initial examination, the patient was neurologically intact throughout all lumbosacral levels with negative straight-leg raises. He also presented with severely limited lumbar flexion active range of motion, and reduction of symptoms occurred with repeated lumbar extension. At the follow-up visit, 10 days later, he reported a new, sudden onset of saddle anesthesia, constipation, and urinary hesitancy, with physical exam findings of right plantar flexion weakness, absent right ankle reflex, and decreased anal sphincter tone. No advanced medical imaging capabilities were available locally. Due to suspected CES, the patient was medically evacuated to a neurosurgeon and within 48 hours underwent an emergent L4-5 laminectomy/decompression. He returned to full military duty 18 weeks after surgery without back or lower extremity symptoms or neurological deficit. DISCUSSION: This case demonstrates the importance of continual medical screening for physical therapists throughout the patient management cycle. It further demonstrates the importance of immediate referral to surgical specialists when CES is suspected, as rapid intervention offers the best prognosis for recovery. LEVEL OF EVIDENCE: Differential diagnosis, level 4. J Orthop Sports Phys Ther 2009;39(7):541-549, Epub 24 February 2009. doi: 10.2519/jospt.2009.2999. [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Retrospective review. OBJECTIVES: To describe bilateral thickness of the lateral abdominal muscles at baseline and during an abdominal drawing-in maneuver (ADIM) in individuals with unilateral transtibial (TTA) or transfemoral (TFA) amputations. BACKGROUND: Although side-to-side symmetry of lateral abdominal muscle thickness has been established in healthy individuals, the degree of symmetry in those with unilateral lower extremity amputations remains unknown. Differences in lateral abdominal muscle thickness may exist based on prior findings of asymmetry and differences measured based on level of amputation in both the size and function of the iliopsoas and back extensor muscles. METHODS AND MEASURES: Seventy patients (69 males, 1 female) with traumatic unilateral lower extremity amputations (TTA, n = 39; TFA, n = 31) received a rehabilitative ultrasound imaging examination. Absolute thickness of the transversus abdominis (TrA) and the external and internal oblique muscles combined (EO+IO) were assessed bilaterally at baseline and during the ADIM. Symmetry was assessed using relative muscle thickness values at baseline. Percent increase in muscle thickness during the ADIM was used to investigate muscle function. Separate 2-by-2 mixed-model ANOVAs were used to compare both within-group (side of amputation versus nonamputated side) and between-group (TTA versus TFA) differences for thickness and function of the TrA and the EO+IO muscles. RESULTS: On the side of the amputation, the relative baseline thickness of the EO+IO measurement was greater (P < .05), while the relative baseline thickness of the TrA muscle was smaller (P < .05). But the mean differences side to side were small (1.3%) and unlikely to be clinically significant. Further, there were no differences in baseline muscle thickness between groups for the TrA (P = .95) or the EO+IO (P = .94) muscles. For thickness measurements during the ADIM, the TrA showed no side-to-side (P = .74) or group (P = .07) differences. Similarly, no side-to-side (P = .60) or group (P = .09) differences were found in the EO+IO thickness during the ADIM. CONCLUSIONS: Despite the limitations of retrospective review, these findings provide an initial reference data set for future studies. Bilateral symmetry of the lateral abdominal wall muscle thicknesses at baseline and during the ADIM for those with unilateral lower extremity amputations is comparable to healthy individuals. Future studies should consider the potential influences of low back pain and gait training on symmetry of muscle thickness and muscle function based on level of amputation. [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Case report. BACKGROUND: The use of spinal manipulation as a treatment to facilitate neuromuscular control of the paraspinal musculature is not well described in the literature. The use of rehabilitative ultrasound imaging (RUSI) may offer a convenient way to investigate and document possible changes occurring in the lumbar multifidus associated with manipulation intervention. CASE DESCRIPTION: The patient was a 33-year-old male with a 21-year history of low back pain and left posterior thigh pain who presented with lumbar hypomobility and met a previously published clinical prediction rule for spinal manipulation. During examination, the patient was asked to perform a prone upper extremity lifting task to assess activation in the lumbar multifidus during an automatic task. Through palpation the examiner noted a decreased contraction of the left multifidus between L4-S1 compared to the right. To explore this further, a decision was made to assess the multifidus with RUSI, which confirmed the activation deficit noted during palpation. A lumbar regional manipulation was performed with the intention of reducing spinal hypomobility and of assessing changes in multifidus activation. Imaging of the multifidus muscles at the L4-5 and L5-S1 levels were obtained premanipulation, immediately postmanipulation, and 1 day after manipulation. OUTCOMES: An increased ability to thicken the multifidus during a prone upper extremity lifting task was noted immediately and 1 day after manipulation. Average percent change in thickness at the L4-5 and L5-S1 levels with the prone arm lift was 3.6% premanipulation, 17.2% immediately postmanipulation, and 20.6% approximately 24 hours postmanipulation. Improvements in the thickening of the multifidus muscle during the upper extremity lifting task were greater than 3 standard errors of the measurement. Other changes included immediate palpable improvement in the contraction of the multifidus during the upper extremity lifting task, along with the patient report of increased ease of lifting. DISCUSSION: In this case report we quantified the short-term influence of spinal manipulation on multifidus muscular activation using RUSI. No cause-and-effect claims can be made; however, the results provide preliminary evidence to suggest that spinal manipulation may influence multifidus muscle function. RUSI offers a convenient way to investigate and document these changes. [ABSTRACT FROM AUTHOR]

