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Orthopaedic Section Abstracts: Poster Presentations OPO2110-OPO2270

The abstracts below are presented as prepared by the authors. The accuracy and content of each abstract remain the responsibility of the authors. In the identification number above each abstract, OPO designates an Orthopaedic Section poster presentation.



Physical Therapy Program, Bellarmine University, Louisville, KY; Stonestreet Physical Therapy, Louisville, KY PURPOSE: A community partnership was formed between the Bellarmine University Physical Therapy Program and Trover Solutions, Inc. to design a self sustaining ergonomic training module based on current best practice. The purpose of this presentation is to describe (1) the systematic process used to create this training module and (2) the delivery of occupational injury/illness prevention and ergonomics services provided by physical therapists. DESCRIPTION: Literature Review. The systematic process used to develop the ergonomic training module integrated 5 elements in the management scheme; examination, evaluation, diagnosis, prognosis, and intervention(s). This process was developed from the guidelines given by the Occupational Health Special Interest group of the APTA. Examination: Trover's training needs were assessed by reviewing employee incident reports and the prevalence of reported injuries. The human resources department suspected nonreported worker complaints, such as generic neck or back pain and overuse injuries. We utilized the 24-item Job Requirements and Physical Demands Survey (JRPDS), a validated ergonomic survey, to objectively determine unreported complaints. The JRPDS was developed in 1996 by the US Air Force and later abbreviated to a 24-item index for ease of administration. This survey evaluates the exposure of workers to different tasks that have associated ergonomic risks and was validated in 2002 for office work environments. The reported reliability of the JRPDS is Cronbach's alpha value = 0.816; the construct validity was reported as r = 0.240-0.262; P<.05; and the criterion validity: r = 0.0328, R2 = 0.1074, P<.01. Evaluation: The JRPDS was administered on-line to employees using Survey Monkey to assist in data collection and analysis. DIAGNOSIS: Responses were analyzed and the following risk categories were identified: headache, eye fatigue, neck pain, shoulder pain, elbow pain, wrist pain, and back pain. A literature review of successful ergonomic programs and ergonomic interventions and level of effectiveness was performed. Prognosis: A verbal report was provided to the company's human resource professionals with analysis of acquired data and observation of work environment. Intervention: The training program consisted of a video media file and power point presentation developed

for the human resource department and unit managers. Instruction was provided according to OSHA ergonomic guidelines for environment, posture, ergonomic products, and specific exercise. CONCLUSION: Physical therapists participate in injury/illness prevention and ergonomics programs by assuming a variety of roles including work site analysis, employee education and training and health promotion. A management model for ergonomic training and intervention is presented here. CLINICAL RELEVANCE: A format for analysis of a company's needs and interventions based on current best evidence can be useful for Physical Therapists practicing in the area of Occupational Health.



Physical Therapy, University of Florida, Gainesville, FL; Clinical and Health Psychology, University of Florida, Gainesville, FL; College of Dentistry, University of Florida, Gainesville, FL PURPOSE/HYPOTHESIS: Neurodynamic techniques (ND) are a form of manual therapy (MT) used to treat carpal tunnel syndrome (CTS). A validated placebo is lacking for MT and is necessary to determine the influence of non specific treatment effects. The purpose of this study was to compare a sham and active ND for believability and influence on pain perception. NUMBER OF SUBJECTS: Thirty-nine participants with CTS. MATERIALS/METHODS: Participants were 18 to 70 years old and experiencing symptoms of CTS for at least 12 weeks. Participants were excluded if inappropriate for conservative treatment or for prior treatment with ND. Measurements of current clinical pain (CCP), Average clinical pain (ACP) (Average of CCP, least pain in past 24 hours, worst pain in past 24 hours), thermal pain perception (TPP), and expectation for the effectiveness of ND were obtained at baseline. Participants were randomly assigned to receive either active or sham ND, underwent brief exposure to the assigned intervention, and a second rating of expectation of effectiveness was obtained. Participants underwent up to 6 sessions over the next 3 weeks in which they received the assigned ND. Follow-up measures of CCP and TPP were obtained immediately following the initial ND session. CCP, ACP, and TPP were obtained immediately prior to the final ND session and CCP and TPP were obtained again immediately following the final ND session. The design allowed assessment of immedi-

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ate change in response to ND (CCP and TPP) and 3-week assessment of change in pain (ACP). Participants were asked at follow-up to indicate whether they believed they had received the active or sham ND. RESULTS: Thirty-nine females participated (mean age, 46.90 years [SD, 10.25]; mean duration, 275.09 weeks [SD, 275.41]). A group-by-time interaction was not observed for expected effectiveness (F1,37 = 0.03, P = .87, partial 2<.01) suggesting the groups did not differ in expectation for pain relief at baseline and following brief exposure to the assigned ND. The frequencies of perceived group assignment did not differ by group 2 (1, n = 37) 1.74 (P = .19). Neither group dependent changes nor main treatment effects in ACP were observed over the duration of the study. Transient decreases in CCP were observed immediately following the ND on evaluation and discharge and this was independent of group assignment. Group dependent changes in TPP were observed during the discharge session with those receiving the active ND experiencing hypoalgesia. CONCLUSIONS: A sham ND was associated with similar expectation for pain relief and perception of group assignment as an active ND. Immediate and 3-week changes in CCP and ACP did not differ by group assignment. Conversely, group differences were observed in TPP. CLINICAL RELEVANCE: The sham ND in this study has potential for use as a placebo in subsequent studies due to its believability and group dependent differences observed in TPP. CCP and ACP did not differ between groups suggesting the biomechanical properties of a given ND may not be influential in the short term effects on pain.



Performance Dynamics, Muncie, IN; Physical Therapy, University of Texas Medical Branch, Galveston, TX PURPOSE/HYPOTHESIS: Recent evidence suggests that chronic lateral epicondylitis (LE) is often degenerative rather than inflammatory. ASTYM is a noninvasive treatment based on physiological principles that enables the clinician to stimulate tissue turnover in areas of degeneration and soft tissue scarring. A stimulus is provided using instruments in a precise dosed manner. It is theorized this triggers capillary leakage leading to release of growth factors and an inflammatory response. Rodent studies have shown an increase in fibroblast recruitment as well as fibroblast activation with ASTYM treatment. Specific exercises and activities are prescribed to provide guiding forces to the healing tissue. The purpose of this study was to test the effectiveness of ASTYM compared to a home exercise program (HEP) in treating patients with LE. It was hypothesized that treatment with ASTYM would result in improved short term outcomes in comparison to a HEP and that patients would maintain their progress long term. NUMBER OF SUBJECTS: One hundred twenty-one subjects who met criteria for LE were randomized into 2 treatment groups, resulting after drop out in 94 elbows (46 ASTYM and 48 HEP) completing the initial treatment phase (43 males, 51 females). MATERIALS/METHODS: The study had a single blinded mixed design. After treatment period of 4 weeks and a wash-out period of 4 weeks, subjects had the option to cross over if unresolved. Measures were taken by blinded raters at baseline, 4, 8, and 12 weeks or until resolution, and questionnaires were obtained at 6 and 12 months. The HEP group received instruction in stretching and eccentric-emphasis strengthening exercises to be performed 2 time per week for 4 weeks. The ASTYM group received the ASTYM protocol 2 times weekly combined with the same stretching/ strengthening exercises as the HEP group. Outcome measures included grip strength, visual analog scale (VAS) for pain at rest and with activity, VAS for function, and DASH (Disability of Arm, Shoulder and Hand). Physician and patient global rating scores determined symptom resolution. Independent t tests of the gain scores were used to analyze the data after careful screening of main and interaction effects. RESULTS: The symptoms resolved either after initial treatment or washout period in 36/46 (78.3%) of ASTYM subjects and 20/48 (41.6%) of HEP subjects. After 4 weeks, the ASTYM group showed superior outcomes to the HEP group, with greater reductions in DASH and pain scores at rest, and greater gains in grip strength (P<.05). Of the unresolved HEP subjects who chose to cross over, 22/23 (95.6%) met resolution criteria after receiving the ASTYM treatment. At 6 months, all subjects who received ASTYM showed improvements as compared to baseline in pain (VAS) at rest and with activity, function (VAS), and DASH scores (P<.0005) and the improvements maintained at 12 months for all variables. CONCLUSIONS: ASTYM was more effective than an HEP alone for patients with LE. CLINICAL RELEVANCE: Based on our studies, ASTYM treatment provides therapists an effective treatment for chronic LE.



DPT Program, Dept EXSC, University of South Carolina, Columbia, SC PURPOSE/HYPOTHESIS: The purpose was to determine if normal adult subjects could perceive a difference between pulsed ultrasound at 1 MHz, 1.0 W/cm2, 20% duty cycle, and sham ultrasound performed on opposite volar wrists within healthy adult subjects. The null hypothesis was that blinded subjects would not correctly identify if they received the same or different treatments to each wrist. NUMBER OF SUBJECTS: Thirty healthy adult subjects (60 wrists) without symptoms of carpal tunnel syndrome. MATERIALS/METHODS: Intervention: Participants were divided into 4 groups. Group 1 received pulsed ultrasound to the left wrist and sham ultrasound to the right wrist, Group 2 received pulsed ultrasound to bilateral wrists, Group 3 received sham ultrasound bilaterally and Group 4 received pulsed ultrasound to the right wrist and sham ultrasound to the left wrist. All treatments were 15 minutes. Main Outcome Measure: Dichotomous, yes or no, answers to whether a difference in sensation was perceived in bilateral wrist ultrasound treatments. Data Analysis: Twosided Fisher's exact test was used to determine if there was a perceived sensation difference between the 2 treatments. RESULTS: Statistical analysis (2-sided Fisher exact test) confirmed that subjects correctly identified treatment conditions more frequently than expected by chance (P = .0301, Fisher exact test). A total of 23/30 subjects correctly perceived the difference or lack of difference in their treatment condition. CONCLUSIONS: Subjects were able to discern whether or not there was a difference in sham and pulsed ultrasound treatments to bilateral wrists at a rate greater than chance alone. CLINICAL RELEVANCE: Pulsed ultrasound may result in perceivable sensations in subjects. Blinded subject clinical research designs that utilize within subject comparisons of sham and pulsed ultrasound to investigate treatment effects may not effectively blind subjects from perceiving differences between real and sham ultrasound treatments.



Iowa State University, Des Moines, IA PURPOSE/HYPOTHESIS: The purpose of this study was to measure the effect of custom orthotics on rearfoot (RF), midtarsal (MF), and forefoot (FF) kinematics using dynamic gait simulation. NUMBER OF SUBJECTS: Eight cadaver specimens (45 5 years) severed 20 cm above the malleoli were obtained for this study.

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MATERIALS/METHODS: Four male and 4 female specimens free from lower extremity deformity were cast in plaster while in a non­weight-bearing subtalar neutral position and fitted with a Bite running sandal that accommodates foot orthotics. Semi-flexible graphite with a vinyl cover was used for all devices and forefoot deformities were balanced to neutral intrinsically. Kirshner wire bone pins were radiographically inserted into 10 bones of the foot and ankle. Cadaver specimens, mounted to a dynamic gait simulator, walked over a force platform while 3-D kinematic data were collected using marker triads mounted to bone pins. Eight extrinsic muscle tendons crossing the ankle joint were connected to load cells in series with electric actuators to simulate muscle activity. Eight successful trials of both a control and orthotic condition were collected and trials were collapsed across subjects for representative values. Cohen's d effect sizes (es) were calculated on variables of interest. RESULTS: Tibial-calcaneal angles in the frontal and sagittal plane were decreased with the use of the custom orthotic (10.3° versus 8.3° [ES, 0.55] and 26.9° versus 22.2° [ES, 0.56], respectively). Calcaneal-talar motion in the sagittal plane was also decreased with the use of orthotics (12.1° versus 8.7° [ES, 0.44]). In contrast to the RF, sagittal plane angles between both the navicular bone-cuneiform and the navicular bone-cuboid increased in the orthotic condition (7.2° versus 8.3° [ES, ­0.77] and 6.5° versus 8.3° [ES, ­0.77], respectively). Furthermore, although the effect was small, motion between the first metatarsal and first phalange also increased (18.9° versus 20.6° [ES, ­0.37]). CONCLUSIONS: When compared to the control condition, the orthotic condition minimized RF motion and resulted in greater motion in the medial column of the MF and FF during cadaveric gait simulation. CLINICAL RELEVANCE: Clinicians need to recognize the opposing effect this type of custom orthotic can have on RF and MF/FF motion. Results of this study indicate that this orthotic minimized movement at the rearfoot. However, MF and FF mobility were increased; thus, this increased mobility in the MF and FF should be consistent with the overall goal of orthotic prescription.

Software (Innsport Training Inc, USA). Kinematic data were used to calculate Cardan angles (z-x-y sequence) hindfoot inversion/eversion (HF relative to the shank) and forefoot dorsiflexion/plantar flexion (FF relative to the HF). Analysis were performed on the univariate correlations between the clinical tests and foot kinematics. Subsequently, multiple linear regression was used to determine which clinical tests and/or foot kinematics best predicted forefoot dorsiflexion at peak heel rise. RESULTS: Significant (P<.05) correlations between clinical tests and forefoot dorsiflexion were moderate for the arch height index (r = ­0.50), isometric inversion strength (r = ­0.47) and heel rise ability (r = ­0.55). Radiograph angles (Calcaneal pitch angle [r = ­0.71] and first metatarsal pitch angle [r = ­0.57]) showed the strongest correlations with forefoot dorsiflexion. Foot kinematics also showed correlations between hindfoot eversion and forefoot dorsiflexion (r = ­0.55). Multivariate models including calcaneal pitch and heel rise ability resulted in an r square of 0.71. CONCLUSIONS: The new findings of this study suggest clinical tests, including arch height index, isometric strength, radiographs, and heel rise ability are associated with forefoot stability. CLINICAL RELEVANCE: These data suggest clinical tests are useful in predicting foot function during a task. Treatment paradigms that target foot posture (orthotics) and muscle function (exercise) may assist these subjects control forefoot movement.



Physical Therapy, Washington University School of Medicine, Saint Louis, MO; Physical Therapy/Internal Medicine, Washington University School of Medicine, Saint Louis, MO PURPOSE/HYPOTHESIS: To compare foot progression angle (FPA) and walking speed (WS) using 2 different gait assessment methods in subjects with diabetes mellitus (DM), peripheral neuropathy (PN) and a unilateral plantar forefoot ulcer. NUMBER OF SUBJECTS: Fourteen subjects (11 male/3 female; mean age, 55 11 years; mean body mass index, 33.3 5.9 kg/m2) with DM (2 type 1, 12 type 2; mean duration of DM, 19.4 years), PN, and a current plantar forefoot ulcer participated. MATERIALS/METHODS: All subjects walked barefoot at their preferred walking speed over an EMED-ST pressure platform (50-Hz sample rate) embedded in a 25-foot walkway using the 2-step approach (Novel Inc, St Paul, MN). Each subject walked 2 to 3 trials for each foot over the platform. In addition, each subject walked 2 trials in their shoes at their preferred WS over a 25-foot length of paper using inked moleskin affixed to the soles of the shoes as previously described by Boenig (1977). FPA was determined from EMED pressure maps by creating a 50% vertical line bisecting the mid foot and forefoot into medial and lateral masks. The angle formed between a line parallel to the line of progression of the platform and an intersecting vertical line bisecting the foot was measured as the FPA. FPA was determined from the moleskin method from a single line drawn that bisected the heel and toe markers to an intersecting line drawn parallel to the line of progression of the paper. WS was measured for both methods with a stopwatch (recorded to the nearest tenth of a second) as subjects walked across the walkway. Mean and standard deviation of FPA and WS were compared for both methods. A coefficient of determination (r2) was used to determine the relationships of FPA and WS between methodologies and post hoc paired t tests were used to determine any differences in measures obtained with the different gait assessment methods. RESULTS: The subjects' preferred WS was similar among the 2 gait assessment methods (inked moleskin paper method, 51 15 m/min) and across the EMED platform (47 14 m/min; P = .46, NS). There was a



Physical Therapy, Ithaca College, Rochester, NY; Orthopedics, University of Rochester, Rochester, NY; School of Nursing, University of Rochester, Rochester, NY PURPOSE/HYPOTHESIS: Failure to invert during either a bilateral or unilateral heel rise is hypothesized to indicate weakness of the posterior tibial muscle. The consequence of decreased hindfoot inversion is thought to lead to midfoot instability measured as increased forefoot dorsiflexion using a multisegment foot model. Clinical tests of arch structure (arch index and radiographic angles), inversion muscle strength, and foot kinematics during a heel raise are expected to predict increased forefoot dorsiflexion. The purpose of this study was to examine the ability of clinical tests of arch structure, foot inversion muscle strength, heel rise ability and foot kinematics to predict forefoot dorsiflexion during a bilateral heel rise task in subjects with stage II PTTD. NUMBER OF SUBJECTS: Thirty-two Stage II PTTD subjects (59.8 11.1 years) and 15 (56.5 7.7 years) Controls volunteered to participate in this study after consenting to the study procedures. MATERIALS/METHODS: Clinical tests included the arch height index, radiographic assessment when available (n = 17), isometric foot inversion strength and heel rise ability. Heel rise ability was quantified as the number of unilateral heel rises a subject could perform. Foot kinematics during a bilateral heel rise task were captured using a multisegment foot model. Data was collected (sampled at 60 Hz, filtered at 6 Hz) from the shank, calcaneus (HF), and first metatarsal (FF) using an Optotrak Motion Analysis System (Northern Digital Inc, CAN) and Motion Monitor

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strong association in WS among methods (r2 = 0.90). FPA was similar for the ulcerated foot and nonulcerated foot in each subject and for each method. Mean FPA measured with the inked moleskin method was 15° 7° and EMED was 15.5 6 (averaged ulcerated and nonulcerated foot). FPA for ulcerated and nonulcerated feet did not differ among methods, (P = .41, NS) with a strong coefficient of determination r2 = 0.53. CONCLUSIONS: WS and FPA obtained using EMED platform and traditional inked moleskin methods are similar in subjects with DM, PN and a plantar ulcer of the forefoot. FPA was similar for ulcerated and nonulcerated feet, though markedly greater than published values for individuals without DM or PN (Boenig, 1977 reports: left foot, 9° 4°; right foot, 8° 3°). CLINICAL RELEVANCE: This study provides an evaluation of the precision of FPA using EMED pressure platform methods compared to the more traditional but time consuming paper, inked moleskin method. Supported by NICHD R21 HD48972. LY and STANDARD groups for wound complications. There was a trend for the patients who did not initiate early ROM to develop early posttraumatic OA and only patients in the STANDARD group developed a DVT (n = 3). CLINICAL RELEVANCE: With no additional complications between the EARLY and STANDARD ROM group, it may be beneficial to initiate ROM exercise early in patients with calcaneal and/or talar fractures to avoid OA and DVT.



The Orthopedic Specialty Hospital, Intermountain Healthcare, Salt Lake City, UT; Department of Physical Therapy, Franklin Pierce College, Concord, NH PURPOSE/HYPOTHESIS: Achilles tendon ruptures account for 40% of all operative tendon repairs and has an incidence rate of 18 per 100 000 people. Research demonstrates that patients with Achilles tendon repairs (ATR) who participate in physical therapy (PT) have better postinjury activity levels and significantly higher satisfaction levels than those who do not. The purpose of this retrospective analysis was to examine clinical outcomes of pain, disability, and utilization of physical therapy (PT) services following ATR. NUMBER OF SUBJECTS: Ninety-two patients (67.4% male; mean age, 41.9 13.7) who had undergone an ATR and received physical therapy at 8 Intermountain Healthcare outpatient clinics between January 2006 and March 2008 provided data for this analysis. MATERIALS/METHODS: Standard processes for data collection of clinical outcomes were used at admission and follow-up visits. Therapists determined intervention, number of visits, and length of stay (LOS) in PT. The numeric pain scale (NPS) and the Lower Extremity Function Scale (LEFS) were used to assess pain and disability. Initial, discharge, and change scores for pain and disability were calculated for all patients. Utilization of visits and LOS was determined. Group differences between patients treated by the Principal Investigator (PI) compared to patients treated by different therapists (OTHER) were examined using independent t tests. RESULTS: On admission, patients reported an average NPS of 2.3 (SD, 2.7) and LEFS 36.4 (SD, 16.3). At discharge, patients reported an average NPS of 1.7 (SD, 2.0) and LEFS 54.6 (SD, 15.7). Patients improved significantly (P<.001) from admission to discharge on the LEFS (mean difference, 18.3; 95% CI: 15.0, 21.4) to a magnitude which was twice the minimal clinically important change. Patients improved significantly (P<.001) on the NPS (mean difference, .60; 95% CI: 0.17, 1.0). The average utilization was 7.2 visits (SD, 3.7) and average LOS was 57.1 (SD, 37.1) days. There was no significant difference between groups (PI versus OTHER) for change in LEFS (4.7; 95% CI: ­1.7, 11.0; P = .15) or pain scores (0.19; 95% CI: ­0.67, 1.1; P = .67). However, patients treated by the PI utilized significantly (P = .002) fewer PT visits (6.1 versus 8.8, respectively) and had a significantly (P = .003) longer LOS (46.6 versus 65.6 days, respectively). CONCLUSIONS: All patients achieved significant improvements in pain and disability. The average change score for the LEFS was both significant and clinically important. No differences in clinical outcomes were observed between patients treated by the PI compared to patients treated by OTHERs. However, the PI achieved similar clinical outcomes with significantly less utilization of visits. CLINICAL RELEVANCE: In the midst of our nation's efforts to control health care spending, the judicious utilization of physical therapy visits postoperatively for ATR is crucial and adds value for the patient. Further research related to postoperative rehabilitation of patients with ATR aimed at patterns of utilization and management strategies appears warranted.



The Orthopedic Specialty Hospital, Intermountain Healthcare, Salt Lake City, UT; Department of Physical Therapy, Franklin Pierce College, Concord, NH PURPOSE/HYPOTHESIS: Although talar and calcaneal fractures occur infrequently, long-term outcomes can be devastating. Posttraumatic arthritis, stiffness, pain, and loss of function are common consequences of these injuries. The purpose of this study was to determine whether initiating range of motion (ROM) earlier than 6-weeks postop in patients following surgery for talus and calcaneus fractures results in differences in clinical outcomes of pain, disability, early onset of osteoarthritis (OA), and additional complications such as deep venous thrombosis (DVT). NUMBER OF SUBJECTS: Forty-five patients (mean SD age, 39.8 14.6; 82% male) who had sustained either a talus (n = 20; mean SD age, 33.1 11.0 years; 90% male) or calcaneus (n = 25; mean SD age, 45.1 15.4; 76% male) fracture and were referred to physical therapy after surgery during 2006 to 2007 were included in the analysis. MATERIALS/METHODS: The numeric pain scale (NPS) and the Lower Extremity Function Scale (LEFS) were used to assess pain and disability. Patients were dichotomized on the basis of whether they initiated ROM exercise prior to their 6-week postop follow-up appointment (EARLY) with the surgeon or afterward (STANDARD). Differences between the groups (EARLY versus STANDARD) were examined using independent t tests for continuous data (age, pain, disability, ROM), and 2 tests of independence for categorical data (complications and OA). RESULTS: Patients achieved significant improvement (P<.001) in LEFS scores from the initial visit to discharge (mean, 17.7 points; 95% CI: 13.4, 21.9). There were 16 patients in the EARLY (age, 36.3; SD, 12.4; 81% male) and 29 patients in the STANDARD group (age, 41.7; SD, 15.8; 83% male). There was no statistical difference in the LEFS change scores between groups (5.5; 95% CI: ­.3.2, 14.1; P = .21), or change in the NPS (1.3; 95% CI: ­0.2, 2.8; P = .09). The EARLY group experienced significantly greater changes in ankle ROM than the STANDARD group (mean difference, 10.0; 95% CI: 4.9, 15.2). No statistical difference (P = .15) existed between the number of complications between groups (EARLY, n = 2; STANDARD, n = 9). There was no significant difference (P = .61) between the groups for the number of patients that developed posttraumatic OA (EARLY, n = 5; STANDARD, n = 9). No difference (P = .26) existed between the numbers of patients developing a DVT after surgery (EARLY, n = 0; STANDARD, n = 3). CONCLUSIONS: All patients who attended PT, regardless of the time for initiating ROM, had a significant improvement in self-reported disability. There were no differences between the EARLY and STANDARD groups except for changes in ROM. There were no differences between the EAR-

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US Army Baylor University Post Professional Doctoral Program in Orthopaedic Manual Physical Therapy, Brooke Army Medical Center, Fort Sam Houston, TX BACKGROUND AND PURPOSE: Plantar heel pain is a common foot condition seen in running athletes. The etiology of the condition is not well established. Contributing factors are thought to include stiffness of the ankle and foot, over-pronation, and poor lower extremity flexibility. Adverse neurodynamics may be among the sources of plantar heel pain. The purpose of this study is to describe an impairment-based examination and intervention utilized in the treatment of an elite runner presenting with plantar heel pain. CASE DESCRIPTION: The patient was a 44-year-old male with 4-month history of left plantar heel pain located posterior and proximal to the Achilles tendon insertion. He presented with a chief complaint of severe pain with walking, running and the first step in the morning. He had a previous history of left sided low back pain with moderate burning pain in the left mid posterior thigh and intermittent numbness along his left lateral foot. All these symptoms had resolved 8 months prior to the onset of heel pain. He was an elite runner training 50 to 70 miles per week. He participated frequently in marathons and ultra-marathons. Previous treatments of rest, anti-inflammatory medication, and activity modification had not resolved his symptoms. The patient's plantar heel pain was reproduced with the straight leg raise and modulated with sensitizing maneuvers suggesting a neurogenic component. He also demonstrated movement restrictions in the hip, ankle, and foot. The patient was treated for 6 visits over 6 weeks. The primary intervention consisted of soft tissue mobilization to improve neurodynamics along the sciatic nerve and to a lesser extent joint mobilization to the hip, ankle, and foot. Home- based therapeutic exercise was used to complement in-clinic treatments. The main outcome instrument was the Foot and Ankle Ability Measure (FAAM). OUTCOMES: The patient's SLR improved from 40° to 65° and no longer produced his heel pain. Dorsiflexion range of motion improved from 5° to 11°. First metatarsal-phalangeal joint extension improved from 75° to 85°. The overall FAAM improved from 77% to 100%. The FAAM activities of daily living subscale improved from 81% to 100% and the sports subscale 65% to 100%. At the 2-month follow-up he had returned to his previous level of training and at the 4-month recheck he denied any return of heel pain despite running 50 to 60 miles per week. DISCUSSION: Adverse neurodynamics of the lower extremity should be considered in the differential diagnosis of patients presenting with plantar heel pain. This case report describes an apparently successful impairment-based approach to a patient with plantar heel pain. Though no cause and effect can be inferred from this case, further studies should assess the prevalence of neural tension signs in patient with plantar heel pain and investigate the effects of treatments aimed to address this impairment.


coordinate axes.