Rehabilitative ultrasound imaging (RUSI) of the abdominal muscles is increasingly being used in the management of conditions involving musculoskeletal dysfunctions associated with the abdominal muscles, including certain types of low back and pelvic pain. This commentary provides an overview of current concepts and evidence related to RUSI of the abdominal musculature, including issues addressing the potential role of ultrasound imaging in the assessment and training of these muscles. Both quantitative and qualitative aspects associated with clinical and research applications are considered, as are the possible limitations related to the interpretation of measurements made with RUSI. Research to date has utilized a range of methodological approaches, including different transducer placements and imaging techniques. The pros and cons of the various methods are discussed, and guidelines for future investigations are presented. Potential implications and opportunities for clinical use of RUSI to enhance evidence-based practice are outlined, as are suggestions for future research to further clarify the possible role of RUSI in the evaluation and treatment of abdominal muscular morphology and function. [ABSTRACT FROM AUTHOR]

Study Design: Prospective cohort using routinely collected health data., Objective: To compare opioid use based on surgery intensity (low or high)., Summary of Background Data: Many factors influence an individual's experience of pain. The extent to which postsurgical opioid use is influenced by the severity of spine surgery is unknown., Methods: The participants were individuals undergoing spine surgery in a large military hospital. Procedures were categorized as low intensity (eg, microdiscectomy and laminectomy) and high intensity (eg, fusion and arthroplasty). The Surgical Scheduling System and Military Health System Data Repository were queried for healthcare utilization the 1 year before and after surgery. We compared opioid use after surgery between groups, adjusting for prior opioid use and surgical complications., Results: A total of 342 individuals met the inclusion criteria, with mean age 45.4 years (SD 10.9), and 33.0% were women. Of these, 221 (64.6%) underwent a low-intensity procedure and 121 (35.4%) underwent a high-intensity procedure. Mean postoperative opioid prescription fills were greater in the high- versus low-intensity group (9.0 vs. 5.7; P <0.001), as were the mean total days' supply (158.9 vs. 81.8; P <0.001). Median morphine milligram equivalents (MMEs) were not significantly different (40.2 vs. 42.7; P =0.287). Of the cohort, 26.3% were chronic opioid users after surgery. Adjusted rates of long-term opioid use were not different between groups when only accounting for prior opioid use but significantly higher for the high-intensity group when adjusting for surgical complications (OR=2.08; 95% CI 1.09-3.97). Of the entire cohort, 52.5% was still filling opioid prescriptions after 6 months., Conclusions: Higher-intensity procedures were associated with greater postoperative opioid use than lower-intensity procedures. Chronic opioid use was not significantly different between surgical intensity groups when considering only prior opioid use. Chronic opioid use was significantly higher among higher intensity procedures when accounting for surgical complications. The presence of surgical complications is a stronger predictor of postsurgical long-term opioid use in high-intensity surgeries than history of opioid use alone., Level of Evidence: Level III., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Access to quality healthcare education across the world is disproportionate. This study explores the potential for Cardiovascular Perfusion education to be delivered online to reach international students., Methods: Exploratory mixed methods were used to identify the barriers, facilitators, and early outcomes of online international health professions education., Results: Qualitative analysis yielded four primary and nine subthemes. Multiple interventions were implemented in the planning of a novel online international Extracorporeal Science (ECS) program based on these themes. Quantitative data from the first semester of the new ECS program was collected along with data from the traditional entry-level program and historic data from previous entry-level cohorts. No significant correlations or differences were found between students. Student satisfaction surveys were determined to be equivalent for each group. Mixed data analysis revealed exceptional student satisfaction in areas where qualitative feedback was incorporated into the program design., Conclusions: Online international education may be a viable option in the health professions. Barriers and facilitators to this mode of education were identified and utilized in designing one such program. Early outcomes from the novel ECS program reveal that student performance and satisfaction are equivalent to those of a traditional in-person training program., (© The Author(s), published by EDP Sciences, 2024.)

Introduction: After elective orthopaedic surgery, many individuals go on to become long-term opioid users. Mitigating this risk has become a priority for surgeons, other members of the medical care team, and healthcare systems. The purpose of this study was to compare opioid utilization after lower extremity orthopaedic surgery between patients who received an interactive video education session highlighting the risks of opioid use and those who did not., Methods: Patients undergoing elective surgery of the lower extremity in the orthopaedic clinic at the Brooke Army Medical Center between July 2015 and February 2017 were recruited at their preoperative appointment and randomized in a 1:1 ratio to receive a one-time interactive opioid education session or usual care education. Unique days' supply of opioids and unique prescriptions were compared using a generalized linear model. Individuals were also grouped by whether they had become long-term opioid users after surgery, and frequencies within each intervention group were compared., Results: There were 120 patients, 60 randomized to each group and followed for 1 year. There were no significant differences between opioid days' supply (mean diff = 8.33, 95% confidence interval -4.21 to 20.87) and unique prescriptions after surgery (mean diff = 0.45, 95% confidence interval -0.25 to 1.15). Most participants did not have any opioids past the initial 30 days after surgery, regardless of intervention (n = 77), and only three became long-term opioid users (one in usual care and two in interactive education). Sixteen in usual education and 18 in enhanced education filled at least one prescription in 6 months or later after the surgical procedure., Conclusion: Opioid use beyond 30 days of surgery was no different for participants who received enhanced education compared with usual education. Few became long-term opioid users after surgery (2.5%), although 28.3% were still filling opioid prescriptions 6 months after surgery., (Copyright © 2022 by the American Academy of Orthopaedic Surgeons.)

Study Design: Parallel-arm randomized controlled trial., Objective: To assess the effectiveness of an enhanced video education session highlighting risks of opioid utilization on longterm opioid utilization after spine surgery., Summary of Background Data: Long-term opioid use occurs in more than half of patients undergoing spine surgery and strategies to reduce this use are needed., Methods: Patients undergoing spine surgery at Brooke Army Medical Center between July 2015 and February 2017 were recruited at their preoperative appointment, receiving the singlesession interactive video education or control at that same appointment. Opioid utilization was tracked for the full year after surgery from the Pharmacy Data Transaction Service of the Military Health System Data Repository. Self-reported pain also collected weekly for 1 and at 6months., Results: A total of 120 participants (40 women, 33.3%) with a mean age of 45.9 ± 10.6 years were randomized 1:1 to the enhanced education and usual care control (60 per group). In the year following surgery the cohort had a mean 5.1 (standard deviation [SD] 5.9) unique prescription fills, mean total days' supply was 88.3 (SD 134.9), and mean cumulative morphine milligrams equivalents per participant was 4193.0 (SD 12,187.9) within the year after surgery, with no significant differences in any opioid use measures between groups. Twelve individuals in the standard care group and 13 in the enhanced education group were classified with having long-term opioid utilization., Conclusion: The video education session did not influence opioid use after spine surgery compared to the usual care control. There was no significant difference in individuals classified as long-term opioid users after surgery based on the intervention group. Prior opioid use was a strong predictor of future opioid use in this cohort. Strategies to improve education engagement, understanding, and decision- making continue to be of high importance for mitigating risk of long-term opioid use after spine surgery.Level of Evidence: 1., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To quantify and compare utilization of opioids, exercise therapy, and physical therapy in the year before spine surgery., Design: A retrospective cohort of surgical and claims data., Setting: Beneficiaries of the Military Health System seen at Brooke Army Medical Center PARTICIPANTS: Patients (N=411) undergoing surgery between January 1, 2014, and December 31, 2015, identified retrospectively through the Surgical Scheduling System (S3) based on procedure type (fusion, laminectomy, arthroplasty, vertebroplasty, and diskectomy)., Interventions: Elective lumbar spine surgery., Main Outcome Measures: Health care utilization variables present during the full 12 months before surgery, which included physical therapy services and visits for exercise therapy or manual therapy procedures and opioid prescriptions., Results: The mean age of participants was 44.8±11.7 years and 32.4% were female. In the year before surgery, 143 (34.8%) patients had a physical therapy plan of care, 140 (34.1%) had at least 1 visit that included exercise therapy, and only 60 (14.6%) had a minimum of 6 exercise therapy visits. However, 347 (84.4%) patients received at least 1 opioid prescription fill (mean of 6.1 unique fills)., Conclusions: Before elective lumbar spine surgery, opioid prescriptions were common but physical therapy services and exercise therapy utilization occurred infrequently., (Published by Elsevier Inc.)

Background: Both physical therapy and intraarticular injections of glucocorticoids have been shown to confer clinical benefit with respect to osteoarthritis of the knee. Whether the short-term and long-term effectiveness for relieving pain and improving physical function differ between these two therapies is uncertain., Methods: We conducted a randomized trial to compare physical therapy with glucocorticoid injection in the primary care setting in the U.S. Military Health System. Patients with osteoarthritis in one or both knees were randomly assigned in a 1:1 ratio to receive a glucocorticoid injection or to undergo physical therapy. The primary outcome was the total score on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at 1 year (scores range from 0 to 240, with higher scores indicating worse pain, function, and stiffness). The secondary outcomes were the time needed to complete the Alternate Step Test, the time needed to complete the Timed Up and Go test, and the score on the Global Rating of Change scale, all assessed at 1 year., Results: We enrolled 156 patients with a mean age of 56 years; 78 patients were assigned to each group. Baseline characteristics, including severity of pain and level of disability, were similar in the two groups. The mean (±SD) baseline WOMAC scores were 108.8±47.1 in the glucocorticoid injection group and 107.1±42.4 in the physical therapy group. At 1 year, the mean scores were 55.8±53.8 and 37.0±30.7, respectively (mean between-group difference, 18.8 points; 95% confidence interval, 5.0 to 32.6), a finding favoring physical therapy. Changes in secondary outcomes were in the same direction as those of the primary outcome. One patient fainted while receiving a glucocorticoid injection., Conclusions: Patients with osteoarthritis of the knee who underwent physical therapy had less pain and functional disability at 1 year than patients who received an intraarticular glucocorticoid injection. (ClinicalTrials.gov number, NCT01427153.)., (Copyright © 2020 Massachusetts Medical Society.)