NUMBER OF SUBJECTS: Eight complete data sets were collected from 9 adult cadaver specimens (5 males, 4 females) without known history of foot surgery. MATERIALS/METHODS: Palpable bony landmarks defined 5 segments to include the calcaneus, navicular, medial cuneiform, first metatarsal, and hallux. With use of the Flock of Birds electromagnetic motion tracking device, a single examiner digitized a minimum of 3 points on each segment. Each landmark was digitized once directly over skin, and again directly on bone following dissection. Local axes were created where x projected approximately forward, y upward, and z laterally. Matrix transformation computations calculated the angular precision in degrees between coordinate axes built from points digitized predissection and postdissection of surface tissues covering bone. The condition of postdissection was considered the criterion standard for comparison. Change about the x axis represented the angular precision of the coordinate in the frontal anatomical plane (inversion/eversion); y axis in the transverse plane (add/abduction); z axis in the sagittal plane (dorsi/plantar flexion). RESULTS: The calcaneus and navicular coordinate axes changed by an average of less than 3° for all axes. Mean coordinate angulation of the cuneiform x, y, z axes changed by 6.0°, 4.6°, 11.9°, respectively. Change in coordinate angulation was largest for the x (inversion/eversion) axis at the first metatarsal (48.6°) and hallux (36.5°). A 2-way repeated-measures ANOVA found a significant interaction between the axis and segment (F = 8.87, P<.01). Tukey post hoc comparisons indicated the change in coordinate angulation of the x axis (inversion/eversion) for the cuneiform, metatarsal, and hallux to be significantly different (P<.05) from the calcaneus and navicular. The x axis (inversion/eversion) of the first metatarsal and hallux was different from all other axis-segment combinations except for the z axis (dorsiflexion/plantar flexion) of the cuneiform. CONCLUSIONS: Differences in locating landmarks reduced angular precision of the coordinate axes. The largest changes were in the smallest foot segments where the points digitized were located close together. CLINICAL RELEVANCE: We can recommend the proposed landmarks for the calcaneus and navicular segments, but kinematics determined about coordinate axes for the small sized medial cuneiform, and the longitudinal x axis of the first metatarsal and hallux (used for the measurement of great toe inversion/eversion joint motions) have excessive error. Alternative coordinate definitions may need to be proposed.



Department of Kinesiology, University of Massachusetts, Amherst, MA PURPOSE/HYPOTHESIS: Excessive rearfoot pronation and flattening of the medial longitudinal arch (MLA) have been implicated as predisposing factors to a number of lower extremity injuries. To correct these faulty mechanics, therapists commonly utilize foot orthoses. Orthoses have been shown to successfully treat a number of conditions when using pain and function as outcome measures. However, biomechanical studies have not consistently demonstrated that foot orthoses control foot motion. To date, most studies have focused on the effect of orthoses on rearfoot kinematics, not taking into account their effect on the MLA. Therefore the purpose of this study was to evaluate the effects of custom foot ortheses (CFO) on MLA kinematics. NUMBER OF SUBJECTS: Ten subjects consented to participate in the study (4 male, 6 female). Mean (SD) age was 30.2 (7.9) years, weight 71.7 (14.0) kg, and height 1.66 (0.11) m. MATERIALS/METHODS: Kinematic analyses were performed in a gait lab equipped with 8 Oqus Qualysis cameras (Qualysis Inc, Gothenburg, Sweden) and an AMTI force plate (AMTI Inc, Watertown, MA). Subjects wore sandals with a removable inset, which accommodated the CFO and



Program in Physical Therapy, University of Minnesota, Minneapolis, MN PURPOSE/HYPOTHESIS: Precise identification of surface landmarks is required for making reliable and valid joint angle measurements. Research has not defined the preferred landmarks when building local coordinate axes for a foot model. This investigation determined the precision in the digitization of bony landmarks commonly used for building foot segment

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still allowed direct marker placement. The foot was modeled as 2 rigid segments. The rearfoot segment was defined using retroreflective markers placed on the proximal heel, peroneal tubercle and sustentaculum tali. Dynamic trials were tracked with a rigid plate on the posterior aspect of the heel. The medial forefoot segment was defined and tracked using markers placed at both the base and head of the first and second metatarsals. Subjects walked at 1.35 m/s ( 5%) while kinematics were captured at 240 Hz. The stance phase of gait was determined using the vertical ground reaction force profiles. The MLA was defined as the sagittal plane angle formed by the forefoot relative to the rearfoot. Lowering of the MLA is indicated by a larger dorsiflexion angles. Kinematics from 5 steps were averaged and the means were evaluated with a paired t test ( = .05). The variables of interest included peak forefoot dorsiflexion angle, peak forefoot plantar flexion angle, and total sagittal plane range of motion (ROM). RESULTS: Subjects demonstrated significantly less peak forefoot dorsiflexion when ambulating with CFO (6.43° 3.54° versus 5.27° 3.6°). The CFO condition also revealed a trend towards increased peak plantar flexion (9.37° 3.16° versus 10.37° 3.26°); however, this was not statistically significant. No statistically significant differences were found for total ROM (15.79° 4.5° versus 15.64° 4.7°). CONCLUSIONS: CFO significantly decreased the amount of peak forefoot dorsiflexion during stance by 1.2°, indicating that they successfully reduced the flattening of the MLA. This kinematic change may result in improved function and decreased pain. CLINICAL RELEVANCE: Foot orthoses are frequently utilized in physical therapy practice to treat lower extremity injuries. While their biomechanical influences on the MLA have not been extensively studied, this study provides evidence that CFO are capable of controlling the kinematics of the MLA. culated for all measures. RESULTS: 3-D digitizer and CT measures of MTPJ angle had high test-retest reliability (ICC = 0.96, 0.99, respectively). Goniometry, 3-D digitizer, and CT measures of tibial torsion had good test-retest reliability (ICC = 0.77, 0.86, 0.98). Goniometric and 3-D digitizer measures were highly correlated with CT measures of MTPJ angle (r = 0.88, 0.88) and tibial torsion (r = 0.72, 0.83). The mean MTPJ angles as measured by goniometry, 3-D digitizer and CT were 36.8 15.6, 41.5 16.0, and 46.4 16.0, respectively. The mean tibial torsion measures were 33.4 4.3, 31.5 4.5, and 32.2 5.1 for goniometry, 3-D digitizer, and CT. The SEM for MTPJ angle measured by 3-D digitizer and CT were 3.2° and 1.6°, respectively. The SEM for tibial torsion as measured by goniometry, 3-D digitizer, and CT were 2.1°, 1.7°, and 0.7°, respectively. CONCLUSIONS: 3-D digitizer and CT scan measures of MTPJ angle and goniometric, 3-D digitizer and CT scan measures of tibial torsion are reliable. Goniometer and 3-D digitizer measures of MTPJ angle and tibial torsion measures are highly correlated with the gold standard CT method indicating good validity of measures. CLINICAL RELEVANCE: Clinical methods to measure hammer-toe deformity and tibial torsion are reliable and validated with radiological measures. Additional research is needed to establish interrater reliability, but these measures can be used to study contributing causes of foot deformity and assess outcomes of treatment interventions.



Movement Science Program, Washington University in St Louis, St Louis, MO; Program in Physical Therapy, Washington University in St Louis, St Louis, MO; Mallinckrodt Institute of Radiology, Washington University in St Louis, St Louis, MO; Department of Physical Therapy, Yonsei University, Seoul, South Korea PURPOSE/HYPOTHESIS: When the toe flexor muscles are weak, the prolonged unopposed actions of the extensor digitorum longus (EDL) and brevis are believed to cause hammer toe deformity at the metatarsophalangeal joint (MTPJ). This problem could be compounded in the presence of limited dorsiflexion range of motion (ROM) at the ankle where the EDL may have increased activity in an effort to increase ROM at the ankle. The purpose of this study was to compare the ratio of toe extensor/flexor muscle strength in toes 2 to 4 among groups of subjects with and without hammer toe deformity (HT and NoHT). In addition, we investigated the correlations between the ratio of toe extensor/flexor muscle strength in toes 2 to 4, dorsiflexion ROM at the ankle and MTPJ deformity. NUMBER OF SUBJECTS: Twenty-seven feet with visible hammer toe deformity (10 female, 17 male feet; mean age, 33 15 years; mean MTPJ angle measured by CT 54° 13°) and 31 age-matched feet without hammer toe deformity (22 female, 9 male feet; mean age, 29 8 years; mean MTPJ angle measured by CT, 37° 10°) were tested. The participants had no other significant impairments or comorbidities. MATERIALS/METHODS: Toe muscle strength was measured using a dynamometer (MSC-100, Chatillon) mounted vertically on a stable wood board with a leather cuff placed around the tested toe. The mean value of 3 trials was used as extensor and flexor muscle strength. The ratio of toe extensor muscle strength to flexor muscle strength was used for analysis. Ankle dorsiflexion ROM was measured via goniometry. The angle of MTPJ hammer toe deformity was measured from a lateral view CT image of the tested toes (Commean et al, 2002). Group differences were determined based on t tests. Association was determined by Pearson correlation coefficients. RESULTS: The HT group had a higher extensor-flexor toe muscle strength ratio compared to the NoHT group, in toes 2 to 4 (2.4 1.6 versus 0.8 0.2; 1.8 0.6 versus 0.8 0.20; 1.5 0.7 versus 0.7 0.2; all P<.001).



Movement Science Program, Washington University in St Louis, St Louis, MO; Program in Physical Therapy, Washington University in St Louis, St Louis, MO; Department of Physical Therapy, Yonsei University, Seoul, South Korea PURPOSE/HYPOTHESIS: Hammer toe deformity is associated with forefoot pain and/or skin breakdown, but is thought to be difficult to measure quantitatively in the clinic. The purpose of this study was to determine the intrarater reliability and validity of measures of metatarsophalangeal joint (MTPJ) deformity (hammer toe angle) and angle of tibial torsion using goniometry, 3-D digitizer (Metrecom), and CT (gold standard). We hypothesized that the reliability of measurements of MTPJ deformity using digitizer and CT; and angle of tibial torsion using goniometry, digitizer and CT scan will be good (ICC>0.7). We hypothesized that goniometry and digitizer measures will be valid indicators of the CT measures (r>0.7). NUMBER OF SUBJECTS: Twenty-nine feet with obvious hammer toe deformity (10 female, 19 male; age, 36 17 years) and 31 feet without obvious hammer toe deformity (22 female, 9 male; age, 29 8 years) were tested. MATERIALS/METHODS: Measures were taken 2 times during the same session by an experienced physical therapist using standardized approaches. MTPJ angle was measured in a long sitting position with the ankle position maintained with a wooden board during all measures. Tibial torsion was measured using a goniometer with the participant positioned in prone. 3-D digitizer and CT scan were used to measure the angle of tibial torsion in a long sitting position. ICC2,2 was used to determine intrarater reliability and Pearson correlation coefficients were used to determine association between the different measurement techniques. Means, standard deviations and standard error of the measure (SEM) were cal-

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The ratio of extensor/flexor toe muscle strength for toes 2 to 4 and MTPJ angle were highly correlated (r = 0.71, r = 0.79, r = 0.68). Ankle dorsiflexion and hammer toe angle were negatively correlated for toes 2 to 4 (r = ­0.50, ­0.59, ­0.40). CONCLUSIONS: The ratio of extensor/flexor toe muscle strength in toes 2 to 4 was 2 to 3 times higher in the HT group compared to the NoHT group. The ratio of extensor/flexor toe muscle strength was highly positively correlated with MTPJ angle and ankle dorsiflexion ROM was negatively correlated with MTPJ angle. CLINICAL RELEVANCE: These results provide insight into potential risk factors (muscle imbalance between toe extensor muscles and toe flexor muscles, limited ankle dorsiflexion ROM) for the development of hammer toe deformity. Additional research is needed to determine if strengthening toe flexor muscles and increasing ankle dorsiflexion ROM could potentially reverse or prevent hammer toe deformity.


Midwest Health Strategies, Muncie, IN; Physical Therapy Department, Clarke College, Debuque, IA; Biomechanics Department, Ball State University, Muncie, IN; Central Indiana Orthopedics, Muncie, IN BACKGROUND AND PURPOSE: Isolated subtalar arthrodesis has been used with favorable outcomes for patients experiencing arthritis of the subtalar joint. This procedure is chosen over triple arthrodesis because it preserves movement of the midtarsal joint and allows for compensation during gait and improves function. However, there can be consequences in fusing the subtalar joint which result in pain, altered foot mechanics and gait deviations. The purpose of this case study is to demonstrate the clinical relevance of the Oxford Foot Model (Vicon, Lake Forest, CA, USA) for determining foot mechanics in the analysis of pathomechanics. CASE DESCRIPTION: A 64-year-old female presented for therapy 14-months after right subtalar fusion, performed secondary to severe degenerative joint disease. At initial evaluation, the patient reported experiencing pain in the dorsum of the midfoot which limited walking, and stiffness in the foot after periods of sitting. The patient had been experiencing this pain for 6 months. Objectively, the patient scored 56/80 on the Lower Extremity Functional Scale (LEFS). Motion Analysis testing utilizing the Oxford foot model was conducted to investigate kinematics of the foot and ankle due to the chronic nature of the symptoms. The benefit of using the Oxford Foot Model over the traditional motion analysis models such as the Modified Helen Hayes or the Plug in Gait Model is that it supplies information on the movement of the mid foot and hind foot relative to the tibia. Data analysis revealed the patient had adopted several compensations throughout the kinetic chain of the operative leg to counteract a structural leg length difference. Measurement of leg length using a tape measure revealed a 1 cm difference, with the operative limb shorter than the nonoperative. The most notable compensation noted in the kinematic data was supination of the right foot in effort to lengthen the limb. This was detected when observing the results from the Oxford Foot model. It was hypothesized that this compensatory supination was causing a torque at the midtarsal joint as the subtalar joint was unable to supinate, resulting in pain. The patient was scanned for eSoles custom orthotics (eSoles, LLC, Scottsdale, AZ, USA) with the addition of a 0.8 cm lift to correct the leg length difference and improve gait mechanics. OUTCOMES: Eight weeks after receiving the orthotics the patient scored 71/80 on the LEFS. This change of 15 points on the LEFS indicates a significant clinical improvement. The patient also reported a notable improvement in her comfort with day-to-day activities. DISCUSSION: The Oxford Foot Model is useful when a detailed exploration of foot mechanics is necessary. It reveals biomechanical compensations that would not be apparent with standard static examination techniques or with standard motion capture techniques. Understanding all components of a patient's mechanics is imperative to effectively treat the source of pain.




Department of Physical Therapy, Biokinesiology, and Dentistry, University of Southern California, Los Angeles, CA PURPOSE/HYPOTHESIS: Posterior tibialis tendon dysfunction (PTTD) is a common cause of flat foot posture that often leads to pain and gait deviations. Current literature supports the use of an eccentric intervention for the nonsurgical treatment of tendinopathies. Despite positive clinical outcomes, no study has demonstrated if tibialis posterior tendon adaptations have occurred following an eccentric intervention for tendinopathies. This study examines the morphology and vascularization of the posterior tibialis tendon using ultrasonography before and after a 10week eccentric intervention targeting the degenerated tendon. In addition, the tendon morphology and vascularization and clinical outcomes are compared. NUMBER OF SUBJECTS: 9 females and 1 male with type I or type IIA tibialis posterior tendinopathy were recruited. MATERIALS/METHODS: Subjects participated in a 10-week progressive eccentric tendon loading program accompanied by calf stretching twice per day and wearing shoe orthoses daily. Subjects were followed once a week for 10 weeks to assess the quality of exercise program, resistance progression, and to monitor compliance. Bilateral tendons were imaged by grayscale and Doppler ultrasound at INITIAL and POST evaluations to assess gross and detailed morphology and the presence of neovascularization. The Foot Functional Index (FFI), Physical Activity Scale (PAS), 5-minute walk test, and single heel raise test were completed at INITIAL and POST evaluations. The Global Rating Scale (GRS) was completed only at 6-month follow-up. Paired t tests were used to compare means between data at the 2 time points. The level of significance was P<.05. RESULTS: The FFI was lowered in total, pain, and function from INITIAL to POST and INITIAL to 6-MONTH evaluations (all at P<.05). The number of single heel raises increased significantly on the involved side from INITIAL to POST evaluations (P = .041). The GRS demonstrated minimal clinical improvement in symptoms at 6-month follow-up. Neither gross morphology (ie, tendon thickness) nor detailed morphology (ie, fibril organization) changed as a result of the intervention. Tendons exhibiting neovascularization (6/10) at entry into the study retained signs of neovascularization at the completion of the intervention. CONCLUSIONS: Participation in a 10-week eccentric program for PTTD demonstrated significant clinical improvements as assessed by FFI, single heel raises, and GRS. These clinical improvements were not accompanied by changes in tendon morphology and neovascularization. CLINICAL RELEVANCE: Exercise, orthoses, tibialis posterior, ultrasound imaging.



Northwestern University, Chicago, IL; Paracelsus Medical University, Salzburg, Austria PURPOSE/HYPOTHESIS: In persons with knee OA, physical activity may add to general well-being, reduce the impact of comorbidity, and help to prevent disability. However, there is a concern that certain weight bearing activities may accelerate OA progression. Studies of summary measures of physical activity provide little evidence of deleterious effect of activity

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on risk of incident radiographic OA. Little is known about effect on OA progression, the impact of specific tasks, and on progression by MRIbased measures of cartilage loss. We examined the relationship between current performance of specific tasks at baseline and baseline-to-2-year loss in each knee cartilage plate. NUMBER OF SUBJECTS: Three hundred eighteen knees from 183 persons. MATERIALS/METHODS: Persons with knee OA (by definite osteophytes) recruited from the community were asked, at baseline, whether they perform housework, and, nearly every day: bending at waist ( 2 hours); walking ( 2 hours); walking on rough or uneven ground ( 2 hours); standing ( 2 hours); kneeling ( 30 minutes); lifting/moving objects greater than or equal to 10 lb; climbing up or down greater than or equal to 10 flights of stairs. Knee articular cartilage was quantified at baseline and 2 years using axial and coronal SPGR images acquired at 1.5 or 3.0 T. Subchondral bone area and cartilage surface were segmented for the patella, medial and lateral tibia, and medial and lateral weight bearing femoral condyle. Baseline and 2-year scans were assessed together with the reader blind to order. Cartilage volume was quantified using proprietary software. Progression was defined as loss greater than 2 × precision error, specific to measure and plate (Eckstein 2005). Those processing physical activity data and cartilage outcome images were blinded to each others data. In analyses, logistic regression with generalized estimating equations (GEE) was used adjusting for age, gender, and BMI. RESULTS: The sample included 318 knees from 183 persons (66 years, BMI 30, 77% women). Too few were kneeling or walking on uneven ground to assess these activities. There was no elevation in the odds of cartilage volume loss over the next 2 years in the knees of persons performing the given physical tasks. There was a significant protective effect for housework and walking greater than or equal to 2 hours in the weight-bearing femoral region. Results were similar for the lateral surfaces and for specific PASE (Physical Activity Scale for the Elderly) items, and for cartilage thickness loss. CONCLUSIONS: In sum, we found no evidence that these physical tasks were associated with a greater likelihood of cartilage volume loss in the surfaces examined: medial or lateral tibia, medial or lateral weight bearing femur, or patella. CLINICAL RELEVANCE: The findings of this study suggest that physical tasks, such as housework, walking, and standing, did not accelerate knee OA disease progression. The risk of cartilage loss in certain region may even be reduced with housekeeping and walking. Since being physically active has significant health benefits, people with knee OA should not be discouraged from participating in physical activities. at the initial assessment, interim and discharge from treatment. The relationships between the LEFS physical functioning subscale and NPRS were examined which included interactions with age, gender, time, and physical therapy visits. RESULTS: Of the 131 identified patients with a hip arthroplasty, the average age was 62.3 years (SD, 12.4), range 21-91 years and 52.3% were female. On average, the initial assessment occurred at 63.3 days (SD, 76.7) after surgery. All subjects had an initial and discharge LEFS and NPRS scores. Mean LEFS scores at initial and discharge were 29.78 (SD, 15.9) and 43.3 (SD, 15.9), respectively. Using a 9 point scale to determine minimal clinically important difference (MCID), 65% of the population showed improvement (defined as changers) while 32% had no change. Between changers and nonchangers, the initial assessment (25.7 13.3 versus 37.3 16.6) and discharge LEFS scores (46.3 15.1 versus 39.0 15.1) were significantly (P<.001) different. The Median NPRS value at initial and discharge was 3 and 2, respectively. Only NPRS scores at discharge were significantly different (P<.001) between changers and nonchangers. Age and gender did not determine change status. Changers had significantly more days from the initial physical therapy assessment until discharge (49.8 34 versus 30.0 21.9), more physical therapy visits (9.2 4.2 versus 6.1 4.1), and fewer days from surgery until first physical therapy session (49.8 days 65 versus 77.9 81.7) than nonchangers. CONCLUSIONS: This study provides real-world evidence of the LEFS and NPRS utility in clinical practice which can potentially facilitate decisionmaking in the management of total hip arthroplasty rehabilitation. Factors that may identify those that change include initial LEFS score, time since surgery, and number of visits. Additional research to better understand patient characteristics, long-term outcomes, and optimal treatment options in the management of total hip arthroplasty is warranted. CLINICAL RELEVANCE: The bridging of clinical and research in the utilization of outcome measures.