Study Design : Nonrandomized controlled trial. Objective : To determine whether translational manipulation under anesthesia/local block (TMUA) adds to the benefit of mobilization and range of motion exercise for improving pain and functional status among patients with adhesive capsulitis of the shoulder (AC). Background : TMUA has been shown to improve pain and dysfunction in patients with AC. This intervention has not been directly compared to physical therapy treatment without TMUA in a prospective trial. Methods : Sixteen consecutive patients with a primary diagnosis of AC were divided into two groups. Patients in the first (TMUA) group received a session of translational manipulation under interscalene block, followed by six sessions of manipulation and exercise. Patients in the comparison group received seven sessions of manipulation and exercise. Outcome measures taken at baseline and 3, 6, 12 months and 4 years included Shoulder Pain and Disability Index (SPADI) scores. Four-year outcomes included percent of normal ratings, medication use, and activity limitations. Results : Both groups showed improved SPADI scores across all follow-up times compared to baseline. The TMUA group showed a greater improvement in SPADI scores than the comparison group at 3 weeks, with no significant differences in SPADI scores at other time points. However, at 4 years, significantly more subjects in the comparison group (5 of 8) had activity limitations versus subjects in the TMUA group (1 of 8). No subject experienced a complication from either intervention protocol. Conclusion : Physical therapy consisting of manual therapy and exercise provides benefit for patients with AC. Translational manipulation under local block may be a useful adjunct to manual therapy and exercise for patients with AC.

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 sit-ups, 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.

Introduction: Corticosteroid injections (CSIs) are commonly used as an initial or a primary intervention for knee osteoarthritis (OA). Consistent evidence indicates CSIs offer symptom relief with conflicting reports regarding long-term efficacy. Physical therapy (PT) offers a non-invasive alternative. There is moderate evidence suggesting short-term and long-term symptom relief and functional improvement with PT interventions. Patients with knee OA are more commonly prescribed CSI than PT prior to total joint replacement. UnitedHealthcare and Military Health System data show substantially more total knee replacement patients receive preoperative CSI than PT. There are no studies comparing CSI to a PT approach in individuals with knee OA. The primary objective of this study is to compare the effectiveness of CSI to PT in individuals with knee OA at 1, 2 and 12 months., Methods and Analysis: We plan to recruit 156 participants meeting established knee OA criteria. Following informed consent, participants will be randomised to receive either CSI or PT. All participants will receive instruction on recommended exercise and weight control strategies plus usual medical care. The CSI intervention consisting of 3 injections and the PT intervention consisting of 8-12 sessions will be spaced over 12 months. Measures of the dependent variables (DVs) will occur at baseline, 4 weeks, 8 weeks, 6 months and 12 months post enrolment. This pragmatic, randomised clinical trial will be a mixed-model 2×5 factorial design. The independent variables are treatment (CSI and PT) and time with five levels from baseline to 1 year. The primary DV is the Western Ontario & McMaster Universities Arthritis Index (WOMAC). We will also compare healthcare utilisation between the 2 groups., Ethics and Dissemination: The protocol was approved by the Madigan Army Medical Center Institutional Review Board. The authors intend to publish the results in a peer-reviewed source., Trial Registration Number: NCT01427153., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Study Design: Descriptive biomechanical study using an experimental repeated-measures design., Objective: To quantify the response of participants with and without knee osteoarthritis (OA) to a single session of manual physical therapy. The intervention consisted primarily of joint mobilization techniques, supplemented by exercises, aiming to improve knee extension., Background: While manual therapy benefits patients with knee OA, there is limited research quantifying the effects of a manual therapy treatment session on either motion or stiffness of osteoarthritic and normal knees. Methods The study included 5 participants with knee OA and 5 age-, gender-, and body mass index-matched healthy volunteers. Knee extension motion and stiffness were measured with videofluoroscopy before and after a 30-minute manual therapy treatment session. Analysis of variance and intraclass correlation coefficients were used to analyze the data., Results: Participants with knee OA had restricted knee extension range of motion at baseline, in contrast to the participants with normal knees, who had full knee extension. After the therapy session, there was a significant increase in knee motion in participants with knee OA (P = .004) but not in those with normal knees (P = .201). For stiffness data, there was no main effect for time (P = .903) or load (P = .274), but there was a main effect of group (P = .012), with the participants with healthy knees having greater stiffness than those with knee OA. Reliability, using intraclass correlation coefficient model 3,3, for knee angle measurements between imaging sessions for all loading conditions was 0.99. Reliability (intraclass correlation coefficient model 3,1) for intraimage measurements was 0.97., Conclusion: End-range knee extension stiffness was greater in the participants with normal knees than those with knee OA. The combination of lesser stiffness and lack of motion in those with knee OA, which may indicate the potential for improvement, may explain why increased knee extension angle was observed following a single session of manual therapy in the participants with knee OA but not in those with normal knees. Videofluoroscopy of the knee appears reliable and relevant for future studies attempting to quantify the underlying mechanisms of manual therapy. J Orthop Sports Phys Ther 2014;44(4):273-282. Epub 25 February 2014. doi:10.2519/jospt.2014.4710.

Objectives: This study determined biomechanical force parameters and reliability among clinicians performing knee joint mobilizations., Methods: Sixteen subjects with knee osteoarthritis and six therapists participated in the study. Forces were recorded using a capacitive-based pressure mat for three techniques at two grades of mobilization, each with two trials of 15 seconds. Dosage (force-time integral), amplitude, and frequency were also calculated. Analysis of variance was used to analyze grade differences, intraclass correlation coefficients determined reliability, and correlations assessed force associations with subject and rater variables., Results: Grade IV mobilizations produced higher mean forces (P<0.001) and higher dosage (P<0.001), while grade III produced higher maximum forces (P = 0.001). Grade III forces (Newtons) by technique (mean, maximum) were: extension 48, 81; flexion 41, 68; and medial glide 21, 34. Grade IV forces (Newtons) by technique (mean, maximum) were: extension 58, 78; flexion 44, 60; and medial glide 22, 30. Frequency (Hertz) ranged between 0.9-1.1 (grade III) and 1.4-1.6 (grade IV). Intra-clinician reliability was excellent (>0.90). Inter-clinician reliability was moderate for force and dosage, and poor for amplitude and frequency., Discussion: Force measurements were consistent with previously reported ranges and clinical constructs. Grade III and grade IV mobilizations can be distinguished from each other with differences for force and frequency being small, and dosage and amplitude being large. Intra-clinician reliability was excellent for all biomechanical parameters and inter-clinician reliability for dosage, the main variable of clinical interest, was moderate. This study quantified the applied forces among multiple clinicians, which may help determine optimal dosage and standardize care.

Background and Purpose: Physical therapists frequently make important point-of-care decisions for musculoskeletal injuries and conditions. In the Military Health System (MHS), these decisions may occur while therapists are deployed in support of combat troops, as well as in a more traditional hospital setting. Proficiency with the musculoskeletal examination, including a fundamental understanding of the diagnostic role of musculoskeletal imaging, is an important competency for physical therapists. The purpose of this article is to present 3 cases managed by physical therapists in unique MHS settings, highlighting relevant challenges and clinical decision making., Case Description: Three cases are presented involving conditions where the physical therapist was significantly involved in the diagnosis and clinical management plan. The physical therapist's clinical privileges, including the ability to order appropriate musculoskeletal imaging procedures, were helpful in making clinical decisions that facilitate timely management. The cases involve patients with an ankle sprain and Maisonneuve fracture, a radial head fracture, and a pelvic neoplasm referred through medical channels as knee pain., Outcomes: Clinical pathways from point of care are discussed, as well as the reasoning that led to decisions affecting definitive care for each of these patients. In each case, emergent treatment and important combat evacuation decisions were based on a combination of examination and management decisions., Discussion: Physical therapists can provide important contributions to the primary management of patients with musculoskeletal conditions in a variety of settings within the MHS. In the cases described, advanced clinical privileges contributed to the success in this role.

Objectives: Describe short- and long-term outcomes observed in individuals with hip osteoarthritis (OA) treated with a pre-selected, standardized set of best-evidence manual therapy and therapeutic exercise interventions., Methods: Fifteen consecutive subjects (9 males, 6 females; mean age: 52±7.5 years) with unilateral hip OA received an identical protocol of manual therapy and therapeutic exercise interventions. Subjects attended 10 treatment sessions over an 8-week period for manual therapy interventions and performed the therapeutic exercise as a home program., Results: Baseline to 8-week follow-up outcomes were as follows: Harris Hip Scale (HHS) scores improved from 60.3(±10.4) to 80.7(±10.5), Numerical Pain Rating Scale (NPRS) scores improved from 4.3(±1.9) to 2.0(±1.9), hip flexion range of motion (ROM) improved from 99 degrees (±10.6) to 127 degrees (±6.3) and hip internal rotation ROM improved from 19 degrees (±9.1) to 31 degrees (±11.5). Improvements in HHS, NPRS, and hip ROM measures reached statistical significance (P<0.05) at 8-weeks and remained significant at the 29-week follow-up. Mean changes in NPRS and HHS scores exceeded the minimal clinically important difference (MCID) at 8-weeks and for the HHS scores alone at 29 weeks. The 8 and 29 week mean Global Rating of Change scores were 5.1(±1.4) and 2.1(±4.2), respectively. Improved outcomes observed following a pre-selected, standardized treatment protocol were similar to those observed in previous studies involving impairment-based manual therapy and therapeutic exercise for hip OA. Future studies might directly compare the two approaches.

Understanding the clinical characteristics of patients with low back pain (LBP) who display improved lumbar multifidus (LM) muscle function after spinal manipulative therapy (SMT) may provide insight into a potentially synergistic interaction between SMT and exercise. Therefore, the purpose of this study was to identify the baseline historical and physical examination factors associated with increased contracted LM muscle thickness one week after SMT. Eighty-one participants with LBP underwent a baseline physical examination and ultrasound imaging assessment of the LM muscle during submaximal contraction before and one week after SMT. The relationship between baseline examination variables and 1-week change in contracted LM thickness was assessed using correlation analysis and hierarchical multiple linear regression. Four variables best predicted the magnitude of increases in contracted LM muscle thickness after SMT. When combined, these variables suggest that patients with LBP, (1) that are fairly acute, (2) have at least a moderately good prognosis without focal and irritable symptoms, and (3) exhibit signs of spinal instability, may be the best candidates for a combined SMT and lumbar stabilization exercise (LSE) treatment approach., (Published by Elsevier Ltd.)

The orthopedic manual physical therapist approach to knee osteoarthritis (OA) is an effective, well-tolerated, and comprehensive strategy that provides a spectrum of intervention measures, which include guidance on activity selection, as well as selection of manual treatment and exercises to systematically address impairments and increase strength and movement in the knee and other related body regions. This approach integrates manually applied treatment while reinforcing exercise and functional activities that are tailored in scope and dose to each patient. Concepts used in the careful design of this exercise program include emphasizing minimal dosing, avoiding exacerbation, using exercises with multiple effects, effective functional positioning, emphasizing the importance of mid-range movements and end-range challenges, and strategic timing of exercises. Focusing on motion and strength gains through range of motion, along with functional or reinforcing activities, such as walking or biking to maintain motion and strength gains, are keys to long-term success. The overarching theme is that well-tolerated strategies using manual treatment, exercise, and activity require deliberate design and targeting of the most common impairments and functional limitations seen in the knee OA population and, more importantly, tailoring to the individual patient.