Physical Therapy, UW-La Crosse, La Crosse, WI BACKGROUND AND PURPOSE: Hip external rotator strength has been measured in regards to lower extremity injury. Most current investigations measure hip rotation strength with the hip in 90° of flexion despite the hip functioning during gait and other daily activities in a more neutral position. The objective of this study is to determine if there are differences in hip rotation isometric strength when the hip is at 90° flexion versus the hip approaching a neutral position at 20° flexion. CASE DESCRIPTION: Thirty-four female and 15 male college students participated in this study. All subjects were in good general health and had no history of hip pathology or surgical intervention. Hip rotation isometric strength was assessed utilizing a handheld dynamometer attached to a strapping system. On the initial testing day, measurements of hip rotation strength were taken with both the hip close to a neutral position (20° of hip flexion) and at 90° of hip flexion. The sequence of testing each extremity was randomized. Each subject performed maximal isometric voluntary contractions of hip external rotators 3 times in each position. The force production of these 3 contractions was averaged. Controls were utilized regarding rest between trials and performance time. Testing using the same protocol and examiner was repeated 5 to 7 days later. Hip external rotator strength was measured in kg by a handheld dynamometer during maximal isometric voluntary contractions of the subjects. A comparison was made of the average force production of the hip external rotators at 20° and 90° of hip flexion. OUTCOMES: A paired-samples t test, with a confidence interval of 95%, compared the average isometric strength of the left and right hip exter-



University of Utah, Salt Lake City, UT PURPOSE/HYPOTHESIS: Outcomes tracking in clinical practice provides a systematic method of monitoring treatment effectiveness and efficiency. Understanding the application of routine outcome measure utilization in a usual-care clinical practice setting may help bridge the gap between evidence based clinical practice and research. The purpose of this study was to evaluate "real-world" outcomes of total hip arthroplasty in a physical therapy outpatient clinic. NUMBER OF SUBJECTS: A total of 131 patients with a hip arthroplasty were identified. MATERIALS/METHODS: Patient data were extracted from the Intermountain Healthcare (IHC) electronic medical record (EMR) physical therapy database from October 1, 2004 through Dec 31, 2007. Patients were greater than or equal to 18 years old with total hip arthroplasty defined by ICD-9 codes. Usual care procedures involved the administration of the numeric pain rating scale (NPRS) and Lower Extremity Function Scale (LEFS)

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nal rotators at 90° and 20° of hip flexion. Each participant's data were averaged across 3 trials. Average strength of the left external rotators was different at 90° of hip flexion (8.60 2.65) than 20° of hip flexion (7.76 2.64) (P<.001). Average strength of the right external rotators was different at 90° of hip flexion (8.90 2.84) than 20° of hip flexion (7.99 2.82) (P<.001). DISCUSSION: Strength differences were observed between the 2 testing positions. Greater isometric strength was found with participants in 90° of hip flexion compared to the more neutral hip position (20° of hip flexion). When evaluating hip strength in clients it may be important to monitor testing position closely.



Hopewell Physical Therapy, Pennington, NJ; Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY; University Medical Center at Princeton, Princeton, NJ BACKGROUND AND PURPOSE: Peripheral nerve blockades are being used with increased frequency during orthopaedic surgical procedures and for postoperative pain management following these procedures. These anesthetic interventions have increased in popularity over recent years due to the decreased risk involved when compared to general anesthetics, the decreased need for narcotic pain medication following surgery, and the limited side effects. Though the efficacy of these procedures has been established successfully for analgesia, there is little research demonstrating the potential complications and effect on nerve function following their use, specifically the potential for nerve injury leading to muscular dysfunction and sensory deficits. CASE DESCRIPTION: A 28-year-old female underwent left knee lateral meniscal transplantation. Epidural anesthesia was used perioperatively and a peripheral femoral nerve block was performed for postoperative pain management. The patient began rehabilitation on postop day 1 and proceeded with physical therapy as per the surgeon's rehabilitation protocol. At 3 months postoperatively quadriceps dysfunction was discovered. A complete neurological evaluation including concentric needle electromyography (EMG) and nerve conduction studies were then performed at 3 months postoperatively and retested at 8 months postoperatively. Neuromuscular electrical stimulation, a specific strength and stretching program, patella taping, bracing and nutritional supplementation were all used as regular intervention throughout rehabilitation and following the discovery of partial left femoral nerve dysfunction. OUTCOMES: Despite a comprehensive rehabilitation program the patient failed to regain full function of the left quadriceps muscle. Additionally, there were persistent deficits in sensory function along the femoral and saphenous nerve distributions. At 1 year postoperatively the patient had regained full active range of motion in the left knee, manual muscle testing of the left lower extremity demonstrated normal strength despite EMG and functional deficits, and the patient continued to experience symptoms and demonstrate functional limitations secondary to lateral patellar instability. DISCUSSION: By 10 weeks after lateral meniscus transplantation it was apparent on exam that there was latency in a portion of the left femoral nerve. Differential diagnosis would suggest the dysfunction could have been instigated my multiple means, including but not limited to: knee joint effusion/edema, tourniquet, epidural catheter, or peripheral femoral nerve block. Diagnostic testing and physical exam suggest the cause to be the peripheral nerve block. The importance of specific strength and sensory testing is emphasized in this case; however, this case also demonstrates a notable deficiency in the specificity of manual muscle testing to measure the partial dysfunction of the quadriceps muscle.



Regis University Manual Therapy Fellowship Program, Orthopaedic Physical Therapy Services, Inc, Wellesley, MA BACKGROUND AND PURPOSE: Surgical decompression or neurectomies are common interventions in the treatment of groin and medial thigh pain of neural origin. Nerve entrapment syndromes of the genitofemoral and ilioinguinal nerves are reported to occur in 0.5% to 2% of all laparoscopic herniorrhaphies. Conservative management for nerve entrapment syndromes of the lower extremity includes rest, cryotherapy and, transcutaneous electrical nerve stimulation. The use of manual physical therapy in treating a nerve entrapment syndrome of the anterior-medial thigh has not been addressed within current literature. CASE DESCRIPTION: A 39-year-old male presented in a direct access setting without physician referral with a 1.5-year history of constant right groin pain with paresthesia and intermittent medial thigh paresthesia. Symptoms began post abdominal hernia repair with a mesh graft. Prior treatment with nonsteroidal anti-inflammatory medications and cortisone injection were unsuccessful. Recurrent hernia was ruled out through imaging studies. A constant ache with paresthesia was reported within the femoral triangle and proximal 2/3 of the medial thigh. This increased with hip extension, sitting with the right leg crossed over the left, trunk flexion with sitting, and right sidelying. Objective examination elicited symptom reproduction and hypomobility with FABER test, marked tenderness, palpable fibrosis, and reproduction of symptoms within iliopsoas, pectineus, and adductor magnus; and decreased short axis hip distraction. A provisional diagnosis of genitofemoral and ilioinguinal nerve entrapment syndrome was made. The primary focus of treatment was to increase soft tissue extensibility and hip capsular mobility to decrease pain during daily functional activities and avoid scheduled surgery. The patient was treated for 4 sessions with soft tissue mobilization to the involved tissues and nonthrust hip joint mobilization. The patient was also provided a specific therapeutic exercise to increase adductor, iliopsoas, and hip capsule length and extensibility. The outcome measures used were the Numeric Pain Rating Scale (NPRS), a repeat pain diagram, and the Global Rating of Change (GROC). OUTCOMES: After 2 visits, the patient reported a 50% decrease in his NPRS. After 4 treatments, the NPRS improved from a 8/10 to a 0/10 and the GROC was "a great deal better." Improvements of pain, paresthesia, and function were maintained at 3 and 12 months. Scheduled surgical intervention was cancelled. DISCUSSION: This case study demonstrates the resolution of symptoms consistent with a nerve entrapment syndrome of the genitofemoral and ilioinguinal nerves post laparoscopic herniorrpaphy. Manual physical therapy techniques were utilized to increase neural mobility though improving surrounding soft tissue extensibility and mobility. Based on the results obtained with this patient, a manual physical therapy approach may be considered prior to more invasive surgical options for patients with genitofemoral and ilioinguinal nerve entrapment syndromes.



Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA; Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA PURPOSE/HYPOTHESIS: Abnormal femoral torsion has been linked to osteoarthritis in the knee as well as patellofemoral pain. Computed tomography (CT) has been considered to be the gold standard in the accurate measurement of femoral torsion. More recently, magnetic resonance (MR) imaging has been used and shown to have many advantages over

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CT, including improved visualization of the femoral neck axis. However, it is costly and often unavailable for use in clinical settings. Ultrasound is a noninvasive, clinically accessible method that can be used for assessment of bone morphology such as femoral torsion. The specific aim of this study is to determine the reliability and concurrent validity of ultrasound to measure femoral torsion using MR imaging as a reference. NUMBER OF SUBJECTS: Seventeen females and 3 males (mean age, 26.9 3.9 years; mean body height, 169.2 8.1 cm; mean body weight, 64.1 9.1 kg). MATERIALS/METHODS: Femoral torsion measurements were taken using ultrasound and magnetic resonance imaging. T1-weighted axial oblique images of the femoral neck and epicondylar axis were acquired using a 1.5 T MR system. To determine femoral anteversion from the MR images, the angle formed by the femoral neck axis and the horizontal field of view was compared to the angle formed by the femoral condyle axis and the horizontal field of view. Ultrasound measurements were then taken using a linear transducer 4.5 cm in length, operating at 11-MHz frequency and 5-cm depth (Sonoline Antares, Siemens) via the tilting technique described in the literature. The femoral neck was identified and its image was projected horizontally on the screen by tilting the ultrasound transducer. The tilt of the transducer was measured with an attached portable inclinometer and the angle recorded was taken to be the angle of femoral anteversion. To establish reliability of this method on human subjects, 1 examiner imaged 6 subjects and averaged 3 measurements taken during 3 sessions. To determine concurrent validity, 20 subjects were imaged using ultrasound and the degree of femoral torsion measured was compared to anteversion angles determined by MR imaging. RESULTS: The average angles of anteversion were 20.4° 12.1° measured with ultrasound and 19° 11.3° measured with MR imaging. The intraclass correlation coefficient (ICCx,y) for repeated measurements of in vivo femoral torsion determined with ultrasound was 0.98. Reliability (ICC2,1) of MR image analysis was 0.96. The SEM for ultrasound was 2.2° and MRI 1.9°. The concurrent validity between MR imaging and ultrasound (r2) was 0.931 (r = 0.965). CONCLUSIONS: A sonographer trained in the tilting technique was able to reliably measure femoral anteversion. This method has high concurrent validity with in vivo MR imaging. CLINICAL RELEVANCE: Ultrasonography may be utilized when assessment of bony morphology is desired, but MR imaging is not accessible. toe in/toe out angle. Repeated-measures ANOVA, with surgical/nonsurgical side as the repeated factor, were used to compare physical impairments and spatial-temporal parameters of gait. Height and weight were controlled in the analyses when they fit criteria for confounder (associated with dependent and independent variables) RESULTS: Twenty-two subjects (51%) had the surgery done on the left knee. The nonsurgical leg had stronger quadriceps muscles than the surgical (136 48.7 and 75 31 Nm, P = .011). The single-leg stance test time was shorter for the nonsurgical leg (12.4 9.3 and 13.4 10.2 seconds, P = .016). The nonsurgical knee extended more than the surgical (­3.7 4.5° and ­5.4 3.6°; P = .005; larger negative numbers represent flexion contracture). As expected due to the prosthesis limitation, the nonsurgical knee had more flexion than the surgical (134° 12.7° and 123° 9.4°; P<.001). Measures of muscle length were not different between sides. Stance time was longer for the nonsurgical side (0.75 0.07 and 0.74 0.07 seconds, P = .023), whereas swing time was shorter in the nonsurgical side (0.40 0.03 and 0.41 0.03 seconds, P = .010). Step length and toe in/toe out were not different. CONCLUSIONS: Subjects at least 2 months after TKA had significant quadriceps weakness in the surgical side, which concur with findings in the literature. The surgical knee presented deficits in extension range of motion. The unexpected shorter time during single-leg stance on the nonsurgical side may be explained by advanced knee osteoarthritis. Subjects spent shorter time during the weight bearing phase of gait in the surgical side. CLINICAL RELEVANCE: Some of these asymmetries are reported for the first time at this timeframe after TKA. This is valuable information to guide future studies on intervention approaches to restore these asymmetries.



Physical Therapy, University of Delaware, Newark, DE BACKGROUND AND PURPOSE: Knee dislocations are rare and due to stability and vascularity compromise, they are often treated with surgical reconstruction. The purpose of this case is to describe a non operative treatment approach used to help restore higher level function in a very active woman following a traumatic knee dislocation. CASE DESCRIPTION: A 58-year-old female was evaluated 10 days after a knee dislocation with MRI evidence of complete left ACL, PCL, and MCL tears. She had slightly limited inferior patella mobility, a good superior glide with a quadriceps set and no lag with a straight leg raise. She had full knee extension range and 81° knee flexion compared to 145° on the opposite side. Her knee effusion was large with lower extremity edema, and positive special tests for: Lachman, Posterior Sag Sign, Quad Activating Test, and Varus Stress Test. Manual muscle testing was painful for quadriceps and hamstring testing however she was able to perform a Maximum Voluntary Isometric Contraction at 45° that showed a strength deficit of 44% (240 Newtons versus 430 Newtons). The Knee Outcome Survey ADL Scale (KOS-ADLS) Score was 39% and a global knee function (0%100%) rating of 20%. She had pain from 1/10 while in her immobilizer and 10/10 with twisting or giving way episodes. Her goals were to return to her part time job cooking, hiking and scuba diving. She was seen for 33 visits over a 5-month period. Slow rehabilitation focused on range of motion and open kinetic chain exercises; patella mobilizations, manual stretching, quadriceps sets, straight leg raises, NMES (Snyder-Mackler, 1995), NMES at home, and weight bearing as tolerated while in an immobilizer for 10 weeks. After those 10 weeks she began weight bearing with knee flexion. At this time her exercises were increased to short arc quads, long arc quads, mini wall squats, lateral step-ups/-downs, standing terminal knee extensions, modified perturbation training (Fitzgerald, 2000), gait training focusing on good quad control using her full range of motion and activities of daily living focusing on minimizing compensation pat-



Physical Therapy, University of Pittsburgh, Pittsburgh, PA PURPOSE/HYPOTHESIS: There is limited information about differences on physical impairments and spatial-temporal parameters of gait in patients after total knee arthroplasty (TKA). Aim: To compare the physical impairments and spatial-temporal parameters of gait between the surgical and nonsurgical legs of individuals post-TKA. NUMBER OF SUBJECTS: Convenience sample of 43 subjects (70% female, means for age and BMI 68 8 and 31 5 respectively) who underwent unilateral TKA 2 to 6 months prior to the study. Subjects have received an average of 19 7 sessions of physical therapy. MATERIALS/METHODS: Cross-sectional study. Measures of physical impairments included muscles strength, muscle length, balance, and knee motion. Quadriceps muscle strength was measured isometrically using an isokinetic dynamometer. Hamstrings muscles length was measured using an inclinometer. A standard goniometer was used to measure gastrocnemius length, soleus length, and the range of passive knee flexion and extension. Balance was measured by the single-leg stance test, and the time of 3 trials was averaged. Spatial-temporal parameters of gait were measured at the self-selected speed using the GAITRite walkway (CIR Systems Inc). Parameters included step length, stance time, swing time, and

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terns with sitting to standing and stair climbing activities. She was progressed using the soreness rules (Axe, 1996) that allowed her to increase her exercises or activities if she had no increase in pain or swelling. OUTCOMES: At discharge (33 visits over 5 months), she had no effusion, full ROM, no pain, full patellar mobility, and a quadriceps index of 100%. She rated herself globally at 99% compared to 20% and her KOS-ADLS score was 83% versus 39%. She was able to return to work at 100% and resume hiking, scuba diving and her previously active lifestyle. DISCUSSION: Knee dislocations often result in a complex surgical procedure followed by slow extensive rehabilitation. In this case, adhering to healing time frames and progressive physical therapy interventions helped a highly active individual with a less than optimistic prognosis return to an active life style nonoperatively.


Touro College, New York, NY PURPOSE/HYPOTHESIS: The purpose of this randomized controlled trial was to determine if a standardized taping technique that combines 3 aspects of McConnell tape; medial pull, medial tilt and medial rotation, to be known as "Combined" taping, will be as effective as the involved process of McConnell taping in reducing pain and increasing function in subjects with patellofemoral pain syndrome (PFPS). NUMBER OF SUBJECTS: Twenty subjects diagnosed with PFPS were randomized into 2 groups; McConnell group (control group) n = 10, Combined group (experimental group) n = 10. MATERIALS/METHODS: The study was a single blinded, 2 group pretest post test, randomized controlled trial. Each subject ascended and descended 4 steps and then reported pain on a 100-mm visual analogue scale (VAS) and completed the Lower Extremity Functional Scale (LEFS) questionnaire. Then, after receiving a standard physical therapy session, were either taped using the McConnell method or the Combined method. Each subject then ascended and descended the same 4 stairs again and repeated the VAS and LEFS. RESULTS: There was a statistical increase in function for both groups as measured on the LEFS. However, there was a significant difference between the groups (P = .001); while the McConnell mean LEFS score increased 5.7 points on the 80 point scale, from 47.4 to 53.1 (P = .017), the Combined group had a considerably higher mean increase on the LEFS, 18 points, from 54.0 to 72.0 (P = .008). For pain there was a significant difference between the groups (P = .001); The McConnell group, had a statistically insignificant 13 mm reduction of mean pain as measured on the VAS (P = .086) compared to the statistically significant reduction of 31.9 mm on the VAS (P = .005) for the Combined group. CONCLUSIONS: Combined tape is significantly more effective than McConnell tape in reducing pain and increasing function in individuals with PFPS. CLINICAL RELEVANCE: Combined tape should be used in conjunction with a standard physical therapy treatment program to decrease pain and increase function. Furthermore, the application of Combined tape takes a fraction of the time compared to McConnell tape and is applied simply and identically in each case, regardless of patellar dysfunction. This will increase the time a physical therapist can spend on manual therapy and exercise prescription during a physical therapy session.




Rehabilitation, Hospital for Special Surgery, New York, NY PURPOSE/HYPOTHESIS: To establish the preoperative demographic profile and functional outcomes, in the acute post operative phase, for patients undergoing primary hip resurfacing. NUMBER OF SUBJECTS: A retrospective normative analysis of 230 primary hip resurfacing patient data forms collected from January 2007 to April 2008. MATERIALS/METHODS: Data forms have been tested for reliability and validity at the Hospital for Special Surgery. The forms included demographics of age, sex, and primary diagnosis as well as preoperative information regarding average daily ambulation distance and utilization of an ambulation assistive device. Incorporated on the data forms were time frames for reaching functional milestones of transfers unassisted, ambulation with crutches unassisted and ability to ascend and descend steps unassisted. Finally, the data form included the patients discharge destination of home versus rehabilitation. These data forms were filled out by the treating physical therapist upon the patient's initial evaluation and updated daily after every treatment session until the patient was discharged from physical therapy. All patients analyzed underwent surgery by the same physician and all received the same preoperative education and postoperative guidelines. RESULTS: When analyzed, the data illustrated that the average patient was 50.9 years old, 96.9% of the patient's primary diagnosis was osteoarthritis, and 70% of the patients were male. Preoperative statistics show that 55.2% of the patients were ambulating greater than 10 city blocks on average per day, 8.5% were ambulating 6-10 blocks per day, 21.7% were ambulating 1 to 5 city blocks per day and only 0.6% were ambulating less than 1 block per day. 87.1% of the patients were not using any assistive device for ambulation prior to surgery. Throughout the patients stay in the hospital 90.2% of the patients achieved unassisted transfers in 2.49 days, 86.5% of the patients achieved ambulation with crutches unassisted in 2.75 days, 93.25% of the patients achieved ascending and descending steps unassisted in 2.8 days. The average length of stay was 3.13 days with 91.4% of the patients being discharged directly home. CONCLUSIONS: Through our data analysis we have found that statistically, a primary hip resurfacing patient fits the characteristics of a male, close to 50 years of age, with a primary diagnosis of osteoarthritis. This patient is a community ambulator who does not utilize an ambulation assistive device preoperatively. A typical hip resurfacing patient will be independent with transfers in 2.49 days, ambulating with crutches independently in 2.75 days and able to ascend and descend steps independently in 2.8 days. This patient's average length of stay is 3.13 days in the acute care setting and will be expected to discharge directly home. CLINICAL RELEVANCE: The establishment of a typical hip resurfacing postoperative functional timetable is beneficial to clinicians when creating goals in the acute care setting.



Kaiser Permanente Southern California Physical Therapy Residency and Fellowships, Kaiser Permanente West Los Angeles, West Los Angeles, CA BACKGROUND AND PURPOSE: The purpose of the case study is to describe the clinical decision process related to the treatment of limited knee flexion with lateral knee pain using a calcaneal inversion in a patient that was 9 months post-ACL reconstruction using a hamstring graft. CASE DESCRIPTION: The patient is a 29-year-old female dancer that suffered a rupture of her right ACL and medial meniscus tear on 5/5/07. She underwent ACL reconstruction on 8/17/07. She previously had 39 PT visits for strengthening, ROM and functional training. She was issued a JAS splint for range of motion during this period of time. She was discharged from care on 2/01/08 due to change of insurance. ROM at discharge was 131° AROM and 140° PROM, with pain 7-8/10 on a VAS. She was referred back to PT on 4/24/08 with a referral of postop knee stiffness secondary to scar tissue. OUTCOMES: At evaluation her AROM was 125° and PROM of 135° with

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pain 8/10 on the lateral knee. Assessment indicated minor hypomobility of the tibial-femoral joint with posterior glide, limited medial glide of the PFJ and proximal tibial-fib joint anterior glide when compared to the opposite side. Her primary complaint was an inability to perform deep squats. She was treated for 5 visits over 6 weeks. Treatment included posterior glides of the tibia, patellar mobs, MWM for flexion of the tibial-femoral joint, MWM of the proximal Tibial-fibular joint, and mobilization of the proximal tibial-fibular joint, and home stretching program. At her sixth visit, she presented with lateral knee pain 8/10 with 135° PROM. Treatment performed was an inversion mobilization of the calcaneus to promote inferior glide of the fibula, as described by Maitland. After mobilization, she had knee flexion PROM of 149° with 0/10 lateral knee pain. She was able to perform a deep squat with pain 0/10 post mobilization. DISCUSSION: Lateral knee pain and limited knee flexion are common presentations in the clinic. Treatment of the tibial femoral joint, PFJ, and anterior glide of the proximal tibial femoral joints are well documented treatments for limited knee flexion and lateral knee pain among manual therapist. Little evidence exists in the literature to quantify superior and inferior glide of the fibula with knee motion, but several authors acknowledge the motion exist. Maitland indicates that superior and inferior glide of the fibula should be part of a knee examination. A search of the literature showed no published cases that describe a case of treatment for superior subluxation of the fibula for lateral knee pain or limited flexion ROM. This case demonstrates the possibility that a superior subluxation of the fibula may be a clinical pathology and treatment with an inversion mobilization of the calcaneus to promote inferior glide of the fibula may be indicated. Assessment and treatment for inferior or superior subluxation of the fibula should be considered when a patient with lateral knee pain or limited knee flexion ROM does not respond to typical treatment strategies. stair climbing test between groups (P>.1); however persons in the staged unilateral TKA group were slower on the 6-minute walk at 6 months (P = .05), 1 year (P = .04) and 2 years (P = .038) after TKA, when compared to the simultaneous bilateral group. There were no differences in quadriceps strength (P>.1); however, the quadriceps index (operated/nonoperated strength) was asymmetrical 1 year after the first TKA in persons in the staged group (P = .031) compared to persons with simultaneous bilateral TKA. CONCLUSIONS: The most notable difference between groups were slower 6-minute walk distances in persons with staged TKA. The 6-minute walk is one of the most responsive tests in persons after TKA; these results show that despite the lack of differences in strength and self-report, there may be differences in persons that stage their TKA, rather than have simultaneous TKA. These preliminary data make conclusions difficult, as there are so few numbers in both groups. Other factors not accounted for here were involved in the surgical decision to have knees replaced simultaneously, such as health of the patient, and the surgical risk involved. CLINICAL RELEVANCE: There may be reduced function in persons that undergo staged TKA procedures, due to undergoing the recovery from surgery and rehabilitation twice.