Purpose/background: Although side to side symmetry of lateral abdominal muscle thickness has been established in healthy individuals, it is unknown whether abdominal muscle symmetry exists in athletes with asymmetrical physiological demands, such as those of single-sided rowers. The purpose of this study was to examine the oarside versus the non-oarside lateral abdominal musculature thickness in collegiate single-sided rowers, as measured by ultrasound imaging (USI)., Methods: The study was a prospective, cross-sectional, observational design. Thirty collegiate crew team members (17 males, 13 females, age 19.8±1.2 years) characterized as single-sided rowers participated. Resting muscle thickness measurements of the transversus abdominis (TrA), internal oblique (IO), and external oblique (EO) muscles were obtained via USI. Comparisons of absolute and relative muscle thickness between oarside and non-oarside were performed using paired t-tests. Potential differences based on gender, rowing experience, and history of low back pain were investigated using mixed model analysis of variance., Results: There were no clinically significant differences in absolute or relative thickness of the TrA, IO or EO on the oarside versus the non-oarside. There were no significant side to side differences in the relative muscle thickness of the TrA, IO or EO based on gender, rowing experience, or history of low back pain., Conclusions: In this sample of single-sided rowing athletes, no clinically significant side to side differences in lateral abdominal muscle thickness were observed. Despite the asymmetrical functional demands of single-sided rowers in this study, thickness of the lateral abdominal muscles was symmetric., Level of Evidence: 4.

Study Design: Prospective single-cohort study., Objectives: To determine and document changes in pain and disability in patients with primary, nonacute acromioclavicular joint (ACJ) pain treated with a manual therapy approach., Background: To our knowledge, there are no published studies on the physical therapy management of nonacute ACJ pain. Manual physical therapy has been successful in the treatment of other shoulder conditions., Methods: The chief inclusion criterion was greater than 50% pain relief with an ACJ diagnostic injection. Patients were excluded if they had sustained an ACJ injury within the previous 12 months. Treatment was conducted utilizing a manual physical therapy approach that addressed all associated impairments in the shoulder girdle and cervicothoracic spine. The primary outcome measure was the Shoulder Pain and Disability Index. Secondary measures were the American Shoulder and Elbow Surgeon and global rating of change scales. Outcomes were collected at baseline, 4 weeks, and 6 months. The Shoulder Pain and Disability Index and American Shoulder and Elbow Surgeon scale values were analyzed with a repeated-measures analysis of variance., Results: Thirteen patients (11 male; mean ± SD age, 41.1 ± 9.6 years) completed treatment consisting of an average of 6.4 sessions. Compared to baseline, there was a statistically significant and clinically meaningful improvement for the Shoulder Pain and Disability Index at 4 weeks (P = .001; mean, 25.9 points; 95% confidence interval [CI]: 11.9, 39.8) and 6 months (P<.001; mean, 29.8 points; 95% CI: 16.5, 43.0), and the American Shoulder and Elbow Surgeon scale at 4 weeks (P<.001; mean, 27.9 points; 95% CI: 14.7, 41.1) and 6 months (P<.001; mean, 32.6 points; 95% CI: 21.2, 43.9)., Conclusion: Statistically significant and clinically meaningful improvements were observed in all outcome measures at 4 weeks and 6 months, following a short series of manual therapy interventions. These results, in a small cohort of patients, suggest the efficacy of this treatment approach but need to be verified by a randomized controlled trial., Level of Evidence: Therapy, level 4.

Background: The combination of manual physical therapy and exercise provides important benefit for more than 80% of patients with knee osteoarthritis (OA). Our objective was to determine predictor variables for patients unlikely to respond to these interventions., Methods: We used a retrospective combined cohort study design to develop a preliminary clinical prediction rule (CPR). To determine useful predictors of nonsuccess, we used an extensive set of 167 baseline variables. These variables were extracted from standardized examination forms used with 101 patients(64 women and 37 men with a mean age of 60.5}11.8 and 63.6}9.3 years, respectively) in 2 previously published clinical trials. We classified patients based on whether they achieved a clinically meaningful benefit of at least 12%improvement in Western Ontario MacMaster(WOMAC) scores after 4 weeks of treatment using the smallest and most efficient subset of predictors., Results: The variables of patellofemoral pain, anterior cruciate ligament laxity, and height >1.71 m (5’7’’) comprise the CPR. Patients with at least 2 positive tests yield eda posttest probability of 88% for nonsuccess with this treatment (positive likelihood ratio=36.7). The overall prognostic accuracy of the CPR was 96%., Conclusion: Most patients with knee OA will benefit from a low-risk, cost-effective program of manual physical therapy and supporting exercise.1,2 The few patients who may not benefit from such a program are identifiable by a simple (preliminary) CPR. After validation,this rule could improve primary patient management,allowing more appropriate referrals and choices in intervention.

Study Design: Prospective case series., Objectives: To investigate changes in abdominal muscle thickness with ultrasound imaging, after spinal manipulative therapy (SMT), in a subgroup of patients with low back pain (LBP) who meet a proposed clinical prediction rule for lumbar stabilization exercise (LSE)., Background: The characteristics of a subgroup of patients with LBP who respond clinically to LSE has been proposed. Although the pathoanatomical characteristics of this subgroup have not been determined, clinicians often assume that this type of LBP is related, in part, to neuromuscular deficits of the lateral abdominal muscles. Recent evidence suggests that SMT may facilitate abdominal muscle activity and, therefore, enhance exercises targeting these deficits., Methods: Nineteen patients (mean age ± SD, 32.5 ± 7.8 years; 11 female) with LBP, who met the criteria for LSE, underwent ultrasound imaging of the transversus abdominis (TrA) and internal oblique (IO) muscles before, immediately after, and 3 to 4 days after lumbopelvic SMT. Measurements of resting thickness, contracted thickness during the abdominal drawing-in maneuver, and percent thickness change from rest to contraction of the TrA and IO muscles were analyzed with repeated-measures analysis of variance. Numeric pain rating scale and Oswestry Disability Index data were also collected., Results: No significant differences in resting, contracted, or percent thickness change in the TrA or IO were found over the 3 time periods. There were statistically significant reductions in numeric pain rating scale and Oswestry Disability Index scores, but mean differences failed to meet the minimal clinically important difference., Conclusion: The results provide preliminary evidence that TrA and IO muscle resting and contracted thicknesses do not change post-SMT in patients with LBP in the LSE subgroup. In addition, while reductions in pain and disability were noted, they were not clinically meaningful.

Background and Purpose: The purpose of this study was to quantify the biomechanical properties of specific manual therapy techniques in patients with symptomatic knee osteoarthritis., Methods: Twenty subjects (7 female/13 male, age 54±8 years, ht 1·7±0·1 m, wt 94·2±21·8 kg) participated in this study. One physical therapist delivered joint mobilizations (tibiofemoral extension and flexion; patellofemoral medial-lateral and inferior glide) at two grades (Maitland's grade III and grade IV). A capacitance-based pressure mat was used to capture biomechanical characteristics of force and frequency during 2 trials of 15 second mobilizations. Statistical analysis included intraclass correlation coefficient (ICC(3,1)) for intrarater reliability and 2×4 repeated measures analyses of variance and post-hoc comparison tests., Results: Force (Newtons) measurements (mean, max.) for grade III were: extension 45, 74; flexion 39, 61; medial-lateral glide 20, 34; inferior glide 16, 27. Force (Newtons) measurements (mean, max.) for grade IV were: extension 57, 76; flexion 47, 68; medial-lateral glide 23, 36; inferior glide 18, 35. Frequency (Hz) measurements were between 0·9 and 1·2 for grade III, and between 2·1 and 2·4 for grade IV. ICCs were above 0·90 for almost all measures., Discussion and Conclusion: Maximum force measures were between the ranges reported for cervical and lumbar mobilization at similar grades. Mean force measures were greater at grade IV than III. Oscillation frequency and peak-to-peak amplitude measures were consistent with the grade performed (i.e. greater frequency at grade IV, greater peak-to-peak amplitude at grade III). Intrarater reliability for force, peak-to-peak amplitude and oscillation frequency for knee joint mobilizations was excellent.

Study Design: Prospective case series., Objective: To examine the relation between improved disability and changes in abdominal and lumbar multifidus (LM) thickness using ultrasound imaging following spinal manipulative therapy (SMT) in patients with low back pain (LBP)., Background: Although there is a growing body of literature demonstrating physiologic effects following the application of SMT, few studies have attempted to correlate these changes with clinically relevant outcomes., Methods: Eighty-one participants with LBP underwent 2 thrust SMT treatments and 3 assessment sessions within 1 week. Transversus abdominis (TrA), internal oblique (IO), and LM muscle thickness was assessed during each session, using ultrasound imaging of the muscles at rest and during submaximal contractions. The Modified Oswestry Disability Index was used to quantify participants' improvement in LBP-related disability. Stepwise hierarchical multiple linear regression and repeated-measures analysis of variance were performed to examine the multivariate relationship between change in muscle thickness and clinical improvement over time., Results: After controlling for the effects of age, sex, and body mass index, change in contracted LM muscle thickness was predictive of improved disability at 1 week (P = .02). As expected, larger increases in contracted LM muscle thickness at 1 week were associated with larger improvements in LBP-related disability. Contrary to our hypothesis, significant decreases in both contracted TrA and IO muscle thickness were observed immediately following SMT; but these changes were transient and unrelated to whether participants experienced clinical improvements., Conclusion: These findings provide evidence that clinical improvement following SMT is associated with increased thickening of the LM muscle during a submaximal task., Level of Evidence: Prognosis, level 4.

The patient was a 44-year-old man who reported palmar/ulnar-sided right wrist pain after injuring his wrist while playing golf. Although pain and function were improved at 6 months following the injury with conservative treatment measures and golfing with a modified grip, the patient was still limited during golf. This prompted the ordering of additional wrist radiographs, which included a carpal tunnel view, that revealed a fracture at the base of the hook of the hamate. The patient was referred to an orthopaedic surgeon and underwent a hook of hamate excision, and at 12 weeks following surgery, he had returned to full golfing activities without limitations. J Orthop Sports Phys Ther 2010;40(5):325. doi:10.2519/jospt.2010.0408.