Physical Therapy Program, Dept of Health Professions, University of Wisconsin - La Crosse, La Crosse, WI PURPOSE/HYPOTHESIS: Authoritative descriptions of popliteus fall into 2 camps: one that limits insertion to the lateral femoral condyle, and the other that includes an insertion onto the lateral meniscus and knee joint capsule. Upon review of the literature on the development of some clinical procedures involving the knee it appears that only the insertion onto the lateral femoral condyle was considered. In this description the popliteus originates on the posteromedial aspect of the tibia, extending behind the knee joint, and then attaches to the inferolateral aspect of the lateral femoral condyle. Our investigations of this muscle show that there are several more potentially relevant, and common, variants. This study describes these variants and speculates on their potential influence in interpreting results of common clinical tests and procedures. NUMBER OF SUBJECTS: Data were drawn from the 24 cadavers used as part of the gross anatomy course at the University of Wisconsin-La Crosse. MATERIALS/METHODS: Close investigations of the popliteus muscle noted differences in bony attachments, associations with components of the knee joint capsule, intrinsic components of knee joint, and structural variation of the muscle's architecture. RESULTS: Nine variants were identified. Each variant was categorized as to limb side and involvement with intrinsic components of the knee joint. Frequency counts are provided for each variant. CONCLUSIONS: Although descriptions of each of the identified variants have appeared in the literature, reported frequency estimates of these variations differ. The literature fails to identify the potential clinical significance of such variations. A survey of clinical sources failed to identify sensitivity to these muscular variations when determining and describing diagnostic tests and procedures. CLINICAL RELEVANCE: The results show that popliteus attaches to the lateral meniscus in about half of all subjects. Through this attachment, the popliteus might serve to protect the lateral meniscus by pulling it posteriorly during knee flexion. The original descriptions of McMurray's and Apley's Tests fail to mention the role that popliteus may have in protecting the lateral meniscus. All of the authorities that describe the protective mechanism of popliteus on the lateral meniscus imply it occurs with 100% frequency. Our data demonstrates that the reality must lie somewhere between these 2 extremes. Other described variants may play a role in determining the proper interpretation of clinical tests such as the



Department of Physical Therapy, University of Delaware, Newark, DE PURPOSE/HYPOTHESIS: Persons who undergo unilateral total knee arthroplasty (TKA) often have bilateral knee osteoarthritis. However, simultaneous bilateral TKA are less commonly performed, due to the surgical risks. The purpose of this investigation was to compare outcomes 2 years after TKA of persons with simultaneous bilateral TKA compared to persons who had staged TKA at a minimum of 1 year apart. We hypothesized that persons with the staged TKA would be weaker and slower on tests of function, and have lower self-report scores at 1 year after the first TKA of the staged procedure. NUMBER OF SUBJECTS: 10 subjects after simultaneous bilateral TKA were compared to 10 subjects after staged bilateral TKA. MATERIALS/METHODS: Persons with the staged TKA had the second knee replaced 1 year after the first TKA. At 6 months, 1 year and 2 years after TKA, the following data were collected: Knee Outcome Survey and the Global Rating Scale self-report, a stair climbing test, the 6-minute walk test, and quadriceps strength was tested isometrically. Repeated-measures ANOVA (time) was used to compare changes over time, and post hoc paired t tests were used to identify the time period of significance. Nonparametric Mann-Whitney U test was used to compare groups. RESULTS: In both groups, there was no improvement over time on the KOS or GRS (P>.05). Results of the stair climbing test and the 6-minute walk test were stable with time (P>.05) in both groups. There was no difference in strength between limbs in both groups (P>.05). However, when the groups are compared, the GRS is significantly lower in persons with the staged unilateral TKA at 1 and 2 years after surgery (P<.04) compared to simultaneous TKA group. There was no difference in the

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recurvatum test. A full understanding of the mechanisms of the popliteus within the knee joint does not exist. Clinical assessment and treatment of the knee may be improved by gaining a better understanding of the functional variations of popliteus. positioning in patellofemoral pain patients have not been unanimous. This may be the lack of deep exploration of patellofemoral alignment subtypes. This study aimed to investigate the effects of quadriceps contraction on the subtypes of patellar alignment. NUMBER OF SUBJECTS: Seventy-eight PFPS patients. MATERIALS/METHODS: Patellar lateral condyle index (PLCI) and patellar tilt angle (PTA) were measured on axial CT images of PFPS knees in extension, with quadriceps relaxed and contracted. A comparison was undertaken between 78 painful knees (Group 1) and 31 pain free knees (Group 2). Group 1 was subgrouped as type 1 to type 4 for laterally displaced, laterally displaced and tilted, laterally tilted, and neither, respectively. RESULTS: Quadriceps contraction rendered significant increase in PLCI in all subtypes (P<.01). However, there was no difference among 4 subtypes. With quadriceps contraction, PTA decreased in Group 2 (P<.05) and type 3 patellae of Group 1 (P<.01). Post hoc analysis revealed no difference in PTA change between groups, but a significant difference between type 3 and type 1 (P = .004). Both measurements of type 4 with quadriceps contraction were the least among 4 subtypes. CONCLUSIONS: Quadriceps contraction exerted differing effects on the patellae in different patellofemoral alignment subtypes. As quadriceps contraction decreased patella tilting in knees of type III patellae, quadriceps strengthening might be more in favor in this kind of patients. A further study of the therapeutic effect of quadriceps strengthening on respective patellofemoral alignment subtypes is needed. CLINICAL RELEVANCE: The favorable outcome of the quadriceps strengthening regime would not be through the correction of the varied patellar misalignments, as reflected by the uniform aggravation of patellar displacement in both symptomatic and asymptomatic knees.



Community Medicine and Rehabilitation, Umeå University, Umeå, Sweden PURPOSE/HYPOTHESIS: Patellofemoral pain (PFP) is characterized by intermittent periods of pain and the present study addresses whether longterm pain leads to compensatory movement strategies that remain even when acute pain is absent. The objective of the present study was to evaluate whether lower extremity kinematics are altered in young women with PFP during stair descent in a period when the person is not significantly bothered with pain. The hypotheses were that individuals with PFP would walk with: (1) reduced knee flexion compensated by greater hip and ankle joint angular displacement; (2) slower cadence and lower knee angular velocity; and (3) reduced movement smoothness. NUMBER OF SUBJECTS: Seventeen women (age, 18-40 years) who had suffered PFP for at least 1 year (11 bilateral, 6 with unilateral) and 17 matched healthy controls. MATERIALS/METHODS: Participants performed a stair descending task at a self selected pace in a laboratory setting. Three dimensional motions were captured (Pro Reflex, Qualisys, Gothenburg, Sweden) and kinematic analyses performed for lower extremity joint angles and angle velocities (C-motion, Maryland, USA). Two dimensional geometric models were constructed to normalize kinematic data for subjects with varying anthropometrics when negotiating stairs of fixed proportions. Trigonometric calculations were used to analyze and compare joint angles between groups. Independent t test was used to determine group differences (P<.05). RESULTS: There were minor differences in movement patterns between groups. Knee flexion did not differ between groups, but knee joint angular velocity in the stance leg at foot contact was lower in the PFP group, 132.2°/s versus 164.0°/s in the control group (P = .007). The 2 dimensional model showed greater plantar flexion in the swing leg in preparation for foot placement in PFP compared to in the control group (17.3 versus 15.4; P = .036), and the movement trajectory tended to be jerkier in the PFP group. CONCLUSIONS: The results suggest that an altered stair descent strategy in the PFP group may remain also in the absence of acute pain. The biomechanical interpretation presumes that the movement strategy is aimed to reduce knee joint loading by lower impact forces and thus less knee joint moments. CLINICAL RELEVANCE: The present results suggest that in PFP attention should be paid not exclusively to the affected knee, but to the entire kinetic chain for both limbs. Our study also indicates that it is important to consider anthropometrics in relation to environmental constraints and that the motor control strategies are modified and preserved according to the clinical conditions.



University of Evansville, Evansville, IN PURPOSE/HYPOTHESIS: Females are 2 to 3 times more likely to develop knee osteoarthritis (OA) than males and have also been observed to develop the disease earlier in life; however, little research has examined why males and females have a differential progression of knee OA. One way to assess knee OA progression is through the analysis of the peak knee abduction moment during gait. Current research suggests that females with knee OA exhibit altered gait mechanics compared to males with knee OA, who demonstrate gait mechanics closer to the asymptomatic population. Thus, changes in gait mechanics across the lifespan may be associated with the differential progression of knee OA between genders. The purpose of this study is to examine the interaction of gender and age on discrete variables measured during gait that have previously been associated with knee OA progression. NUMBER OF SUBJECTS: Twenty individuals (10 male and 10 female) between the ages of 18 to 22 years and 5 individuals (3 male and 2 female) between the ages of 36 to 40 years volunteered to participate in the study. MATERIALS/METHODS: All participants underwent a gait analysis with the subjects ambulating at a self-selected walking speed. Data collected during the gait analysis were reduced to calculate joint kinematics and kinetics. Specific variables of interest were the peak knee and hip internal joint moments in the frontal plane and the peak frontal plane knee and hip joint angles. The data were to be analyzed utilizing a 2-way ANOVA (gender-by-age group) with a P<.05 to determine significant differences; however, due to the small sample size of the older population the data were assessed by analyzing the percentage of change. RESULTS: Between the ages of 18 to 22 and 36 to 40 years, the female group exhibited a 38% increase in the peak knee abduction moment compared to only a 13% increase in the male group. Additionally, the females exhibited a 19% increase in the peak hip abduction moment com-



School and Graduate Institute of Physical Therapy, Taipei, Taiwan; Department of Orthopaedics, West Garden Hospital, Taipei, Taiwan; Department of Orthopaedics, En Chu Kong Hospital, Taipei, Taiwan; Department of Neurology, University of California Los Angeles, Los Angeles, CA PURPOSE/HYPOTHESIS: The effects of quadriceps contraction on patellar

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pared to a 9% increase in the males. In averaging across the age groups, the females exhibited a 23% higher peak hip abduction moment. Regarding the peak joint angles, males exhibited a 4° increase in the amount of peak knee adduction from the ages of 18 to 22 and 36 to 40 years while there was only a minimal change in the females. There were minimal changes in the amount of peak hip adduction for both genders between the age groups. CONCLUSIONS: Females exhibit a greater percentage increase in the peak knee and peak hip adduction moment compared to males between the ages of 18 to 22 and 36 to 40 years, which may provide a potential mechanism behind the earlier onset of knee OA in females. CLINICAL RELEVANCE: In light of this finding, females may benefit from early, conservative interventions which have been suggested to slow the progression of knee OA and potentially reduce the incidence of the early onset of the disease. Additionally, it may be of interest to examine how gait mechanics change in females during female specific life events that may cause adaptations in gait mechanics that could lead to a greater risk for the early onset of knee OA. to quickly identify atypical tibial torsion and determine if it is clinically relevant to an individual patient's function.



Biomechanics and Movement Sciences, University of Delaware, Newark, DE; Physical Therapy, University of Delaware, Newark, DE PURPOSE/HYPOTHESIS: Buckling is common in people with knee osteoarthritis (OA) and buckling occurs most commonly during stair climbing and when changing direction. High level tasks like changing direction challenge the neuromuscular system and can be used to study the control strategies. The aim of this study was to analyze the neuromuscular control of the OA knee during normal walking and a sidestep activity. NUMBER OF SUBJECTS: Six with knee OA and 6 controls from an ongoing study. MATERIALS/METHODS: For 10 trials each, subjects walked straight ahead and then they stepped laterally, away from the involved extremity. Kinematic, kinetic data and EMG were captured from the medial (M) and lateral (L) quadriceps (Q), hamstrings (H) and gastrocnemeii (G). The EMG data were analyzed over 3 intervals: Preactivation (PA); loading response (LR) and Midstance (MS). Statistical analysis included a 2-way repeated-measures ANOVA, post hoc paired t tests with correction for multiple comparisons. The alpha was set to 0.10 for EMG and 0.05 for all other variables. RESULTS: In LR knee flexion excursions were lower in the OA group during level walking (P = .035) but not during the side step (P = .102). Knee adduction moments were higher in the OA group only during level walking (P = .039). Knee extension excursions in MS were lower during both activities (level walking, P = .004; side-step, P = .033). In PA phase, OA subjects used higher MH activation (P = .077) during level walking and higher MH (P = .075) and LH (P = .093) activation during sidesteps. In LR, OA subjects had higher activation in the LG (P = .043), MG (P = .069), LH (P = .062), and VL (P = .075) muscles during level walking but only the MH (P = .049) during side steps. In MS, during level walking VM (P = .092) activity was higher in the OA subjects whereas during the step trials muscle activation was higher in the OA group in the LH (P = .035) and MH (P = .029). CONCLUSIONS: The results show that OA subjects used different hamstring activity during preactivation in both activities compared to controls which may represent an attempt to stabilize the joint by increasing stiffness in the knee muscles. However, the lack of difference between the OA and control subjects is likely due to the small number of subjects included here however it may also indicate that the side steps were more challenging than level walking for both groups making differences more difficult to detect. Overall, the OA subjects used their hamstrings more in both activities across all intervals which may be associated with the lesser flexion and extension excursions that were also evident. CLINICAL RELEVANCE: Increase in muscle activations with lower joint excursions seen in the OA group in both activities could be a compensation for buckling and could lead to higher cartilage loading and rapid progression. Inclusion of more subjects will provide more insight into the effect of buckling on the control of the knee in OA during different activities.



Department of Physical Therapy, University of Wisconsin Hospital and Clinics, Madison, WI; Program of Physical Therapy, University of St Augustine for Health Sciences, St Augustine, FL PURPOSE/HYPOTHESIS: A reliable clinical method to measure tibial torsion is necessary for physical therapists to identify this structural impairment in order to assist in clinical decision making regarding interventions. Reliability for measurement has not been established. This study investigated the intrarater and interrater reliability of 3 clinical tests that measure tibial torsion. The hypothesis was that the clinical tests would have good intrarater reliability but poor interrater reliability. NUMBER OF SUBJECTS: Thirty-four adult volunteers, recruited from the University of St Augustine for Health Sciences students, faculty and staff (26 females, 13 males; age range, 23-64 years). MATERIALS/METHODS: This reliability study was a single-factor repeated measures design with 1 testing occasion over a period of 1 month. The subjects received random assignment of tester order and testing method order. Three physical therapists with at least 7 years of outpatient orthopedic clinical experience were the testers in the study and were blind to the measurements, using a masked goniometer to measure the angle of tibial torsion, which was read and recorded by a nontester. Three measurements of each testing method (seated, supine and prone) were obtained for each subject's lower extremity. RESULTS: The correlation of measures of each tester and between testers was analyzed using ICC2,3. The correlation coefficients will be considered good ( .75), fair (.50-.75) and poor ( .50). The results are: seated method, tester A 0.85, tester B 0.75, tester C 0.84; supine method, tester A 0.95, tester B 0.84, tester C 0.83; prone method, tester A 0.83, tester B 0.78, tester C 0.90; seated method 0.64, supine method 0.72, prone method 0.90. CONCLUSIONS: The intrarater reliability of all 3 testing methods was determined to be good. The interrater reliability of the seated and supine testing methods was fair, the prone method was good. Based on this data, the choice for measuring tibial torsion should be the prone testing method. CLINICAL RELEVANCE: Tibial torsion is a naturally occurring entity, however, an increase or decrease in tibial torsion may contribute to the development of musculoskeletal impairments and pain. A patient's structure when combined with their specific activity may be a factor in their loss of function and inability to participate in social relationships. This study provides evidence for good intrarater reliability of 3 clinical methods that measure tibial torsion and good interrater reliability of the prone testing method. These testing methods may be useful for the physical therapist



Physical Therapy, University of Delaware, Newark, DE PURPOSE/HYPOTHESIS: Individuals 3 months after total knee arthroplasty (TKA) have asymmetry of knee flexion excursion during weight acceptance due to asymmetry of quadriceps strength. Asymmetry of knee flexion excursion persists until 12 months after TKA while quadriceps strength on the operated limb increased. Generally weight acceptance

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requires the quadriceps to work eccentrically which is a more demanding task compared a concentric contraction during midstance. However, there is no report demonstrating asymmetry in midstance after TKA or whether improvements in midstance are better than improvements in weight acceptance based on the task differences for quadriceps. Our hypotheses are that individuals after TKA (1) will also show asymmetry of knee extension excursion during midstance at 3 months after TKA due to greater asymmetry of quadriceps strength, and (2) the knee extension excursion during midstance will improve to achieve gait symmetry along with increased quadriceps strength. NUMBER OF SUBJECTS: Twenty-six patients after TKA for knee osteoarthritis (16 men, 10 women; 62.5 7.7 years old; BMI, 28.4 6.5) were tested at 3 and 12 months after the surgery. MATERIALS/METHODS: Maximum voluntary isometric contraction was tested to measure quadriceps strength. Gait analysis was performed using a 3 dimensional motion analysis system. Sagittal plane knee joint angle was calculated using rigid body analysis. Paired t tests were applied to compare limbs and over time. Pearson Product Moment Correlation was also applied to assess the relationship between knee kinematics and quadriceps strength in each test period. RESULTS: Knee flexion excursion during weight acceptance was significantly decreased on the operated limb compared to the nonoperated limb at both 3 and 12 months (P<.01). Knee extension excursion during midstance was also significantly decreased on the operated limb over time (P<.01). At 12 months after TKA, peak knee flexion during weight acceptance became symmetrical between limbs (P = .693) though peak knee extension during midstance still remained asymmetrical (P = .008). On the other hand, the nonoperated limb was significantly decreased in both knee flexion and extension excursion from 3 to 12 months (WA, P = .027; MS, P = .021). Quadriceps strength significantly improved from 3 to 12 months (64%-13%, P<.01), while it still showed asymmetry between limbs at 12 months after TKA (P = .015). There was no correlation between asymmetry of quadriceps strength and asymmetry of knee excursion during stance except knee flexion excursion at 3 months after TKA as reported previously. CONCLUSIONS: Only peak knee flexion angle during weight acceptance became symmetrical between limbs at 12 months after TKA. They achieved gait symmetry by reducing knee excursion on the nonoperated limb. Both the eccentric contraction task and the concentric contraction task during stance seem difficult for individuals after TKA even 12 months after the surgery. CLINICAL RELEVANCE: This suggested that the nonoperated limb may demonstrate a first sign of asymptomatic osteoarthritis. between sides as the cutpoint for asymmetrical weakness for both HHD and Biodex dynamometry. All isometric Biodex and HHD tests were performed at 60° of knee flexion. RESULTS: Dynamic HHD peak torques were correlated to isokinetic Biodex peak torques (r = 0.69), and isometric HHD peak torques were correlated to isometric Biodex peak torques (r = 0.78). Diagnostic accuracy of dynamic HHD for determination of asymmetrical quadriceps weakness was 0.52 at 10%, 0.58 at 15%, and 0.88 at 20% between limb peak torque differences. Diagnostic accuracy of isometric HHD for determination of asymmetrical quadriceps weakness was 0.60 at 10%, 0.63 at 15%, and 0.85 at 20% between limb peak torque differences. CONCLUSIONS: Dynamic HHD torques correlated moderately with isokinetic Biodex measures of torque and isometric HHD torques correlated highly with isometric Biodex measures of torque. Diagnostic accuracy determinations of the presence or absence of asymmetrical weakness via both dynamic and isometric HHD was poor when using 10 and 15% torque differences on isokinetic and isometric Biodex assessments respectively as the best standard. Diagnostic accuracy of HHD was greater than or equal to 84% when a 20% torque difference was used for both dynamic HHD/isokinetic Biodex and isometric HHD/isometric Biodex comparisons. Most of this improvement in diagnostic accuracy resulted from improved specificity as only 3 of 26 subjects demonstrated weakness greater than or equal to 20%. CLINICAL RELEVANCE: Isometric and dynamic HHD have poor diagnostic accuracy in determining asymmetrical weakness as compared to isometric and isokinetic Biodex determinations of asymmetrical weakness at 10 and 15% differences in side-to-side peak torque output. Both forms of HHD dynamometry may have greater diagnostic accuracy in assessing asymmetric quadriceps weakness when the best standard shows a difference of greater than or equal to 20%. Only 3 subjects had this level of weakness in this study. HHD may be useful in assessing asymmetric quadriceps peak torque production when differences in peak torque output between the weak and stronger limb exceeds 20% on both the HHD and Biodex torque assessments.



Physical Therapy, Massachusetts General Hospital Institute of Health Professions, Boston, MA PURPOSE/HYPOTHESIS: The purpose of this systematic review was to determine the effects of clinical pathways on length of hospital stay, hospital costs, and functional outcomes in patients undergoing total hip or knee arthroplasty. NUMBER OF SUBJECTS: Fifteen articles related to clinical pathways for total knee and hip arthroplasty and their effects on length of stay, hospitalization costs, and functional outcomes were identified and reviewed. All 15 of the articles looked at the effect of clinical pathways on length of stay, 5 studies looked at the effect of clinical pathways on hospitalization cost, and 6 studies analyzed the effect of clinical pathways on functional outcomes. MATERIALS/METHODS: Two reviewers independently reviewed and scored the quality of evidence using the Evaluation Guidelines of MacDermid (2003) and Sackett's levels of evidence. A third reviewer was consulted to resolve disagreements about a score or level of evidence. RESULTS: All 15 studies found that clinical pathways were effective in reducing length of stay. Five studies examining the effect of clinical pathways on hospital cost showed a reduction in hospital costs with the use of clinical pathways. However, results of 2 of the studies were not statistically significant. Out of 5 studies that assessed the effect of clinical pathways on functional outcomes, 2 of the studies found significant improvement in function in patients on clinical pathways. In addition, 1 study



DPT Program, Dept EXSC, University of South Carolina, Columbia, SC; Biostatistics, University of South Carolina, Columbia, SC PURPOSE/HYPOTHESIS: The objective of this study was to examine the diagnostic accuracy of dynamic and isometric handheld dynamometry (HHD) in detection of asymmetric strength of the quadriceps in persons with and without suspected lower extremity dysfunction. NUMBER OF SUBJECTS: Twenty-six subjects with an age range of 18 to 56 years. MATERIALS/METHODS: A best standard of asymmetrical strength difference was obtained isokinetically and isometrically using a Biodex dynamometer. Subjects were then tested by 2 licensed PTs in random order using isometric HHD and dynamic HHD. Dynamic HHD was compared to isokinetic Biodex dynamometry, and isometric HHD was compared to isometric Biodex dynamometry using 10%, 15%, and 20% differences

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found improved function in their total hip arthroplasty group while no change in total knee arthroplasty group. CONCLUSIONS: This systematic review provides evidence that clinical pathways for total knee and hip arthroplasties are effective in reducing hospital length of stays and hospitalization costs. The effect of clinical pathways on functional outcomes is variable. Evidence is lacking to definitively support improvement in functional outcomes in patients undergoing total knee or hip arthroplasties utilizing a clinical pathway. CLINICAL RELEVANCE: A major objective of clinical pathways is to contain costs while maintaining a high standard of care. While this systematic review supports the reduction of hospital costs and length of stay in patients undergoing a total knee or hip arthroplasty utilizing a clinical pathway, evidence in the literature is lacking to support the improvement in functional outcomes in these patients. Therapists need to ensure functional outcomes are not compromised when using clinical pathways in patient undergoing total knee or hip arthroplasty. femur. In this case, the sign of the buttock led to an appropriate referral and the eventual diagnosis of a condition for which physical therapy was contraindicated. In a direct access setting, the sign of the buttock may be useful in identifying patients with serious hip pathology requiring medical referral.



Rehab Services Department, Mile Bluff Medical Center, Mauston, WI; Department of Health Professions, University of Wisconsin La Crosse, La Crosse, WI PURPOSE/HYPOTHESIS: To determine whether females with hip abductor weakness will demonstrate different single leg landing kinematics than age and activity matched females with strong hip abductors. Proposed hypotheses: 1. Females with weak hip abductors will demonstrate greater amounts of knee valgus and hip adduction during a single leg landing. 2. There will be no differences in static alignment measurements for Qangle and navicular drop between the weak and strong groups. NUMBER OF SUBJECTS: One hundred healthy females, ages 18 to 44 years. MATERIALS/METHODS: Hip abduction strength of 100 healthy females was measured as peak isometric force using a dynamometer mounted to an anchoring station; measurements were normalized to each subject's individual body weight and reported as a percentage. The 15 strongest and 15 weakest subjects were evaluated for single leg landing kinematics using 3-D motion analysis; navicular drop and Q-angle. RESULTS: The strong group demonstrated a mean of 54.23% hip abductor peak force normalized to body weight compared to a mean of 22.38% for the weak group. The subjects with weak hip abductors demonstrated 2.77° greater knee valgus angle at initial contact (P<.05). The weak group had 11.36° less hip flexion and 11.11° less knee flexion during the landing cycle (P<.05). There were no differences found in hip adduction angle at initial contact or during the landing cycle (P<.05). No differences were found in Q-angle or navicular drop between groups (P<.05). CONCLUSIONS: Hip abductor weakness may affect the landing kinematics of otherwise healthy females. These altered landing mechanics have previously been shown to contribute to various lower extremity injuries. CLINICAL RELEVANCE: The ability to identify weakness that is associated with altered landing mechanics may improve screening processes to prevent injury and treatment programs to rehabilitate injuries.



Manual Physical Therapy Fellowship Program, Regis University, Denver, CO; Physical Therapy Program, University of Colorado Denver, Aurora, CO BACKGROUND AND PURPOSE: As more states gain direct access it is imperative that physical therapists are able to accurately screen patients for contraindications to physical therapy (PT) care. The sign of the buttock test is implicated in serious pathologies of the hip which would necessitate a referral to a medical provider. The purpose of this case report is to describe the presentation of a patient status post total hip arthroplasty (THA) who had a positive sign of the buttock test. CASE DESCRIPTION: A 68-year-old male 3 years status post right THA presented to PT with the insidious onset of sharp pain in the right buttock accompanied by a dull ache in his posterior calf and foot. Lumbar magnetic resonance imaging (MRI) was remarkable for mild retrolisthesis at L3-4 and herniated discs at L3-S1. Previous treatment for this condition offered no relief and included examination by an orthopedic surgeon, chiropractic, PT and an L2-3 epidural steroid injection. His pain was 6/10 on the Numeric Pain Rating Scale (NPRS), his Oswestry Disability Index score was 46% and he scored 13/80 on the Lower Extremity Functional Scale. Pertinent range of motion (ROM) measurements included lumbar flexion of 50° limited by right buttock pain, 0° of hip internal rotation on the right, and hip flexion limited by buttock pain at 65°. Buttock pain was noted with all hip motions, particularly hip flexion. Slump testing increased symptoms with cervical and trunk flexion and worsened with knee extension and ankle dorsiflexion. Cervical extension relieved the distal symptoms but his right buttock pain remained with trunk flexion. Manual muscle testing yielded global right lower extremity weakness with severe pain in his right buttock. The straight leg raise test (SLR) was positive at 65° on the right for buttock pain. Hip flexion did not increase when the knee was flexed following the SLR test, indicating a positive sign of the buttock. No visible swelling of the buttock was noted but the patient had marked tenderness to palpation globally in the right buttock. OUTCOMES: Utilizing the first level of classification outlined in the Treatment Based Classification for the conservative management of low back pain, it was deemed that this patient was not appropriate for physical therapy intervention at this time and he was referred back to his physician. Radiographs, MRI and electromyography of the right hip were normal. Bone scan and aspiration of the right hip revealed an infection which required surgical intervention. DISCUSSION: The sign of the buttock is purported to identify serious conditions around the hip and pelvis that warrant referral to a medical provider, including infections, osteomyelitis, and neoplasms of the upper



Physical Therapy, Washington University, St Louis, MO PURPOSE/HYPOTHESIS: Based on data from muscle modeling, moment arms for hip rotator muscles have been shown to vary between the hip flexed (HF) and the hip extended (HE) positions. For example, some hip external rotators (ERs) in the HE position switch their moment arms from external to internal rotation in the HF position. These changes in the moment arms suggest strength for hip internal rotators (IRs) may be greater in the HF position but this has not been examined in human subjects. Therefore, the purpose of this study is to examine the difference between hip rotator muscle strength in the HF compared to the HE position in healthy adults. Our hypothesis is that strength measures for hip IRs will be significantly higher in the HF versus the HE position. NUMBER OF SUBJECTS: The sample consisted of 25 healthy adults (5 males, 20 females; mean age, 24 years). Both lower extremities were tested on each subject resulting in 50 data sets. MATERIALS/METHODS: Strength measures were taken for hip IRs and ERs in 3 positions: (1) sitting with the HF to 90° and the lower leg hanging

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over the edge of the table, (2) prone with the HE and knee flexed to 90°, and (3) supine with the HE and the lower leg hanging over the edge of the table. Two experienced physical therapists tested all subjects. The microfet2 handheld muscle tester was placed against the subject's lower leg just proximal to the medial or lateral malleolus with the hip positioned in neutral rotation during all tests. An isometric force measured in pounds was taken as the subject pushed against the device with maximum effort for 2 to 3 seconds. Two measures were taken for IRs and ERs in each test position and recorded by a blind reader. The mean of the 2 measures was used for data analysis. The same 2 measures were used to determine intrarater reliability for each examiner. The order of testing for position, side and direction of rotation was randomized across subjects. Reliability was determined using intraclass correlation coefficients (ICC). Paired t tests were conducted to test for differences in strength measures among the 3 positions. All significance testing was set at P<.05. RESULTS: Both examiners demonstrated excellent intrarater reliability (ICC = .91 and .92, P<.001). Strength of hip IRs was significantly greater in the HF position than either of the HE positions (HF, 30.89 5.60; HE prone, 22.39 4.26; HE supine, 21.72 4.93; P<.001). Strength for hip IRs did not vary significantly between the 2 HE positions. Strength for hip ERs did not vary significantly between any 2 positions (HF, 28.03 5.49; HE prone, 27.09 5.84; HE supine, 26.96 4.62). CONCLUSIONS: These findings support our hypothesis that strength of hip IRs is greater with the HF. Changes in the moment arms of the rotator muscles, particularly the gluteals, may be one explanation. CLINICAL RELEVANCE: Manual muscle testing is typically performed in sitting with the hip flexed to 90°. Normal findings for hip internal rotator strength in sitting may not relate to performance of the hip internal rotators with the hip extended as in standing. This may be important for functional activities such as pivoting.

CLINICAL RELEVANCE: The results support the use of sEMG-triggered NMES as an adjunct to exercise for AROM in postsurgical knee rehabilitation.



Duquesne University, Pittsburgh, PA; Stanford University, Stanford, CA; Hospital for Special Surgery, New York, NY; Schulthess Clinic, Zurich, Switzerland; Oklahoma Sports Science and Orthopaedics, Oklahoma City, OK; University of Calgary, Calgary, AB, Canada; Steadman-Hawkins Research Foundation, Vail, CO; University of Michigan, Ann Arbor, MI PURPOSE/HYPOTHESIS: The ability to properly diagnose young active individuals with potential intra-articular hip pathology has been questioned. The objective of this study was to determine the diagnostic accuracy of an examination in identifying the presence of labral pathology, femoroacetabular impingement (FAI) and/or capsular laxity in hip arthroscopy candidates. NUMBER OF SUBJECTS: Forty-eight observations as 8 subjects (3 male, 5 female, average age 30 years) were evaluated by 6 experienced clinicians (1 PT and 5 surgeons). MATERIALS/METHODS: Clinicians were given a printed history before independently examining each subject. All subjects then underwent arthroscopic surgery. The presence or absence of labral pathology, FAI and/or capsular laxity was noted after the clinical examination and then again after surgery. Sensitivity, specificity, likelihood ratios, and diagnostic odds ratio values with 95% confidence intervals were calculated to determining the accuracy of the clinical exam in identifying the presence or absence of labral pathology, FAI and laxity. RESULTS: Using surgical findings as the gold standard, 4 subjects had labral pathology, 5 FAI, and 3 laxity. In determining the presence of labral pathology clinical exam had sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio values of 0.75 (0.55-.88), 0.66 (0.47-.82), 2.3 (1.2-4.1), 0.38 (0.18-.79), and 6 (1.7-21), respectively. In determining the presence of FAI, clinical examination had sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio values of 0.77 (0.59-.88), 0.72 (0.49-.88), 2.8 (1.3-6), 0.32 (0.16-.66), and 8.5 (2.3-32), respectively. In determining the presence of capsular laxity clinical exam had sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio values of 0.61 (0.39-.8), 0.57 (0.39-.72), 1.4 (0.8-2.4), 0.69 (0.3-1.3), and 2.1 (0.6-6.8), respectively. CONCLUSIONS: In this study clinicians could not accurately diagnose those with labral pathology, FAI and/or capsular laxity based on history and clinical examination alone. CLINICAL RELEVANCE: It seems that even in experienced hands, examination is suboptimal when trying to identify labral pathology, FAI or laxity as a potential source of hip pathology.



Athletic Training, Baylor University, Waco, TX; Physical Therapy, Texas Woman's University, Dallas, TX PURPOSE/HYPOTHESIS: Various interventions to facilitate muscle recruitment are used following knee surgery. Neuromuscular electrical stimulation initiated by a surface electromyographic biofeedback threshold (sEMG-triggered NMES) has been studied in neurological population but has not been applied to the orthopedic population. The purpose of this single-blinded, randomized clinical trial was to investigate sEMGtriggered NMES on knee extension active range of motion (AROM), function, and torque in patients following arthroscopic knee surgery. NUMBER OF SUBJECTS: Twenty-five. MATERIALS/METHODS: Participants were randomly assigned to 2 groups: (1) sEMG-triggered NMES with exercise group, or (2) exercise-only comparison group. Participants received outpatient physical therapy treatment 2 to 3 times a week for 12 visits. At the first, sixth, and twelfth visits, AROM and function using the lower extremity functional scale (LEFS) were collected. Peak isometric extensor torque was assessed using an electromechanical dynamometer at 3 months post surgery. Two ANOVAs with repeated measures were used to analyze knee AROM and LEFS data. An independent samples t test was used to analyze the peak torque index (%) of the involved extremity compared to the uninvolved. RESULTS: A significant difference was found between groups for AROM (P = .049). No significant difference was found between groups for LEFS scores or torque index. CONCLUSIONS: sEMG-triggered NMES intervention improved AROM but did not improve function or peak torque. Knee strength deficit remained substantial in the involved extremity 3 months post surgery; 72.5% of the uninvolved extremity.



Program in Physical Therapy, Columbia University, New York, NY BACKGROUND AND PURPOSE: Anterior knee pain is a common pediatric complaint with a reported incidence of up to 10% of young athletes. While found in only 1% to 6% of the population, bipartite patella (BP) should be considered in the differential diagnosis of the young athlete with anterior knee pain. BP is a variant of normal patellar development in which 2 or more ossification centers are joined by a synchondrosis. Secondary patellar ossification centers appear before age 12, but usually fuse during adolescence. Most people with bipartite patella are asymptomatic. When symptomatic, painful BP may be mistaken for patellofemoral pain syndrome (PFPS) in that both scenarios involve overuse, increasing symp-

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toms with strenuous activities, and weak and/or painful knee extension. The abnormal patellar tracking or peripatellar pain common in PFPS, however, is typically absent in BP. Instead, the cardinal sign of BP is tenderness focused at the superolateral patellar border. The pain pattern together with X-ray images can also lead to misdiagnosis as a fracture or quadriceps rupture. The instigating trauma in painful BP, however, is often just a minor bump without the effusion or loss of ambulatory ability typical after acute fracture or rupture. CASE DESCRIPTION: A 12-year-old male athlete presented with anterior knee pain of 3-month duration that worsened during a baseball season in which he played primarily pitcher and catcher. He described dull aching pain and focused sensitivity at the superolateral patella border. Knee bending, squatting, and sports activity increased pain. X-rays revealed a nondisplaced partially fused BP with smooth borders and no evidence of joint effusion. Examination findings included palpation tenderness at the superolateral patellar border with sensitivity to tapping and vibration, painful passive knee flexion, pain on resisted knee extension, and antalgic gait. Patellar tracking was normal and there was no effusion. Physical therapy intervention consisted of pain relief and correction of pelvic postural deviations; knee joint mobilization and restoration of ROM; open and closed kinetic chain strengthening; and proprioceptive, agility, and sports specific training. The patient was seen a total of 9 times in 6 weeks, with follow-up conducted 16 weeks after the initial examination. OUTCOMES: The patient returned to pain free pitching after 3 weeks and catching after 6 weeks. At the time of discharge, he had full pain-free knee range-of-motion and full hip and knee strength. He completed the summer baseball season with only mild pain in full squat with knee flexed beyond 110°. At follow-up, he was playing competitive basketball. DISCUSSION: Though an unusual condition, BP can cause anterior knee pain and should be considered in the differential diagnosis of young athletes. The case of this young baseball pitcher/catcher is the first reported case of successful rehabilitation for anterior knee pain due to BP. The outcome suggests that physical therapy may be indicated in select cases of BP.

RESULTS: The subjects' mean side-to-side knee extensor strength ratio (weaker/stronger leg × 100) was 91%. Quadriceps muscle activation was significantly higher in the subjects' stronger legs (94.20 versus 90.19; P = .018). There were no significant differences, however, in the magnitude of antagonistic medial (P = .251) and lateral (P = .678) hamstrings muscle activity recorded by side in the knee extensor tests. Side-to-side differences in voluntary quadriceps activation explained 34% of the side-toside variation in knee extensor peak torque. CONCLUSIONS: The results of this study confirm prior reports indicating that healthy young people typically have a 10% difference in their sideto-side knee extensor strength. Approximately one-third of this difference was explained by inter-limb differences in voluntary quadriceps muscle activation. Antagonistic hamstrings activity did not explain a significant portion of the observed side-to-side differences in knee extensor torque. The results of this study indicate that knowledge of quadriceps activation levels is helpful in interpreting strength tests and may lead to more valid assessment of muscle function. CLINICAL RELEVANCE: Quadriceps activation failure is commonly encountered in patients with knee disorders. The results of this study indicate that quadriceps activation levels also impact knee extensor strength tests in healthy young people and reinforce the importance of taking quadriceps activation levels into account when testing knee strength.



Physical Therapy, Stony Brook University, Stony Brook, NY PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate the effectiveness of a new single measure of complex closed kinetic chain lower extremity (LE) movements as a differentiator in individuals with patellofemoral pain syndrome (PFPS) and to determine if this new measure, frontal transverse deviation (FTD), provides information different from other measurements. FTD is a 2-D linear frontal plane measurement of the horizontal displacement of the knee joint center relative to the second ray of the foot while in the closed kinetic chain. NUMBER OF SUBJECTS: Forty-six volunteers participated in the study (PFPS, n = 23; without knee pain, n = 23). MATERIALS/METHODS: Participants' dynamic FTD was determined with a VICON 370 motion analysis system as they performed various functional tasks: squatting with feet in a (1) self-selected position; (2) constrained to shoulder width; ascent of an (3) 8-in step; (4) 12-in step and descent of an (5) 8-in step; (6) and 12-in step. In addition to FTD, participants' hip internal rotation, hip adduction (HAD), knee external rotation, and Q-angle were measured during the chosen tasks. Independent sample t tests, Discriminant Analysis, and Pearson Correlations were used to determine if individual's FTD differed between the subject groups and if FTD provided unique information. RESULTS: Between group comparisons of the variables that utilized FTD as a measure (alpha set at .05) found 4 of the 6 FTD variables were different without multiple comparison adjustment; however, none of the FTD variables differed when adjusted. Additionally, 4 of the 6 variables that used HAD differed between groups. Three Discriminant Function analyses (24, 18, and 12 variable models) included FTD and HAD (12 total variables). All were effective at differentiating between the 2 groups. The 24 and 18 variable models correctly classified 45 of 46 subjects (97.8%), while the 12 variable model correctly predicted membership for 43 of 46 subjects (93.5%). The 12 variable model used only the measures of FTD and HAD. Correlation of FTD with HAD found little to no relationship between the variables (squat with self-selected foot position, r = ­0.06; squat with feet shoulder width, r = ­0.06; ascent of an 8-in step, r = 0.18; descent of an 8-in step, r = 0.1; ascent of a 12-in step, r = 0.2; and descent of a 12-in step, r = ­0.05).



Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA PURPOSE/HYPOTHESIS: Side-to-side strength ratios are commonly used to assess knee strength in clinical settings and research on patients with knee disorders. Research has demonstrated that healthy young people typically have side-to-side differences in knee strength of about 10% when strength is contrasted using a stronger leg versus weaker leg design. The purpose of this study was to test the hypothesis that inter-limb variations in agonist and antagonist muscle activation levels would explain side-to-side differences in peak knee extensor torque. NUMBER OF SUBJECTS: Twenty-two active young people (11 males, 11 females) of similar age (mean 24.18 2.48 years) and activity level with no history of significant lower extremity injuries. MATERIALS/METHODS: Subjects underwent isometric strength testing of the knee extensors at 60° of flexion. Quadriceps muscle activation was evaluated using a burst superimposition interpolated twitch technique. The magnitude of antagonistic hamstrings muscle activity present during testing was evaluated with surface electromyography. A within-subjects design was employed wherein the magnitude of quadriceps activation and antagonistic hamstrings activity recorded from the subjects' stronger legs was contrasted with that recorded from their weaker legs. Linear regression analysis was used to determine the degree to which quadriceps activation and antagonistic hamstrings activity explained side-toside variance in knee extensor peak torque.

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CONCLUSIONS: Results of this study support the conclusion that FTD (a single measure of complex closed kinetic chain LE movements) is effective at discriminating between the participant groups. Additionally, FTD provided information about participant's movements that was different for the other measurements taken during the chosen functional tasks. CLINICAL RELEVANCE: Examination of LE movements in 3 planes across several joints requires complex measurement techniques not typically available in clinics. Utilization of this single clinically convenient measure of closed kinetic chain LE movements could improve identification of individuals with PFPS during the evaluative process.



Mayo Foundation, Rochester, MN PURPOSE/HYPOTHESIS: To investigate the level of activation of the gluteus medius muscle as measured by surface EMG signal amplitude during 5 weight bearing exercises performed on stable and unstable surfaces. NUMBER OF SUBJECTS: Twenty healthy subjects (14 female and 6 male) MATERIALS/METHODS: Raw EMG signals of the gluteus medius were collected with D-100 bipolar surface electrodes. EMG surface electrodes were positioned over the muscle belly of the gluteus medius on the dominant leg (leg used to kick a ball). Subjects preformed 5 exercises which consisted of bilateral stance, single limb stance, single limb squat, single limb stance on an Airex cushion and single limb squat on an Airex cushion. Prior to testing, a maximal voluntary isometric contraction (MVIC) was obtained as a normalization reference in analysis of the EMG activity during the 5 exercise conditions. The MVIC was recorded using a break manual muscle test for the gluteus medius. RESULTS: Repeated-measures ANOVA indicated a significant difference in EMG activation of the gluteus medius across exercises (F = 40.259, P<.001). Post hoc Bonferroni adjusted t tests revealed that all single limb exercises resulted in significantly greater gluteus medius activity compared to double limb stance. Furthermore, single limb squatting produced significantly greater gluteus medius EMG activity compared to single limb stance. Though there was a trend towards an increased level of EMG activity for exercises on the unstable surface, the activation of the gluteus medius was not statistically greater than the EMG activity of the same exercise performed on a stable surface. CONCLUSIONS: The findings of this study provide objective measures of gluteus medius activation during specific weight bearing exercises. Single limb stance places more demands on the gluteus medius than double limb stance. Single limb squatting places more demands on the gluteus medius than single limb stance. While the EMG values did not show a significant difference in gluteus medius activation when exercises were performed on a unstable versus stable surface, the increased gluteus medius demands as indicated by the increased EMG values may have clinical relevance as well as proprioceptive and functional implications. CLINICAL RELEVANCE: Our results provide clinicians information describing the activation of the gluteus medius during various exercises. The clinician can implement specific exercises based on the amount of gluteus medius activation desired progressing patients from static exercises requiring less activation to more challenging dynamic exercises requiring more gluteus medius activation. Our results also showed a trend that exercises on an unstable surface would be appropriate to further challenge the gluteus medius.

Orthopaedic Manual Physical Therapy, Brooke Army Medical Center, Fort Sam Houston, TX BACKGROUND AND PURPOSE: The differential diagnosis of hip pain in physical therapy patients must include nonmusculoskeletal pathology. This case report will describe the presentation, differential diagnosis and rehabilitation of hip pain due to eosinophilic granuloma (EG). CASE DESCRIPTION: A 33-year-old male was referred to physical therapy 3 weeks after a right grade II ankle sprain. The patient responded well to a manual therapy and exercise intervention. At a follow-up physical therapy visit, he reported a new onset of right anterior dull ache hip pain. A thorough examination of the lumbopelvic region revealed that his pain was not increased with compressive hip loading and was relieved with long axis distraction. He was prescribed hip stretching exercises. He also followed up for his ankle sprain with a physician's assistant (PA) and radiographs were ordered of his right hip. The radiographs were read as normal by the radiologist. Due to job related travel, the patient was treated 4 times over the next month with manual physical therapy and exercise to the hip with moderate but temporary relief after each intervention session. A second series of radiographs ordered by another PA were also normal. For further screening, the physical therapist (PT) ordered an erythrocyte sedimentation rate which was normal. Given the poor sensitivity of plain film radiographs for many early stage pathologies, the PT ordered a bone scan that revealed increased metabolic activity in the lesser trochanteric region of the right hip. This finding prompted the radiologist to perform a computed axial tomography scan that revealed a lytic lesion in the proximal hip. The radiologist's differential diagnosis included an osteoid osteoma or osteochondroma. The patient was placed on crutches to reduce the chance of pathologic fracture and referred by the PT to orthopaedic surgery. OUTCOMES: The patient underwent needle biopsy and was diagnosed with eosinophilic granuloma by orthopaedic oncology. While awaiting treatment for the lytic lesion, the patient continued physical therapy for a hip range of motion (ROM) and strengthening program. The patient progressed from a pool therapy program to low impact land-based exercises. Currently, his hip is pain free. He has returned to daily living activities but is restricted from running. DISCUSSION: This is a case of nonmusculoskeletal hip pain identified through a collaborative effort facilitated by the physical therapist. EG is a benign bone tumor that typically occurs in the pediatric population. To prevent a pathological fracture, early recognition of the atypical presentation is essential. Timely referral to the orthopaedic oncologist for definitive treatment was of primary importance, however continued physical therapy care to address impairments to gait, strength and ROM may have been essential to the patient's current normal functional status.



Emory University, Atlanta, GA BACKGROUND AND PURPOSE: To date, there is little research that has examined the association of impairments at the hip with overuse injuries of the hip. The purpose of this case study is to describe outcomes for a patient with non specific bilateral hip pain associated with recreational walking following an impairment based approach to intervention. CASE DESCRIPTION: The patient was a 28-year-old female research assistant who reported an onset of bilateral hip pain about 2 years prior to her initial physical therapy evaluation. At her initial visit, the patient reported intermittent pain bilaterally in the anterior aspect of her hips, which she rated as 6/10 after 25 to 30 minutes of walking at an approximate velocity of 3.5 mph. During visual assessment of posture from an anterior view, the patient exhibited "squinting" patellae and internal rotation of the femur bilaterally. After examination, the physical therapist diagnosis was that hip pain, muscle weakness of the iliopsoas, gluteus



US Army - Baylor University Postprofessional Doctoral Program in

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maximus, gluteus medius and quadriceps, and limited hip flexion range of motion (ROM) resulted in ambulation limitations. Intervention consisted of a home exercise program to increase hip flexion range of motion and strengthen the iliopsoas, gluteus maximus, gluteus medius (specifically, the posterior portion), and quadriceps muscles. The patient performed the home exercises program, gradually progressing the strengthening exercises for a total of 41 days over a 10-week period. Hip and knee joint angles (using a motion tracking system), muscle activity of the gluteus maximus, gluteus medius and tensor fascia latae (using surface electromyography), and ground reaction force (using a force plate) during the stance phase of gait (determined by the force plate) were assessed before and after the intervention. OUTCOMES: After 10 weeks, the patient reported 0/10 pain when walking 30 minutes or more. Passive hip flexion ROM and MMT grades of the iliopsoas, gluteus maximus, and gluteus medius muscles improved. Global score on the WOMAC improved from 10/96 preintervention to 0/96 postintervention. Compared to the stance phase of gait at preintervention, maximum hip extension decreased, maximum hip flexion increased, maximum ground reaction force increased, normalized mean electromyographic (EMG) activity of the gluteus maximus increased, and EMG activity of the gluteus medius and tensor fascia latae (TFL) decreased following the intervention. DISCUSSION: This patient's improvement in impairments and functional outcome following a home exercise program appear to have been accompanied by some kinematic and kinetic changes during gait. The changes in muscle activity at postintervention are consistent with previous descriptions of a common muscle imbalance (shortened and overactive TFL and weakness of the gluteus maximus and posterior portion of the gluteus medius), that contributes to increased femoral medial rotation. maintain the new PA. With examiner 1 holding the subject's thigh and heel, the subject was instructed to relax the quadriceps and another investigator measured the PA with the blinded UG. RESULTS: Utilizing an intraclass correlation coefficient (ICC3,1) intratester reliability for PA was 0.92 and the minimal detectable change (MDC95) was 7°. PA difference values were 12° and 10° for HR, and 14° and 16° for HR-AC for men and women, respectively. A mixed-model analysis of variance (ANOVA) for PA difference scores revealed that HR-AC yielded greater increases in PA than HR (P<.001). A stretch type by gender interaction was also detected (P<.05). CONCLUSIONS: HR-AC may improve hamstring muscle length more effectively in females, whereas males respond similarly to both stretching techniques. Both HR and HR-AC PNF stretch techniques produced average increases in hamstring muscle length in healthy subjects that exceeded our estimate of the MDC (7°). HR-AC produced greater increases in PA compared to HR. CLINICAL RELEVANCE: Healthy subjects with impaired HML demonstrated clinically meaningful changes in PA following a single, brief bout of PNF stretching.