Background: Previous studies have shown military physical therapists (PT) to have comparable clinical diagnostic accuracy (CDA) and interobserver agreement to orthopaedic surgeons (OS). However, no studies have examined hip pathology or used intraoperative findings as the reference standard for diagnosis., Objective: To compare the CDA of physical examination findings among a PT, an OS, and two surgical orthopaedic residents (ORs) for hip labral tears., Methods: Thirty-six patients (15 males, 21 females) aged 18-47 (mean + SD, 31.4 + 8.1 years) with 37 symptomatic hips were enrolled in a prospective study and underwent a standardized clinical examination followed by hip arthroscopy. A PT, an OS, and two ORs independently performed history and examinations with the emphasis of diagnosis on the results of six special tests., Results: Thirty-two of 37 individuals (86%) had labral tears to the hip at arthroscopy. Analysis of agreement between clinical diagnosis and intra-operative findings of a labral tear produced a CDA of 85.3% (29/34 correct) for the PT, 84.4% (27/32 correct) for the OS, and 80.0% (24/30 correct) for ORs. No significant difference in CDA occurred in comparing the PT, OS, and ORs., Conclusions: Using arthroscopy as the reference standard, hip labral tears were clinically suspected with 80-85% accuracy. The clinical diagnostic accuracy of the PT, OS, and ORs was high with no significant difference between examiners. In this study, an experienced PT, an OS, and two ORs demonstrated similarly high diagnostic skills.

Background Context: With lumbar arthroplasty gaining popularity, limited data are available highlighting changes in adjacent-level mechanics after multilevel procedures., Purpose: Compare operative- and adjacent-segment range of motion (ROM) and intradiscal pressures (IDPs) after two-level arthroplasty versus circumferential arthrodesis., Study Design: Cadaveric biomechanical study., Methods: Ten human cadaveric lumbar spines were used in this investigation. Biomechanical testing was performed according to a hybrid testing protocol using an unconstrained spine simulator under axial rotation (AR), flexion extension (FE), and lateral-bending (LB) loading. Specimens were tested in the following order: 1) Intact, 2) L3-L5 total disc replacement (TDR), 3) L3-L5 anterior interbody cages+pedicle screws. IDP was recorded at proximal and distal adjacent levels and normalized to controls (%intact). Full ROM was monitored at the operative and adjacent levels and reported in degrees., Results: Kinematics assessment revealed L3-L5 ROM reduction after both reconstructions versus intact controls (p < .05). However, global quality of segmental motion distributed over L2-S1 was preserved in the arthroplasty group but was significantly altered after circumferential fixation. Furthermore, adjacent-level ROM was increased for the arthrodesis group under LB at both segments and during AR at L2-L3 relative to controls (p < .05). FE did not reveal any intergroup statistical differences. Nonetheless, after arthrodesis IDPs were increased proximally under all three loading modalities, whereas distally a significant IDP rise was noted during AR and LB (p < .05). No statistical differences in either biomechanical parameter were recorded at the adjacent levels between intact control and TDR groups., Conclusions: Our results indicate no significant adjacent-level biomechanical changes between arthroplasty and control groups. In contrast, significant alterations in ROM and IDP were recorded both proximally (ROM=LB & AR; IDP=AR, FE, LB) and distally (ROM=LB; IDP=AR & LB) after circumferential arthrodesis. Therefore, two-level lumbar arthroplasty maintains a more favorable biomechanical environment at the adjacent segments compared with the conventional transpedicular fixation technique. This, in turn, may have a positive effect on the rate of the transition syndrome postoperatively.

Study Design: An in vitro biomechanical cadaver study of long segment thoracic pedicle screw constructs with transverse connectors (TC)., Objective: To determine the resultant degree of motion of the instrumented thoracic spine after segmental pedicle screw instrumentation with and without TC. SUMMARY OF BACKGROUND DATA.: TC are generally not thought to be necessary with thoracic pedicle screw constructs, yet to date no study has reported the effect of TCs after all pedicle screw long thoracic fusions., Methods: Eight human cadaveric spines were potted and then instrumented from T4-T10 with bilateral 5.5 mm multiaxial titanium (Ti) pedicle screws and 5.5 mm contoured Ti rods. Specimens were tested with a six-degree-of-freedom spine stimulator in the intact condition, after instrumentation, after placement of 1 TC (3 different locations) and after placement of both TCs. Data were analyzed by loading modality (axial rotation, flexion-extension, and lateral bending) using one-way analysis of variance with an alpha of 0.05. Paired t tests were used for post hoc analysis with correction for multiple comparisons., Results: There was no difference with the addition of 1 or 2 TCs in terms of flexion-extension or lateral bending when compared to the instrumented condition (P > 0.05). Biomechanical testing of the long-segment thoracic constructs in axial rotation (torsion) loading modes generated the most significant findings of this study. After instrumentation with thoracic pedicle screws, T4-T10 full ROM was significantly reduced from the intact condition (P < 0.05). On average, TPS alone resulted in a 65% decrease in ROM. However, the addition of a transverse connector at 1 of the 3 positions tested yielded another 20% improvement in axial segmental stability as represented by further ROM reduction. These differences were significant from the TPS only group (no TCs), regardless of the TC position (P < 0.05). Furthermore, 2 TCs placed at the proximal and distal ends of the construct provided the greatest biomechanical axial stability to the instrumented specimens (P < 0.05). This was highlighted by an average of 35% ROM reduction from the stability level achieved with the TPS only constructs (P < 0.05), or an additional 15% improvement in axial stability over a single TC., Conclusion: For long thoracic pedicle screw constructs, the addition of 1 or 2 TCs significantly decreases construct axial rotation, which is the primary plane of motion for the thoracic spinal region. A single TC contributed to a significant reduction of T4-T10 ROM (an additional 20%) relative to TPS fixation alone (P < 0.05), while the location of the TC within the construct was irrelevant. A second TC had an additive effect (an additional 15% reduction) on axial stability. (P < 0.05) Flexion-extension and lateral bending are not affected. Single TC significantly improves axial rotation stability in long thoracic pedicle screw constructs. Two crosslinks, however, are better than one.