Musculoskeletal Biomechanics Research Laboratory, Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA PURPOSE/HYPOTHESIS: Quadriceps strengthening is commonly advocated as a treatment for patellofemoral pain. Given as such, weight bearing (WB) and non­weight-bearing (NWB) exercises are employed in patellofemoral joint rehabilitation programs. An important consideration in prescribing various forms of exercise to strengthen the quadriceps is to choose exercises and ranges of motion that minimize patellofemoral loading. Currently, there is disagreement in the literature as to what types of exercise and/or ranges of motion should be used to minimize patellofemoral joint stress. Therefore, the purpose of this study was to compare patellofemoral joint stress among WB and NWB exercises. NUMBER OF SUBJECTS: Ten healthy subjects participated (age, 26.7 3.3 years; height, 172.7 6.9 cm; weight, 64.6 9.8 kg). MATERIALS/METHODS: Lower extremity kinematics (Vicon motion analysis system, 60 Hz), kinetics (AMTI force plate, 1560 Hz), and muscle activity of the knee musculature (surface electrodes, 1560 Hz) were obtained during 3 conditions: WB-Squat (bilateral squatting), NWB-Ankle Weight (average resistance, 4.4 kg), and NWB-Knee Extension Machine (average resistance, 4.1 kg). All activities were performed from 90° to 0° of knee flexion. A previously described biomechanical model was used to estimate patellofemoral joint stress. Briefly this model uses subject input variables (ie, knee joint kinematics, kinetics and normalized EMG) as well as variables from the literature (ie, knee moment arms, quadriceps force/patella ligament force ratios and joint contact area). Model output was average patellofemoral joint stress as a function of knee angle. A repeated measured ANOVA was used to compare average patellofemoral joint stress among 3 conditions at discrete knee flexion angles (0°, 15°, 30°, 45°, 60°, 75°, and 90°). Post hoc tests with Bonferroni adjustments were employed to compare the specific differences between exercises. The significance level was set at P<.05. RESULTS: The WB-Squat task generated significantly higher stress at 75° (10.5 1.6 MPa) and 90° (12.3 1.6 MPa) when compared to the NWBAnkle Weight (2.6 0.8 MPa at 75°; 0.5 0.5 MPa at 90°) and NWBKnee Extension Machine (6.4 0.9 MPa at 75°; 5.4 1.6 MPa at 90°). Conversely, the NWB-Ankle Weight task resulted in significantly greater stress at 15° (5.6 1.0 MPa) and 0° (8.4 1.6 MPa) when compared to the NWB-Knee Extension Machine (4.7 0.8 MPa at 15°; 5.0 1.1 MPa at 0°) and WB-Squat (0.9 0.9 MPa at 15°; 0.3 0.8 MPa at 0°).



Mayo Clinic, Rochester, MN PURPOSE/HYPOTHESIS: The effect of PNF stretching on hamstring muscle length has not been fully investigated. We hypothesized there would be a statistically significant improvement in popliteal angle (PA) following the use of a single bout of hold-relax with agonist contraction (HR-AC) stretch when compared to a single bout of HR stretch in subjects with impaired hamstring muscle length (HML). NUMBER OF SUBJECTS: Thirty-five healthy individuals (23 women and 12 men; age, 22-59 years) demonstrated reduced hamstring muscle length bilaterally. We defined reduced hamstring muscle length as a PA less than 160°; to utilize a muscle-tendon unit that could be lengthened and inclusion criteria that could be met by the general population. MATERIALS/METHODS: Participants were randomly assigned each PNF procedure to opposite lower extremities. PA values were measured using a masked goniometer. HR required subjects to produce a 10-second resisted isometric activation of the hamstrings against manual resistance provided by the examiner. Upon completing the HR contraction, the examiner instructed subjects to relax while he passively extended their knee joint until he consistently felt a firm end point with each subject. PA was remeasured with the UG. For HR-AC the opposite lower extremity was used. PA was measured passively, followed by the same procedure of isometric contraction of the hamstrings. This time, following isometric hamstring contraction, the subject immediately began a 10-second concentric activation of the ipsilateral quadriceps femoris known as the agonist contraction (AC). While extending the leg, the subject maintained contact of the distal anterior thigh of the test extremity with the crossbar of the PVC frame. Upon completion of the AC portion of the PNF procedure, the examiner grasped the subject's thigh and leg being careful to

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No differences in patellofemoral stress were observed among 3 conditions at 45°. CONCLUSIONS: In order to prevent high patellofemoral stresses during rehabilitation, we suggest that the WB-Squat should be avoided from 75° to 90°. Additionally, the NWB-Ankle Weight should be avoided from 0° to 15°. In general, the NWB-Knee Extension Machine resulted in moderate stress across all angles tested suggesting this exercise can be performed from 0° to 90°. CLINICAL RELEVANCE: Our study provides a general guideline for prescribing quadriceps exercises for individuals with patellofemoral joint disorders.


Physical Therapy, University of South Dakota, Vermillion, SD PURPOSE/HYPOTHESIS: A maximum isometric muscle contraction is used for normalization in the majority of published electromyographic (EMG) studies of the quadriceps femoris (QF), but may not be the best contraction to use for normalization purposes. Therefore, the purpose of this study was to find other exercises that elicit higher levels of QF muscle activity that may be more appropriate for normalization of EMG data. NUMBER OF SUBJECTS: Forty-one healthy volunteers (23 female, 18 male) with no lower extremity pain or injury participated in the study. MATERIALS/METHODS: Surface electrodes recorded EMG amplitudes from the vastus lateralis (VL), rectus femoris (RF), and vastus medialis obliquus (VMO) muscles during 6 different exercises. The exercises were 5-second maximum isometric QF contractions on a Cybex Norm at 45° knee flexion, unilateral lower extremity squat to maximum (mean, 84°) on a 15° incline, unilateral lower extremity squat to maximum (mean, 84°), and a unilateral wall squat (mean, 84°). In addition, an active unilateral 8-in step-up exercise, and isokinetic knee extension at 60°/s were performed. All data were normalized, and muscle activity was expressed as percent maximum voluntary contraction (%MVC). An intraclass correlation coefficient (ICC3,1) was used to determine same day test-retest reliability of the EMG recordings. A 1-way repeated-measures analysis of variance (ANOVA) was applied with significance established at the .05 level. RESULTS: The ICC scores for test-retest reliability of the EMG recordings ranged from 0.89 to 0.95 for the 3 muscles. Isokinetic knee extension at 60°/s (VL, 95% 11% MVC; RF, 99% 5% MVC; VMO, 92% 13% MVC) activated the QF significantly more than any of the other exercises. For the unilateral lower extremity squats, the unilateral wall slide, and the step-up exercise the EMG amplitudes ranged from 65% to 73% MVC for the VL and VMO with no significant differences between the exercises. The VMO (52% 21% MVC) and VL (59% 17% MVC) demonstrated relatively low levels of muscle activity during the isometric QF contraction at 45° of knee flexion. The RF activity during a maximum isometric QF contraction at 45° of knee flexion was 70% 16% MVC and was significantly greater than all other exercises except isokinetic knee extension at 60°/s (99% 5% MVC). CONCLUSIONS: The EMG amplitudes tend to be significantly greater during maximum concentric contractions of the QF as compared to maximum isometric contractions. Therefore, it may be better to normalize EMG data using a concentric contraction such as the isokinetic knee extension at 60°/s or a speed that closely matches the exercise studied. CLINICAL RELEVANCE: Since a maximum isometric contraction does not seem to elicit the greatest amount of QF muscle activity, studies that use isometric contractions for normalization may over estimate the value of exercises for strengthening purposes. For example, studies that have used isometric contractions for normalization report high levels of QF activity during some closed chain exercises that are fairly easy to perform.




Krannert School of Physical Therapy, University of Indianapolis, Indianapolis, IN PURPOSE/HYPOTHESIS: Prolonged activation of lower extremity musculature is critical to dynamic stabilization and underlies successful and safe execution of many sporting maneuvers and functional tasks. Specifically, stabilization of the hip in the frontal plane is requisite to many activities. While gross weakness of the hip abductors has been identified as a risk factor for injury in females, less is known about endurance of the hip abductors and functional performance. This study examined the effect of acute fatigue of the hip abductors on control of balance in young adult women. The hypothesis was that control of balance would decline following acute fatigue. NUMBER OF SUBJECTS: 30 young adult women without orthopedic compromise were examined (22.8 2.0 years; range, 19-29 years). MATERIALS/METHODS: Balance was examined before and after induction of acute fatigue of the hip abductors. Static balance was examined using the single-limb-stance-time-test (SLSTT) while multidirectional dynamic balance was examined using the modified functional reach test (mFR) and the lower extremity reach test (LERT). The mFR required the subject to remain standing on the dominant leg while reaching the upper extremity in the forward and lateral directions. The LERT required the subject to remain standing on the dominant leg while reaching the opposite leg forward and then laterally, away from the stance leg. Testing order was randomized between subjects and within subjects from prefatigue and postfatigue conditions. Acute fatigue was induced by repeated resisted sidelying hip abduction with the dominant leg through 50% of the subject's active range of motion using 3% of body weight placed at the ankle. A metronome was used to pace the lift and lower phases yielding a normalized rate of 25 lifts per minute for all subjects. Fatigue was defined as the point at which the subject failed to reach the target ROM or became out of synch with the pacing for 3 consecutive repetitions. Paired samples t tests were used to compare prefatigue and postfatigue conditions. Bonferroni adjusted t tests were used for tests of balance with more than 1 direction. RESULTS: Control of static balance decreased 33% (P = .001) while none of the dynamic multidirectional tests changed (P = .051-.503). However, notable changes in movement strategies and use of compensatory actions to minimize the effects of hip fatigue were observed. CONCLUSIONS: Acute fatigue of the hip abductors resulted in a decline in control of static but not dynamic balance. However, changes in movement strategies following fatigue, such as increased lateral trunk flexion and increased knee flexion, may be underlying manifestations of hip fatigue in efforts to compensate for local fatigue. CLINICAL RELEVANCE: While acute fatigue of the hip abductors did not result in decreased balance, the compensatory patterns or changes in movement strategy are of importance. It is the compensations and changes in movement control that may underlie an increase in the risk of injury and/or decrease in performance capacity under conditions of prolonged muscular exertion.



Physical Therapy, Armstrong Atlantic State University, Savannah, GA PURPOSE/HYPOTHESIS: Previous studies have shown that 2 weeks of daily long duration (10-minute) stretches can be as effective in increasing hamstring flexibility as 6 weeks of short duration (30-second) stretches. The purpose of this study was to examine the efficacy of long duration hamstring stretching in therapist-led group stretching classes. NUMBER OF SUBJECTS: Twenty individuals with tight hamstrings (defined

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as active knee extension lacking 30° or more with femur positioned in 90° of flexion) and no prior history of back/hip/knee dysfunction or surgery participated. MATERIALS/METHODS: Subjects were randomly assigned to control and stretching groups. The experimental group attended a stretching class 5 days a week for 2 weeks. Participants in the stretching class held a static stretch for a total of 10 minutes (3.5- and 3-minute stretches with 30-second rest between stretches). An investigator led the class, timed each session, and observed and corrected subjects' stretching techniques. Subjects in the control group continued with their everyday activities. Subjects in both groups agreed not to change their activity level or stretching routine throughout the study. Two investigators blinded to group assignment measured active knee extension with the hip positioned in 90° of flexion in subjects from both groups at 6 times during the study: (1) prior to beginning the stretching protocol, (2) at the end of the first 5 days of stretching, (3) following 2 days of not stretching, (4) following an additional 5 days of stretching (total of 10 days of stretching), (5) at 10 days following the cessation of stretching, and (6) at 14 days following the cessation of stretching. Analysis of variance (ANOVA) for repeated measures was performed followed by post hoc 2-tailed paired t tests with the alpha level set at .05. RESULTS: Throughout the study the control group showed no significant change in active knee extension. The stretching group showed a significant increase in active ROM after both 5 (mean of 6.85° gain) and 10 days of stretching (mean of 8.6° gain). The stretching group maintained significant gains in active knee extension for 10 and 14 days following the cessation of stretching. These changes were significantly different from control at stretching days 5 and 10 and post stretching days 10 and 14. CONCLUSIONS: A 10-minute static hamstring stretch in a group stretching class gained and maintained active knee extension ROM as compared to a control group whom did not participate in stretching exercises. These outcomes were comparable to therapist-assisted stretching and better than that seen in similar home exercise stretching programs. CLINICAL RELEVANCE: Participation in a group stretching class produces improvements in hamstring flexibility. The results of this study suggests that therapist supervision is as effective as therapist assisted stretching and is more effective than when the subject stretches on their own. tal plane using MATLAB (MathWorks Inc, Version 7.1). A Pearson correlation was calculated using SPSS Version 14.0; statistical significance was defined as P<.05. RESULTS: Test-retest reliability yielded ICCs of 0.80 for the pelvic drop measure and 0.90 for GM isometric force. The standard error of the mean for the kinematic measure was 0.36°. Poor correlations between average frontal plane pelvic drop and average GM torque were found for the left (r = ­0.212, P = .356) and right (r = 0.022, P = .925) sides. When the relationship between these 2 variables was assessed at each data collection period, there was still no significant correlation on either the left or right side at any time point. CONCLUSIONS: Isometric GM torque was a poor predictor of frontal plane pelvic drop. CLINICAL RELEVANCE: Clinically, qualitative observations during running analysis are linked to quantitative static strength assessments. Based on these findings, clinicians should question whether a dynamic rather than static measure of GM strength would be more appropriate. Future research is needed to identify dynamic strength measures that would predict biomechanical components of running gait.



Physical Therapy Department, Nova Southeastern University, Ft Lauderdale, FL BACKGROUND AND PURPOSE: The purpose of this case study is to describe the use of isokinetic and functional testing to guide the decision-making process for returning an athlete to her sport after injury and the Physical Therapist's role as part of a multi-specialty sports medicine team. CASE DESCRIPTION: The subject was a 20-year-old female athlete, division II collegiate softball player who suffered a catastrophic knee injury. The patient was seen in physical therapy after simultaneous ACL reconstruction, LCL repair, and biceps femoris repair. Isokinetic and functional test results were used to guide the decision to return the athlete to play and to enhance communications among all members of the sports medicine team (primary care physician, orthopedic surgeon, athletic trainer, physical therapist, and strength and conditioning staff). Functional testing included star excursion balance test, single leg hop for distance, and single leg timed-hop test. OUTCOMES: Isokinetic and functional testing was performed at 6 months, 7.5 months and 9 months. Goals for return to play were: Quadriceps deficit less than 10%, Hamstring deficit less than 10%, Quadriceps Peak Torque to Body Weight Ratio 44% to 48%, Agonist/Antagonist Ratio 80%, Star Excursion Balance Test less than 10% deficit, Single-Leg Hop for Distance less than 10% deficit, and Single-Leg Timed Hop Test less than 10% deficit. The subject began softball and strength and conditioning activities at 6 months. She met the goals for return to full participation at 9 months postsurgery. She performed at a high level for the entire softball season with minimal restrictions on her participation. DISCUSSION: A battery of isokinetic and functional tests can be used to help determine readiness for return to play. Using established norms and comparisons to the uninvolved limb provides valuable information for the sports medicine team to make appropriate decisions and to communicate activity status of an injured player returning to player. The Physical Therapist can play a primary role in providing the quantitative data needed for making evidence-based return to play decisions.



Physical Therapy, VCU, Richmond, VA PURPOSE/HYPOTHESIS: To investigate the relationship between isometric gluteus medius muscle (GM) torque and the magnitude of frontal plane pelvic drop seen during the stance phase of running. It was hypothesized that subjects with decreased isometric GM torque would have more frontal plane pelvic drop on the ipsilateral limb during stance phase. NUMBER OF SUBJECTS: Twenty-one healthy subjects (9 males, 12 females; mean age, 25.19 3.83 years; height, 173.39 10.24 cm; weight, 70.63 12.29 kg) were obtained from a sample of convenience. Subjects were recreational runners who ran greater than or equal to 8.05 km/wk (5 miles/wk) (mean, 33.26 18.70 km/wk) MATERIALS/METHODS: Subjects were asked to run on a treadmill for 30 minutes at a self-selected speed (10.74 1.06 km/h). Torque-GM isometric strength was determined prior to the run with the subject side lying using a hand-held dynamometer (Lafayette Instruments, Lafayette, IN), and converted to torque. Kinematics: 3-dimensional pelvic kinematic data were sampled at a rate of 60 Hz using an electromagnetic tracking system (MotionMonitor, Innovative Sports Training, Chicago, IL), with sensors (Polhemus Fastrak, Colchester, VT) secured over the posterior superior iliac spines (PSIS). Kinematic data were collected in 10-second increments every 2 minutes. Bilateral frontal plane pelvic drop was calculated as the angle between left and right PSIS relative to a horizon-



University of Delaware, Newark, DE

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PURPOSE/HYPOTHESIS: Varus knee alignment is a risk factor for the development of medial knee osteoarthritis (OA). It is likely that individuals with varus knee alignment are predisposed to disease due to high knee varus torques and angles. A common feature of varus knee alignment is a tibial mechanical axis (TMA) that deviates from vertical in the frontal plane. It is possible that the rearfoot excessively everts to compensate for a deviated TMA in this population. Therefore, the first aim of this study is to compare peak knee varus torque, peak knee varus angle, and peak rearfoot eversion angle between young, healthy individuals with varus knee alignment (VAR), and those with normal alignment (CON). We hypothesized that these variables would be greater in the VAR group. Secondly, we expected that these variables would be significantly correlated to the degree of TMA across subjects. NUMBER OF SUBJECTS: Twenty-six (5 females; mean age, 24.0 years; mean BMI, 24.1) individuals with healthy knees were recruited. Thirteen subjects were assigned to the CON group, with TMA values ranging from 7° to 9° from vertical. Thirteen were assigned to the VAR group with TMA greater than 11°. These TMA reference values were based on a database of 30 healthy individuals measured with a caliper-inclinometer device. MATERIALS/METHODS: All subjects then underwent an overground gait analysis at a controlled walking speed. Peak knee varus torque and angle, and peak rearfoot eversion angle were compared between groups using independent t tests. Spearman's rank correlations were also calculated between TMA and the outcome variables for all subjects. RESULTS: Peak knee varus torque was 41% greater (P<.001) in the VAR group. Further, peak knee varus angle was 5° greater (P<.001). At the rearfoot, peak eversion angle was greater in the VAR group by 3° (P = .002). There were significant correlations between TMA and peak knee varus torque (r2 = 0.64, P<.001), peak knee varus angle (r2 = 0.55, P<.001) and peak rearfoot eversion angle (r2 = 0.33, P = .002). CONCLUSIONS: Based on these data, knee varus torques and angles are substantially increased in the VAR group. In addition, these individuals walk with greater rearfoot eversion, suggesting a compensation for the increased inclination of the tibia. The correlation data suggest that the TMA accounts for significant variation in knee varus torque and angle, and accounts for moderate variation in rearfoot eversion. CLINICAL RELEVANCE: These data suggest that young, healthy individuals with varus knee alignment demonstrate altered walking patterns that likely increase their risk for developing medial knee OA later in life. They may also be at risk for problems related to the compensatory mechanisms they exhibit. These data also suggest that higher TMA values may serve as an indication for preventative, load-altering interventions to abate the likelihood of developing medial knee OA.

Assessment which included: (a) physical fitness measures of muscular strength and endurance, upper and lower extremity flexibility, and cardiovascular endurance; (b) functional tests for fall risk and community ambulation; (c) a subjective measure of function and disability. Each participant was provided an individualized exercise prescription based on the impairments identified during the assessment. Post tests will be performed after 16-weeks. All assessments and personalized instruction were provided under the general supervision of licensed physical therapists by Senior Fitness Specialists who were entry-level DPT students, Certified Strength and Conditioning Specialists (CSCS), and certified Silver and Fit Instructors. RESULTS: The average age of participants was 69.8 6.4 years. Average body mass index was 27.3 5.2. Participants were all community-dwelling independent individuals. However, many presented with musculoskeletal and/or neurological comorbidities (osteoarthritis, osteoporosis, post-CVA, Parkinson's disease, etc), which required specialized assessment and care. Participants scored at or above the 25th percentile on fitness tests. The Functional Gait Assessment yielded an average score of 25 3 points which may indicate an increased risk of falls. CONCLUSIONS: Participants were independent community dwellers with unrestricted community ambulation times and age-appropriate fitness levels with a propensity for being overweight. Many presented with an increased risk for falls and at least 20% of the participants presented with musculoskeletal and/or neurological comorbidities which required specialized assessment and care. CLINICAL RELEVANCE: Collaborative health and wellness programs led by physical therapists present an opportunity for the profession to take an active and entrepreneurial role in preventative care. Physical therapists are best qualified to implement exercise programs for a population with a variety of musculoskeletal and neurological comorbidities.



Kentucky Orthopedic Rehab Team, Nicholasville, KY; School of Physical Therapy, Regis University, Denver, CO PURPOSE: Exercise is an important component to the evidence based treatment of many orthopedic conditions treated in an outpatient setting. Exercise can present health risks to patients with certain pulmonary, metabolic, orthopedic and cardiovascular diseases. The American College of Sports Medicine (ACSM) has proposed a 3-tiered exercise risk stratification to identify patients who should be medically screened prior to beginning or increasing exercise. The 3 risk categories of low, medium and high are based on body metrics and self reported symptoms and signs. The ACSM recommends medical examination prior to initiating exercise for patients in the medium and high risk groups. Calculating exercise risk stratification in the outpatient physical therapy (PT) setting should be a component of clinical decision making for safe and effective patient care. The purpose of this study was to review the risk stratification in a population of orthopedic PT outpatients in rural Kentucky. DESCRIPTION: A sample of 101 charts from one clinic were reviewed for preparticipation exercise risk factors based on ACSM guidelines. Two examiners recorded age, sex, body mass index (calculated from height and weight) and blood pressure. The self reported medical history screening form was reviewed for family history of MI or sudden death, history of smoking, sedentary lifestyle, angina, shortness of breath, dizziness, orthopnea, ankle edema, palpitation, intermittent claudication, heart murmur, unusual fatigue, cardiovascular, metabolic or pulmonary disease. The investigators excluded fasting glucose and cholesterol measurements due to the lack of available resources in this setting. The patients were stratified into low, medium and high risk for exercise groups, based on ACSM guidelines.



Department of Physical Therapy and Athletic Training, Northern Arizona University, Flagstaff, AZ; Summit Health and Fitness, Flagstaff, AZ PURPOSE/HYPOTHESIS: The purposes of this project are to: (a) describe a novel physical therapy directed health and wellness program provided in collaboration with a third party payer specifically for the Medicare eligible population; (b) present descriptive data regarding participant demographics and baseline fitness and functional measures. NUMBER OF SUBJECTS: Twenty-eight females and 16 males participated in this study. MATERIALS/METHODS: Humana Medicare Advantage and Medicare Supplement plan members received a full membership to a local fitness club (Summit Health and Fitness, LLC) offering the American Specialty Health program Silver and Fit. Participants received individualized exercise sessions, group fitness sessions, and healthy aging classes. Participants underwent a comprehensive physical therapy-based Senior Fitness

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SUMMARY OF USE: Out of 101 patients, 14.9% were found to be in the low risk group, 45.6% in the medium risk group and 39.5% in the high risk group. 85.1% of this sampled outpatient PT population stratified into the medium and high risk categories where the ACSM recommends medical examination prior to initiating exercise. IMPORTANCE TO MEMBERS: While the data gathered lacks 2 components of the ACSM risk stratification, it presents new epidemiologic information and perspective on an outpatient orthopedic PT population in regard to health risks from exercise. Based on these results, it appears that the outpatient physical therapist who obtains the necessary information to stratify patients into exercise risk groups enhances clinical decision making regarding treatment, exercise prescription and referral.



Department of Physical Therapy and Athletic Training, Northern Arizona University, Flagstaff, AZ; Summit Health and Fitness, Flagstaff, AZ PURPOSE/HYPOTHESIS: To determine whether participation in a physicaltherapy-initiated and educationally based weight loss program (Lose to Win) held at a community fitness center was associated with improvements in body mass, body mass index, and/or estimated percent body fat. NUMBER OF SUBJECTS: The participants consisted of 21 women and 10 men with ages ranging between 23 and 66 years old. MATERIALS/METHODS: Lose to Win was a 16-week-long program designed to use comprehensive Physical Therapy educational classes, professional instruction, and group competition to facilitate improvements in weight management, body composition, and health behavior. The main goal of the program was to create knowledgeable, healthy, and active lifestyle changes. Each participant attended an education class taught by a health professional once per week. Class instruction consisted of topics such as weight management, fitness, nutrition, low back protection, skin care, and healthy decision making. Participants also weighed in each week to monitor weight loss. Participants had full access to fitness center facilities on days of classes and weigh in. During the first 2 weeks of the program, each participant's body composition was estimated using a 3 site skinfold, waist circumference, and body mass index (BMI). At the end of the 16 weeks, participants returned for post measures. Each participant was given a print out of their scores compared to norms after the pre and post measures. RESULTS: All participants received pre and post measures of body mass and BMI. Body mass decreased an average of 16.8 lb in females (range, 0-49 lb) and 30.6 lb in males (range, 3-71 lb). BMI decreased an average of 2.3 kg/m2 in females (range, 0-4 kg/m2) and 3.6 kg/m2 in males (range, 0-6 kg/m2). Of the 31 participants, 16 female and 4 male participants received pre and post body composition measures. Percent body fat loss averaged 4.7% in females (range, 1%-11%) and 9.8% in males (range, 4%-13%). CONCLUSIONS: Participants experienced decreases in body mass, body mass index, and percent body fat through a comprehensive, educationally based weight loss program. Future programs should consider strategies to improve participant adherence and program completion. CLINICAL RELEVANCE: To effectively improve community health, physical therapists have an opportunity to provide education on weight management, specifically on the role of exercise in weight management.

Various medications including dexamethasone are used by physical therapists to treat inflammatory conditions. There is limited research, however, to substantiate the efficacy of phonophoresis using dexamethasone. The purpose of this study was to ascertain if different US intensities influence the transmission of 0.4% dexamethasone through swine skin in vitro. DESCRIPTION: Methods: Swine skin was harvested from the back of a pig and cut into 2 × 2-in squares. Tissue samples received phonophoresis using 0.4% dexamethasone cream with 1 MHz continuous US for 5 minutes at 0.5, 1.0, 1.5, 2.0, and 2.5 W/cm2. A control group received US only using the same parameters as the treatment group. Subcutaneous collection gel was tested for the presence of dexamethasone using high performance liquid chromatography (HPLC). RESULTS: Swine skin treated via phonophoresis with 0.4% dexamethasone at 0.5, 1.0, 1.5, and 2.0 W/cm2 were below detection limit for the presence of dexamethasone in collected subcutaneous gel using HPLC. One of the 2 trials at 2.5 W/cm2 showed trace amounts of dexamethasone which was unable to be quantified by HPLC. The control group samples were below detection limit. CONCLUSIONS: The results indicate that 0.4% dexamethasone can be transmitted through swine skin using a high intensity at 2.5 W/cm2; however, when using lower and safer intensities dexamethasone is not transmitted. The results of this study suggest that phonophoresis with 0.4% dexamethasone is not an effective physical therapy intervention. Importance to Members: Evidence in practice.



Physical Therapy, Washington University in St Louis, St Louis, MO; Rehab Institute, St Louis, MO PURPOSE/HYPOTHESIS: To examine the effects of a patient-specific exercise program that emphasizes correction of movement and alignment impairments of the upper quarter. Particular attention is given to the alignment of the cervical spine and precision of movement of the mandible with treatment. NUMBER OF SUBJECTS: Twenty-six patients (25 females, 1 male; mean age 31.88 17.49 y) with a diagnosis of temporomandibular disorder (TMD) in a university-based outpatient physical therapy clinic (2002-2007) were included. MATERIALS/METHODS: A retrospective analysis of clinical records was conducted. One physical therapist examined all patients. Patients received an average of 4.00 2.46 physical therapy visits over the course of 1.5 months. The focus of the intervention was the correction of movement and alignment impairments of the upper quarter. Particular attention was given to precision of mandibular joint movement and avoidance of joint disturbances (clicking/popping). Data collected included (1) total temporomandibular joint (TMJ) active opening range of motion (AROM), (2) TMJ AROM prior to the onset of joint disturbances, (3) pain complaints (pain/no pain), and (4) joint clicking and popping (yes/no). RESULTS: Patients displayed an increase in TMJ AROM. Before treatment TMJ AROM was 39.03 8.66 mm and at follow-up TMJ AROM was 42.04 6.22 mm (mean difference, 3.01 mm; 95% C.I: 1.47 to 4.55; = .01). A subset of 16 patients who initially reported joint disturbance with TMJ active opening demonstrated an initial AROM of 29.12 10.70 mm before the onset of joint disturbance. At follow-up this subset of patients demonstrated significant improvement. This subset of patients demonstrated 39.94 6.65 mm AROM before the onset of joint disturbance (mean difference, 10.82 mm; 95% CI: 8.90 to 12.74; = .001). All patients reported a reduction in TMD pain complaints and joint disturbances. Forty-two percent of patients with complaints of pain were pain-



Physical Therapy, Nazareth College, Rochester, NY PURPOSE: Phonophoresis utilizes sonic waves produced by ultrasound (US) to mechanically propel medication through the skin. Introduction:

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free at follow-up, and 50% of patients with joint disturbances reported no disturbances at follow-up. CONCLUSIONS: This patient-specific exercise approach in the treatment of TMD resulted in an increase TMJ AROM and a reduction of associated pain and joint disturbances. CLINICAL RELEVANCE: Impairments not only in the TMJ region but also in the adjacent regions are important to consider in the treatment of TMD. A patient-specific exercise program that emphasizes correction of a patient's movement and alignment impairments in the entire upper quarter region resulted in positive outcomes. The specific attention given to the alignment of the cervical spine and precise movement of the mandible appears to provide an effective, efficient and noninvasive treatment for TMD. legiate softball players. NUMBER OF SUBJECTS: Thirty healthy volunteers (age range, 21-27 years) were recruited to assess intrarater reliability of trunk rotation passive ROM during 2 separate sessions on the same day. Seventeen female competitive, collegiate softball players (mean SD age, 19.7 1.3 years; range, 18-22 years) who batted right-handed were tested for trunk rotation passive range of motion and isokinetic concentric flexion/extension strength. MATERIALS/METHODS: Trunk extension and flexion muscle performance was tested on a Biodex System 3 isokinetic dynamometer at 60°/s in a semi-standing position. Trunk rotation passive ROM was measured bilaterally using dual inclinometer. Subjects were positioned on their side with an inclinometer at the mid-axillary line, 1 finger width below the inferior angle of the scapula. A second inclinometer was positioned against a wooden straight edge (located between the posterior superior iliac spines) and maintained at 0° throughout the procedure. The subject's trunk was passively taken into a fully rotated position and the measurement recorded. RESULTS: The ICC values calculated for the intrarater reliability of the repeated measurements were 0.91 for left rotation, 0.89 for right rotation, and 0.92 for total rotation. The standard error of measurement was found to be 2.91° for left rotation, 3.59° for right rotation, and 5.10° for total rotation ROM. For the athletes tested, the total trunk rotational range of motion was 127.5° with a right to left rotation ratio of 1.12. Trunk extension to flexion peak torque ratio was 2.15 with a mean extension/flexion peak torque of 157.4/73.7 Nm. Significant inverse correlations were found between trunk strength variables and rotation range of motion, with correlation coefficients (r) ranging from ­0.56 to ­0.58 (P<.03). CONCLUSIONS: Using inclinometers with this procedure to measure trunk flexibility appears to be a reliable method that can be implemented in the clinical setting with relative ease. These data demonstrate the inverse relationship between flexibility and strength and have implications for rehabilitation and training programs. Trunk extension peak torque was twice that of flexion and this relationship should be considered when examining certain athletic populations. CLINICAL RELEVANCE: A better understanding of the relationship between trunk strength and range of motion can assist clinicians in evaluating and training athletes who use trunk strategies to produce force.



Orthopaedic and Rheumatology Institute, Cleveland Clinic, Cleveland, OH; School Of Health Sciences, Duquesne University, Pittsburgh, PA BACKGROUND AND PURPOSE: Objective: To describe an examination and intervention using basic orthopaedic physical therapy principles of a patient presenting with complaints of dizziness with supposed neck origin. Background: The patient was a 41-year-old female with an approximate 2- year history of light-headedness and unsteadiness. She reported intermittent episodes of light-headedness, a rocking sensation, with facial parasthesias, neck crackling, and neck pain. Earlier diagnostic testing ruled out cardiovascular and more serious vestibular causes to the patient's symptoms. She rated her symptoms as 4/10 on a numeric rating scale for both light-headedness and neck pain, where 0 indicated no symptoms, and 10 the worst symptoms possible. CASE DESCRIPTION: The patient was treated 6-times over an 8-week period. Impairments of postural alignment /awareness, muscle strength, and movement of the cervical spine, and upper segmental cervical spine mobility were identified. Outcome measurements included the numeric rating scale, cervical spine range of motion and spinal segmental mobility, the Neck Disability Index (NDI), and the Dizziness Handicap Inventory (DHI). Intervention included manual soft tissue and specific joint mobilization, postural training, and modification of movement during active cervical and upper extremity movements. OUTCOMES: The patient reported having 0/10 on the numeric rating scale for both light-headedness and neck pain over the last 3 weeks of therapy. She reported a decrease in her DHI score from 36 (moderate disability) to 8-points (minimal disability). The patient also demonstrated an increase in her cervical spine range of motion and had symmetrical and full segmental mobility of her upper cervical spine. DISCUSSION: A thorough history and examination facilitated specific intervention techniques that included manual therapy to the cervical spine and trunk, and a specific active exercise program. Combining these interventions with home instruction emphasizing postural awareness and dynamic muscle balance appeared to have been successful in decreasing light-headedness complaints in a patient having neck pain.



University of Delaware Physical Therapy Clinic, Newark, DE BACKGROUND AND PURPOSE: Thoracic outlet syndrome (TOS) when encountered warrants conservative management. Surgical success rates range from 50% to 75%, with full resolution of symptoms occurring in less than 25% of cases. Much of the literature on TOS treatment is on operative management, leaving therapists seeking clinical guidance through successful case studies. The purpose of this case is to share a successful plan of care for a patient with TOS using a multi-modal treatment approach emphasizing manipulative techniques. CASE DESCRIPTION: A 47-year-old female school teacher began experiencing left scapula and upper extremity numbness and tingling radiating into all digits 2 months after painting. The constant symptoms were 7/10 pain at worst and increased with driving, sitting erect, and lifting her arm overhead. This impacted her ability to perform work activities and hug her son; her goals were to resolve these deficits. On examination, Spurling's was negative, but the following tests were positive: Military Brace, Roos, and Adson's on the left. Upper quarter screening revealed decreased fifth finger abduction strength and pin-prick to C6 dermatomal distribution, and a left biceps reflex of 3+ (right 2+). Neural tension was positive for recreation of her symptoms with ulnar and median bias



Physical Therapy, University of Maryland Eastern Shore, Princess Anne, MD PURPOSE/HYPOTHESIS: The aims of this study were to (1) evaluate the intrarater reliability of a new clinical examination procedure for measuring combined thoracic and lumbar rotation range of motion (ROM) using dual inclinometers, and (2) using this new procedure, determine the relationships between trunk strength and rotation ROM in female col-

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testing. Joint mobility revealed thoracic hypomobility at left first rib, centrally at T1-4 with symptoms reproduced at T3 and T4, and palpable tenderness of the left pectoralis and scalenes. Mid-trap strength testing was pain-limited. Posterior-anterior cervical joint mobility indicated hypomobility at C2-3 and hypermobility at C4-C6. Right cervical rotation was 65° and left was 90. NDI and DASH were 14 and 6%, respectively. The patient did not meet the diagnostic classification for cervical radiculopathy based on Wainner (2003) due to a negative Spurlings and cervical rotation greater than 60°. However, given a diagnosis of TOS with thoracic hypomobility, the seated cervico-thoracic and thoracic traction manipulation techniques were used in conjunction with joint mobilizations, scalene and pectoralis self and manual stretching, neural glides, and scapular stabilization exercises. OUTCOMES: After 1 manipulation with each technique, the patient was pain-free with mid-trap testing. Within 7 visits, all TOS special tests were negative, ulnar neural tension was resolved, and only median nerve irritability at end-range remained. Normal joint mobility was restored throughout the thoracic spine and no muscle tenderness was elicited. NDI was 0% and her DASH was 2%. She returned to full pain free teaching and childcare responsibilities. DISCUSSION: The literature suggests the above-mentioned manipulative techniques may be successful in the treatment of cervical dysfunction. These techniques in the presence of findings suggestive of TOS may demonstrate promise. Standard care for TOS including stretching and neural mobilizations coupled with thoracic mobilizations helped resolve symptoms in this patient in 7 visits. tifactorial. This experience can be influenced by both intrinsic factors, such as previous experience with other healthcare providers, and extrinsic factors such as the skills of the healthcare provider. The results of this study support previous investigations on patient satisfaction in identifying factors that influence the patient's perception of their care. CLINICAL RELEVANCE: The APTA vision statement includes the projection that physical therapists will be `the practitioners of choice to whom consumers have direct access' to care. Realizing vision 2020 requires an understanding of what contributes to the patient experience in treatment settings and identification of factors that contribute, both positively and negatively, to patient satisfaction. Factors that can be identified and are modifiable can be addressed, which can help improve quality of care and enhance the practice of physical therapy.



Physical Therapy, Stony Brook University, Stony Brook, NY; Physical Therapy, Long Island University, Brooklyn, NY PURPOSE/HYPOTHESIS: Multiple studies have suggested links between breath control, intra-abdominal pressure (IAP), and stabilizing the lumbar spine. However, little study has focused on breath control during functional tasks requiring lumbar stabilization. Previously, we examined breath control during a lifting task and found both volume and breath type (inspiration, expiration, or breath hold) are related to load and timing of lift-off. This study examines a functional task that requires trunk stabilization with little change in trunk posture (going up to tiptoe and reaching overhead) to determine if breath control is related to the timing of the challenge to lumbar stability. NUMBER OF SUBJECTS: Ten healthy subjects (mean, 25 years). MATERIALS/METHODS: A pneumograph and facemask were used for breath data collection. Vital capacity and baseline tidal volume were measured. Subjects completed 5 consecutive trials of going onto tiptoe, reaching overhead with the right hand to squeeze a target for 3 seconds, and then returning to stance. Pressure sensors were placed under the left heel and on the target. Ascent phase occurred from heel off to contact with the target, the hold phase occurred from contact with the target to release of the target, and descent occurred from release of the target to return of the heel. Only trials 2 to 4 were used for analysis. Timing of ascent and descent was unconstrained but the hold phase was determined by an auditory cue occurring 3 seconds after the target was initially pressed. The amount of volume in the lungs as a percentage of vital capacity and breath type (inspiration, expiration, or breath hold) were identified. Since ascent and descent time varied between subjects, as well as the time during the hold phase due to differences in response time, each phase was expressed as a percentage totaling 100%. Points used for analysis were baseline, start of ascent, 50% ascent, end of ascent/start of hold, 50% hold, end of hold/start of descent, 50% descent, and end of descent. Oneway and Friedman's repeated-measures ANOVA were used to identify differences in volume and breath pattern. RESULTS: A significant main effect (P<.001) indicated that volume changed throughout the tiptoe task. Post hoc analysis using a Bonferroni correction revealed that volume increased at 50% ascent and throughout the hold when compared to the start of ascent. Additionally, the volume at contact with the target and at 50% hold was increased as compared to the average tidal volume measured during baseline. Post hoc analysis of breath pattern using Tukey test indicated that inspiration was most frequent throughout ascent and that expiration became more frequent during descent. CONCLUSIONS: Frequency of inspiration and volume significantly increase during ascent of a tiptoe task. These findings support the theoretical link between breath control, IAP, and lumbar stability. CLINICAL RELEVANCE: Breath control may assist lumbar stability during



Physical Therapy, Nazareth College, Rochester, NY PURPOSE/HYPOTHESIS: The Nazareth College Orthopedic Clinic (NCOC) is an outpatient physical therapy center where students provide patient care under the supervision of licensed physical therapists in a direct access environment. One important aspect of clinic outcomes assessment is patient satisfaction. Patient satisfaction reflects the overall experience of patients in a healthcare setting and has been shown to be influenced by a variety of factors. The purpose of this study was to investigate the nature of the physical therapy experience, from the patient perspective, in the NCOC and identify factors that impact that experience. We hypothesized that longitudinal continuity of care, access to care, and clinician skills will influence patient satisfaction. NUMBER OF SUBJECTS: Subjects were patients with musculoskeletal conditions who attended the NCOC during the spring of 2007. A total of 30 subjects participated in the study. MATERIALS/METHODS: Each subject completed an anonymous patient satisfaction survey at the time of discharge. A subset of patients participated in one-on-one interviews with the investigators. Survey data was analyzed with SPSS 13.0. Interview data was transcribed and analyzed by the primary investigators. Qualitative data was reviewed multiple times until consensus was reached on interpretation of responses. RESULTS: Subjects ranged in age from 17 to 78 years. Patient primary complaints were distributed across all body regions, with cervical spine conditions representing the largest percentage of patient cases at 25%, followed by lumbosacral spine at 17%. Results indicate a high level of overall patient satisfaction, with a mean score of 3.70 on a scale of 0-4. Based upon both the survey results and interviews, the following factors positively impacted the patient experience: interpersonal skills and competence of the providers, access to care, and longitudinal continuity of care. Factors that could be improved upon in order to enhance the overall experience include hours of operation and provision of more written materials on home exercise programs. CONCLUSIONS: In any healthcare setting, the patient experience is mul-

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tasks where postural stability is challenged. Training may be important in those with poor trunk stability. were 5/5, while right lateral excursion was 4­/5. Intervention consisted of instruction in proper erect sitting posture. He was instructed to rest with the tip of his tongue at the roof of his mouth, teeth apart, muscles relaxed, and to perform range of motion exercises from that position, 5 repetitions, 5 times per day. He was also advised to avoid large bite portions of food and to keep his mandible in midline when smoking. At his second visit 1 week later, he was progressed to isometric stabilization exercises in the resting position. Gentle manual resistance was applied to his mandible in 6 different directions, and he was advised to perform these 5 repetitions, 5 times per day. At his third visit, the stabilization exercises were progressed to a mid-range mandibular depression position. During his fourth visit, his home exercise program was reviewed and we mutually agreed to discontinue physical therapy. OUTCOMES: The patient was seen in physical therapy for 4 visits over a 5 week period. At the time of discharge, his static sitting postures improved and his mandibular depression range of motion increased to 35 mm without apprehension. Mandibular strength in all directions was 5/5 to MMT. By the fourth visit, he reported no episodes of right TMD. Ten weeks after his initial visit, he stated by phone that he continued a daily routine of his home exercise program and had not had any episodes of subluxation. DISCUSSION: This case report demonstrates the successful outcome after physical therapy intervention of 1 patient with an asymmetrical bite surface and temporomandibular joint hypermobility. Compliance with his home exercise program contributed to improvements in his head and neck posture, strength, range of motion, and meeting his goal of eliminating his right TMD.



Physical Therapy, Dominican College, Orangeburg, NY PURPOSE/HYPOTHESIS: New York City firefighters have recently had new gear added to their Personal Protective Equipment (PPE). This additional gear, called the Personal Safety System (PSS), consists of a harness worn at the waist, and a pouch containing a rope that is located on the right hip. Firefighters have stated that the additional gear affects their performance due to its additional weight and asymmetrical location. The investigators in this study measured the velocity, step length, and swing to stance ratio of firefighters using the GAITRite system. NUMBER OF SUBJECTS: Forty-nine. MATERIALS/METHODS: Forty-nine male firefighters aged 21 to 50 ambulated at their self selected pace across the GAITRite mat under 3 conditions: (1) without gear (street clothes), (2) with their basic gear (PPE), and (3) with PPE and the PSS. This study was a within subjects single factorial design. Velocity and step length data were analyzed using a 1-way analysis of variance (ANOVA). Significant differences between conditions were differentiated using the Tukey post hoc analysis. The alpha level was set at P<.05. The left and right swing/stance ratio data were analyzed using a nonparametric Wilcoxon Signed Ranks Test. RESULTS: Left versus right step length showed no significance, right swing to stance ratio showed significance between street clothes and PPE and between street clothes and PSS. Velocity approached significance under all 3 conditions. Results suggest that the weight and the asymmetric placement of the PSS play a role in changing swing to stance ratio during gait. CONCLUSIONS: New York City firefighters were issued a piece of equipment that was meant to save lives and we found, based on our study parameters, that it is not a significant hindrance to their overall performance. However, in our study, it did affect some of their gait characteristics. CLINICAL RELEVANCE: Based on these results, we feel that further clinical study is warranted on this subject.



Physical Medicine and Rehabilitation, University of Colorado Denver, Aurora, CO PURPOSE/HYPOTHESIS: Evidence suggests that psychosocial stress can cause elevated muscle activity that may increase the risk of overuse injuries in the workplace. The purpose of this study was to compare stressevoked activation of the upper trapezius (UT) muscle in subjects with and without work-related neck pain. NUMBER OF SUBJECTS: Eight women (31 10 years; 25.5 4.7 kg/m2) with neck pain limiting job performance for greater than 3 months duration (cases), and 8 age-matched women (34 10 years; 20.2 8.9 kg/m2) with no history of neck pain (controls) participated in the study. MATERIALS/METHODS: Activity of the UT muscle was recorded with surface electromyography (EMG) during typing and mousing tasks performed at a standard computer workstation under low and high stress conditions. Subjects were informed that their performance would not be monitored during the low stress condition, whereas the high stress condition was performed with time and accuracy constraints, video surveillance, feedback regarding mistakes, and a monetary incentive. Subjects performed each task for 5 minutes under low and high stress conditions, with the order of the tasks randomized and the low stress condition presented first. Subjects also completed a series of health-related questionnaires. RESULTS: During typing, UT EMG increased from 11.2% 11.0% MVC in the low stress condition to 17.1% 12.5% MVC in the high stress condition for cases (53% increase), compared to an increase from 9.4% 6.6 to 11.1% 7.6% MVC for controls (18% increase). During mousing, UT EMG increased from 4.6% 4.8%MVC in the low stress condition to 10.1% 7.3% MVC in the high stress condition for cases (120% increase), compared to an increase from 6.0% 4.3% to 7.9% 5.4% MVC for controls (32% increase). Compared to controls, cases reported higher trait anxiety (Spielberger Trait Anxiety Index = 38.5 8.1 versus



Division of Physical Therapy Education, University of Nebraska Medical Center, Omaha, NE BACKGROUND AND PURPOSE: Temporomandibular joint hypermobility has been described as occurring when the condyle translates beyond the articular eminence and onto the articular tubercle. A typical complaint from a patient with this problem is "my jaw feels like it goes out of place." The purpose of this case report is to describe the physical therapy intervention and outcome of a patient with temporomandibular joint hypermobility and an asymmetrical bite surface. CASE DESCRIPTION: The patient was a 68-year-old male with a 6-month history of right temporomandibular disorder (TMD). He described his jaw as "popping in and out with eating and yawning" a minimum of 2 to 3 times per day, which resulted in pain. Since having all left lower molars extracted 3 years ago, he chewed food only on the right side. His sitting posture demonstrated a kyphotic thoracic spine, forward head and shoulders, and a preference for crossing his legs. His mandible was in a retracted position. Mandibular opening was 28 mm and the patient was apprehensive with this movement. Lateral excursion range of motion was equal and symmetrical bilaterally. Manual muscle tests (MMT) to mandibular opening, closing, and left lateral excursion

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30.0 2.9) and lower physical activity (Baecke Physical Activity Questionnaire Score = 7.7 1.4 versus 10.1 2.3), job satisfaction (Minnesota Job Satisfaction Questionnaire Score = 65.1 12.3 versus 71.9 8.4), physical health (SF-36 Physical Health Subscale = 49.0 7.4 versus 54.9 3.8), and mental health (SF-36 Mental Health Subscale = 49.8 6.7 versus 54.0 3.3). Discriminant analyses using stress-evoked muscle activity, trait anxiety, and physical activity as independent predictors of group membership correctly identified 14 of the 16 subjects as either cases or controls. CONCLUSIONS: Preliminary trends suggest that women with chronic neck pain respond to psychosocial stress with a greater increase in trapezius muscle activity than do women without a history of neck pain. Results also indicate that EMG responses to a standardized stress protocol can differentiate among women who do and do not have chronic neck pain, thereby supporting the discriminant validity of this screening tool. CLINICAL RELEVANCE: Development of a standardized protocol to screen for the presence of stress-evoked muscle activity may help identify individuals who are most likely to benefit from stress management interventions to prevent and treat chronic neck pain.


Department of Physical Therapy, The Sage Colleges, Troy, NY; Department of Physical Therapy, Springfield College, Springfield, MA PURPOSE/HYPOTHESIS: Orthopedic injuries/surgeries can result in a need for partial weight bearing (PWB), but patients have difficulty achieving the prescribed weight limit. The purpose of this study was to compare the effectiveness of the Snapdome Weight Bearing Indicator (WBI) to the bathroom scale method (BS) of teaching PWB gait. The WBI is a low cost, personal weight-bearing biofeedback device that is being developed for clinical use. We hypothesized that the subjects using the WBI would be better able to achieve the designated PWB than those using the BS. NUMBER OF SUBJECTS: Sixty-one healthy subjects participated: 31 females (mean age, 23.5 5.1 years; height, 1.7 0.1 m; weight, 63.8 10.1 kg) and 30 males (mean age, 20.7 1.9 years; height, 1.8 0.1 m; weight, 77.0 7.2 kg). MATERIALS/METHODS: Subjects were randomly assigned to either the WBI or BS group. A weight of 45 to 50 lb (20.4-22.7 kg) was designated as the target partial weight bearing force on the right limb. Subjects were instructed in axillary crutch use and completed 5 pretraining trials where they were asked to estimate 45 to 50 lb of weight bearing which was measured over a force plate. Subjects then received partial weight bearing gait training using either the WBI or BS. Subjects completed 5 posttraining trials to assess their learning of 45 to 50 lb partial weight bearing. RESULTS: A repeated-measures ANOVA with 1 within and 2 between subjects variables revealed a significant main effect (P<.001) and a significant interaction for training method (P = .004). A post hoc t test revealed no significant difference between the pretraining scores of the 2 groups. Posttraining, the WBI group had a significantly lower partial weight bearing force than the BS group. The pretraining force was 98.8 lb (SD, 31.6) and 98.7 lb (SD, 27.9) for the WBI and BS groups respectively and posttraining was 66.8 lb (SD, 21.1) and 89.4 lb (SD, 27.7). CONCLUSIONS: While neither group achieved the target PWB, the WBI group was closer to the target. The WBI needs further refinement to improve its accuracy and consistency. CLINICAL RELEVANCE: Patients taught to PWB with a specified weight range using the traditional bathroom scale method may not be at or even near their target weight limit. The Snapdome WBI may be a useful tool for helping patients achieve a prescribed partial weight bearing status. Since the Snapdome WBI is designed to fit into a shoe and to be worn whenever the patient is weight bearing, it may provide more consistent maintenance of the prescribed PWB than only training in the clinic with a bathroom scale.




Physical Therapy, California State University Sacramento, Sacramento, CA PURPOSE/HYPOTHESIS: The Star Excursion Balance Test is a measure of dynamic balance in single-leg stance. The Star Test has good reliability and is sensitive to the presence of chronic ankle instability. The purpose of this study was to examine the relationship between age and performance on the Star Test. NUMBER OF SUBJECTS: We recruited 161 community dwelling adults. Subjects had to stand in a single-leg stance for 10 seconds using each lower extremity to be included. We had 78 subjects greater than or equal to 60 years old (older group); 60 subjects 40 to 59 years old (middle group); and 23 subjects 20 to 39 years old (young group). All subjects were free of any known balance disorder and serious lower extremity injury/pathology. MATERIALS/METHODS: Subjects performed 3 trials of the Star Test. The 3 trials were converted to a mean for each of the 10 test movements and an overall test average. Normalized reach was calculated by converting each mean to a% of the subject height. The data was analyzed using SPSS v15.0. The groups were compared for height, weight and normalized reach using ANOVA (P<.05). A Spearman correlation analysis and a curvilinear regression analysis were performed. RESULTS: There were no differences in height and weight between the 3 groups. Reaching straight ahead was different between the older group (39.8% [of subject height]) versus the young (45.4%) and middle (45.0%) groups. Reaching straight back was different between the older (31.1%) group versus the young (43.3%) and middle (40.0%) groups. The overall test average was different between the older (36.9%) group versus the young (45.4%) and middle (43.5%) groups. The correlation coefficient for age and normalized reach for the overall Star Test was r = 0.70. The coefficient of determination for age and normalized reach was r2 = 0.48. CONCLUSIONS: Performance (normalized reach) on the Star Test decreased significantly with advancing age. The correlation between age and normalized reach was good (r = 0.70). The coefficient of determination (r2) value was 0.48; therefore 48% of the variance in normalized reach can be accounted for by knowing the age of the subject. CLINICAL RELEVANCE: In future studies we hope to determine: (1) if adding BMI to our regression equation will increase the value of r2; and (2) if there is a threshold for normalized reach that could be used to determine if someone has impaired dynamic balance.



Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA; School of Medicine, Stony Brook University, Stony Brook, NY PURPOSE/HYPOTHESIS: Empathy is defined as a cognitive (as opposed to affective) attribute that involves an understanding of the patient, combined with a capability to communicate this understanding to the patient. The effective use of empathy promotes diagnostic accuracy, therapeutic adherence, and patient satisfaction. Empathy has been measured in several health care practitioners (physicians, nursing, and physician assistant) and has shown to change over the course of training in these clinicians. The primary objective of this study is to determine the level of empathy among physical therapists who were admitted to post graduate residency programs. The secondary objective is to assess whether the level of empathy changes over the course of residency training.

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NUMBER OF SUBJECTS: Seven physical therapists were enrolled in the post graduate residency programs at USC in orthopaedics and neurology. MATERIALS/METHODS: Empathy levels were determined by 2 methods, self assessment and observation. Each of the residents completed the Jefferson Scale of Physician Empathy (JSPE) questionnaire 3 times over the course of their year long residency program. The observational component of this study was conducted as an interview of a standardized patient. The scripted response of the patient was formed prior and adhered to for each interview. A trained observer gave instructions for the interview process. After the interview, the student was scored with the use of the Hogan General Empathy Rating (GER). The standardized patient completed Barrett-Lennard Patient Relationship Inventory and GER. RESULTS: The JSPE scores were 122.3, 124.1, and 124.3, respectively, of the 3 time periods. On the observation of empathy levels from the standardized interview, there was agreement between the observer and standardized patient using the GER. When comparing the results of the GER to the results of the self assessment of empathy level using the JSPE, there was no relationship. CONCLUSIONS: Empathy levels did not change over the course of the residency. Self assessment and observation of these traits had poor agreement. CLINICAL RELEVANCE: In post graduate residency programs, the concepts of empathy should be presented to allow for the most effective interaction with each patient, which should improve the outcome of the interventions.

screening tool to assess high school athletes' dynamic function prior to participation. This procedure provides an opportunity to incorporate additional testing or rehabilitation to potentially prevent or reduce injury risk. There is a need for an appropriate cut-off time for single-leg standing balance tasks that does not yield a ceiling effect with higher level adolescent athletes.



Institute for Physical Therapy Education, Widener University, Chester, PA PURPOSE/HYPOTHESIS: The aim of this narrative review of the literature is to investigate the effect of low-intensity pulsed ultrasound (LIPUS) on healing process of fractures and detect the best LIPUS parameters. NUMBER OF SUBJECTS: Fifteen studies were selected for this review. MATERIALS/METHODS: Studies were selected by using a computer-based literature search of 4 databases: PubMed, MEDLINE, Physiotherapy Evidence Database (PEDro), and Cochrane Database to identify the clinical trials of LIPUS with fractures in humans, published from 1990 to 2007. Studies that were selected for this review met the following inclusion criteria: randomized control trials, meta analysis, participants of either sex with different fractures, use of low- intensity pulsed ultrasound treatments to one of the treatment groups, and evaluation of the healing process time by clinical and radiological outcomes. RESULTS: Computer-based literature search of databases identified 272 citations. We reviewed 15 studies. Seven studies indicated that LIPUS was effective on delayed union and nonunion fractures, 5 Studies showed that LIPUS accelerated the healing time in fractures of long bone, 1 study supported that LIPUS enhanced the healing process in smokers, and 2 Studies concluded that LIPUS was not effective. CONCLUSIONS: The results of this review suggested that using LIPUS with (1.5 MHz and 20-30 mW/cm2, 20 min/day, for 14-140 days) can improve the fracture bone healing. CLINICAL RELEVANCE: Additional studies are needed to investigate the effect of LIPUS on delayed healing in smokers in order to generalize the outcomes. Also, further studies are required to asses the effect of LIPUS produced by standard ultrasound machine.



Bay State Physical Therapy, Boston, MA; MGH Institute of Health Professions, Boston, MA PURPOSE/HYPOTHESIS: To determine whether high school athletes and nonathletes differ in their ability to perform single-leg standing or the crossover hop test. NUMBER OF SUBJECTS: Cross-sectional study of 108 healthy high school volunteers ages 12-19 years (mean SD age, 16.4 1.31 years). MATERIALS/METHODS: Subjects were divided into 3 groups based on athletic participation: varsity athletes (47 females, 26 males), recreational athletes (6 females, 16 males) and nonathletes (8 females, 5 males). Each subject performed 3 trials of single-leg standing on foam with eyes open and eyes closed and 3 trials of a crossover hop on each leg. Data Analyses: Descriptive statistics were computed for age, athletic participation, grade, race, ethnicity and BMI. Two-way analysis of variance (ANOVA) compared performance among the athletic group and gender. RESULTS: There were no significant differences in single-leg standing performance among groups or gender. Gender and athletic group were significant factors for right and left crossover hop test performance (Right hop gender [P = .001] and athletic group [P = .002] and Left Hop Test gender [P .001] and athletic group [P = .001]). Post hoc testing indicated significant differences between athletes and nonathletes on the cross over hop test. CONCLUSIONS: Students of various levels of athletic participation and gender did not differ in single-leg standing performance. This lack of association may reflect the methodology which did not use a threshold value for a cut off point. Males performed better on the Crossover Hop Test than females and varsity athletes performed better than nonathletes. This study supports the hypothesis that varsity athletes have better Crossover Hop ability than nonathletes. The Crossover Hop Test is a performance-based outcome measure that reflects the combined effect of neuromuscular control and strength and is frequently used as a criterion to return to athletic activity as it incorporates components of direction change and speed necessary during sports. CLINICAL RELEVANCE: The Crossover Hop Test may be a useful, simple



Carroll College, Waukesha, WI PURPOSE/HYPOTHESIS: Procedures commonly used to treat patients in orthopedic physical therapy (PT) practice can cause significant pain. A thorough literature review identified no studies exploring the cardiovascular (CV) response to common noxious orthopedic interventions such as stretching and deep soft tissue mobilization (STM). The purpose of this study was to determine the blood pressure (BP) and heart rate (HR) response of healthy subjects to painful stretching and deep STM. We hypothesized there would be a statistically significant increase in both HR and BP in response to both noxious deep STM and stretching. NUMBER OF SUBJECTS: One hundred five (34 female, 37 male, 34 control). MATERIALS/METHODS: A pretest-posttest control group design was used. After exclusion criteria were applied, each subject received deep STM 2 minutes or stretching for 1 minute. The interventions were randomly sequenced and sufficient rest was provided between repetitions for BP and HR to return to baseline. All interventions were performed within the subject's pain tolerance. BP, HR and pain levels were recorded both during intervention application and until return to baseline. Data Analysis Differences were calculated between the mean HR, systolic BP, diastolic BP, and pain levels that occurred during each intervention. The results of the HR and BP calculations were then analyzed using a single factor

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ANOVA at a 0.05 level of significance. RESULTS: There was no statistically significant difference (P>.05) between the control and experimental groups for age or initial HR and BP. There was a significant difference (P<.001) for HR and BP change in the group receiving stretch and in BP for the group receiving STM. There was no significant difference in HR change for the group receiving STM. CONCLUSIONS: Noxious PT interventions have a statistically significant effect on BP and HR in healthy subjects, which may have implications for patients with CV pathology. More research investigating systemic responses to common orthopedic PT interventions is needed if physical therapists are to offer best patient care as autonomous practitioners. CLINICAL RELEVANCE: It is common that PT interventions such as deep STM and stretching create varying degrees of short-term pain during application. Because physical therapists apply these interventions to patients with variable cardiac status, it is crucial to understand the CV response to these interventions. This study provides much needed insight into commonly used treatment interventions that are not well understood in terms of the CV response they elicit in our patients. Physical therapists can use this information to be more aware of CV changes that occur in patients experiencing pain during treatment. Additional research is needed to investigate CV response to common orthopedic interventions with patients who have known pathologies, impairments, functional limitations, and disabilities. We believe physical therapists can and should be a leader in this area of research. cial issues are not properly identified and may not be provided with the most optimal treatment interventions. CLINICAL RELEVANCE: A better understanding of a patient's composite profile, including psychosocial issues, can assist in developing the most appropriate evidence-based treatment interventions, leading to better patient outcomes and enhanced quality of life.



Rehabilitation Institute, Cleveland Clinic, Cleveland, OH PURPOSE/HYPOTHESIS: To evaluate the outcomes from the Cleveland Clinic IMATCH (Interdisciplinary Method of Assessment and Treatment of Chronic Headache) program using a retrospective chart review. Chronic headaches account for up to 8% of all medical visits and 10% of emergency room visits. Chronic headaches are associated with higher frequencies of head and neck trauma and are often referred to physical therapy for treatment. Anxiety, depression and other psychological disorders are commonly associated with chronic headaches. The IMATCH program is designed for headache sufferers whose lives have been severely compromised. The comprehensive nature of the program simultaneously addresses medical, physical and emotional needs, combining medical management, physical therapy and group and individual psychotherapy. NUMBER OF SUBJECTS: Consecutive series of 94 patients from 2007-2008. Inclusion criteria: adult patient evaluated by a neurologist, has exhausted all medication options without improvement, and currently has at least 15 headaches per month for 3 or more months. MATERIALS/METHODS: The IMATCH program is a standardized outpatient program. Patients are seen daily for 3 weeks and then re-evaluated at 3 months. All patients receive initial evaluations by neurology, psychology and physical therapy. Treatment plans are then individualized due to the findings of the examination and may consist of medication infusions, various muscular injections, nutrition planning, biofeedback and relaxation training. Physical therapy consists of group and individual sessions. Group sessions include cardiovascular training 3 days per week and weight training on the opposite 2 days. Individual sessions focus on improving the biomechanics of the spine and temporomandibular joints, strengthening of the neck and upper quarter as well as resolving any myofascial restrictions. Outcomes are measured via the Neck Disability Index, Headache Disability Inventory and the Dizziness Handicap Inventory. Questionnaires were provided to the patient at the initial physical therapy evaluation, at the end of the 3 week program and finally at 3 months. These 3 standardized outcome measures were chosen due to their reliability and validity. RESULTS: Preliminary results are based on data from 47 patients (n = 47). After the 3 week program a decrease was noted in all of the outcome measures (NDI, DHI, and HDI). The improvement in each outcome tool was NDI 42%, DHI 62%, and HDI 56%. Each of the improvements was considered statistically significant (P<.001). CONCLUSIONS: Our data indicates that there is significant benefit from the IMATCH program for patients with chronic headaches. The role of physical therapy may potentially be assessed by the improvement in NDI score. Additional objective measures such as CROM may further support this. CLINICAL RELEVANCE: Physical therapy may have a significant role in assisting patients with chronic headaches as evidenced by the significant changes in the disability outcomes.



Physical Therapy, University of Maryland Eastern Shore, Princess Anne, MD PURPOSE/HYPOTHESIS: The aim of this study was to determine the prevalence of outpatient physical therapy clinics within the State of Maryland that consistently screen patients for psychosocial factors. NUMBER OF SUBJECTS: A total of 120 outpatient physical therapy settings from Maryland were expected to be surveyed. Eighty-four randomly selected clinics met the inclusion criteria and agreed to participate in the study. Each county in the state was targeted, with a representation of at least 1 and no more than 5 clinics per county. MATERIALS/METHODS: A 3-item survey instrument was developed. After face and content validity were established, the survey instrument was administered by phone to all participants. Randomization occurred through a process using the business directory listings. Five zip codes for each county were randomly selected and within each zip code a random process was used to select a specific clinic. Clinics were excluded if they were owned or managed by healthcare professionals other than physical therapists. A total of 3 questions with yes/no responses were administered to the receptionist/administrative assistant responsible for coordinating the documentation that each patient is required to complete prior to the initial physical therapy evaluation. The questions administered were designed to discover if a clinic was currently using a document or series of questions to screen patients for (1) psychological or social withdraw issues, (2) depression, or (3) excessive fear of movement or fear of physical activity. The study provides summary data on comments/feedback most frequently reported by respondents after the survey had been administered. RESULTS: According to the surveys, the clinics responded that they were routinely screening patients for psychological or social withdraw issues (9.5% of the respondents), depression (8.3%) or excessive fear of movement or fear of physical activity (0%). The target sample of respondents was not obtained secondary to zip code overlap between counties and the lack of outpatient physical therapy clinics in rural sections of the state. CONCLUSIONS: Consistent patient screening for psychosocial factors in physical therapy outpatient clinics throughout the State of Maryland is clearly inadequate. These data demonstrate that patients with psychoso-



Marquette University, Milwaukee, WI

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PURPOSE/HYPOTHESIS: The benefits of exercise-induced analgesia are potentially large but the mechanisms are not well understood. Our purpose was to assess motor cortex activation during a mechanical noxious stimulus before and after isometric exercise. We hypothesized that isometric exercise would influence corticospinal excitability during a noxious stimulus. NUMBER OF SUBJECTS: Twenty-three healthy men and women (21.1 4.1 years) participated in 3 research sessions. MATERIALS/METHODS: During the first session, subjects were familiarized to the experimental set-up. During the last 2 sessions, pain perception and corticospinal excitability were assessed before and after (1) 30 minutes of quiet rest or (2) a submaximal isometric contraction (25% MVC held to task failure) with the elbow flexor muscles. Pain perception was measured through the application of a 10 N force via a Lucite edge (8 × 1.5 mm) to the right index finger for 2 minutes. Subjects pressed a timing device when they first felt pain (pain threshold) and pain ratings, using a 0-10 scale, were reported every 20 seconds. Corticospinal excitability was assessed as the amplitude of the motor evoked potential (MEP) evoked at rest in the elbow flexors muscles in response to transcranial magnetic stimulation. RESULTS: (1) MEPs increased during application of the mechanical noxious stimulus (P = .0001), and this increase was similar following 30 minutes of quiet rest (P = .77). (2) After the submaximal isometric contraction, this pain-induced increase in MEPs was significantly attenuated (P = .003). (3) Pain threshold (P = .88) and pain ratings (P = .36) did not change following the 30 minutes of quiet rest. (4) Pain threshold increased following the submaximal isometric contraction (P = .01), however pain ratings did not change (P = .11). CONCLUSIONS: The increase in corticospinal excitability during the application of a mechanical noxious stimulus is prevented with exercise. CLINICAL RELEVANCE: Regulation of pain after isometric exercise is accompanied by a down regulation of corticospinal excitability. CONCLUSIONS: Pain perception can be reliably assessed in people with Fibromyalgia using a pressure pain device but may require several sessions. Experimental pain assessment was not influenced by anxiety levels or chronic pain severity. CLINICAL RELEVANCE: Pain perception in patients with Fibromyalgia can be reliably measured using a pressure pain device, with reliability increasing with practice. Furthermore, the application of a pressure pain stimulus did not increase anxiety levels.



Physical Therapy, University of Iowa, Iowa City, IA PURPOSE/HYPOTHESIS: Fatigue is a common symptom in people with chronic musculoskeletal pain conditions such as osteoarthritis and fibromyalgia. The fatigue associated with these conditions is thought to be mediated by the central nervous system. The nucleus raphe obscurus and pallidus (NRO/NRP) are well known for their ability to modify motor output and also modulate nociception. We therefore hypothesized that fatigue would enhance the response to nociceptive stimuli through activation of neurons in the NRO/NRP. NUMBER OF SUBJECTS: Forty adult male and female C57/BL6 mice (2040 g). MATERIALS/METHODS: To induce fatigue mice were run in a running wheel for 2 hours prior to muscle insult. A control group that did not run was used for comparison. Two hours after the fatigue task the gastrocnemius muscle was injected with either the second injection of pH 5.0% or 0.03% carrageenan (20 l). Mechanical sensitivity of the paw was measured by applying increasing forces of von Frey filaments to hind paw: the number of withdrawals to 10 trials of each filament was assessed and averaged. The mechanical sensitivity of the muscle was measured by compressing the gastrocnemius muscle with tweezers: withdrawal thresholds to 3 trials were assessed and averaged. Mechanical sensitivity was measured bilaterally before fatigue and 24 hours after muscle insult. In a separate group of animals mice were anesthetized and implanted with brain cannulae into the NRO/NRP 1 week prior to the fatigue task. Either the NMDA antagonist AP5 (1 nmol/20 l) or the serotonin reuptake inhibitor fluoexetine (3.5 nmol/20 l) were microinjected immediately prior to the fatigue task. Mechanical sensitivity was measured before and 24 hours after muscle insult with pH 5.0 saline or 0.03% carrageenen. Control groups were (1) injection of vehicle with running, or (2) AP5 or fluoexetine without the run. Statistical analysis was performed with a repeated-measures ANOVA for time and group followed by post hoc testing with a Tukey test as appropriate. P<.05 was considered significant. RESULTS: The fatigue task produced a 10% reduction in muscle force immediately after the task. Two injections of pH 5.0 saline or a single injection of 0.03% carrageenan has no effect on the mechanical withdrawal threshold of the paw or the muscle in the nonfatigued group of animals. However in animals that performed the fatigue there was a significant increase in the number of responses to repeated application of von Frey filaments applied to the paw 24 hours after injection of pH 5.0 or carrageenan when compared to baseline measures or the nonfatigued group, indicating mechanical hyperalgesia. Microinjection of AP5 or fluoexetine into the NRO/NRP significantly prevented the mechanical hyperalgesia induced by fatigue and muscle insult when compared to controls. CONCLUSIONS: Muscle fatigue enhances the nociceptive response to muscle insult. This effect is mediated by the NRO/NRP and involves NMDA receptors and serotonin transporters. CLINICAL RELEVANCE: Understanding mechanisms and interactions of fatigue and pain can provide insight into treatment of pain conditions associated with fatigue.



Marquette University, Milwaukee, WI PURPOSE/HYPOTHESIS: Our purpose was to determine the repeatability of experimental pain assessment using a mechanical noxious stimulus in people with Fibromyalgia. We hypothesized that pressure-induced pain perception would not change following 30 minutes of quiet rest. NUMBER OF SUBJECTS: Fourteen women with Fibromyalgia (51.5 11.2 years) participated. MATERIALS/METHODS: Pain perception was assessed using a pressure stimulus consisting of a 5 N force applied by means of a Lucite edge (8 × 1.5 mm) to the right index finger for 2 minutes. Subjects were asked to say "pain" when they first felt pain (ie, pain threshold) and to rate their pain intensity in 20-second intervals, using a 0-10 numerical ratings scale. Pain threshold and pain ratings were measured before and after 30 minutes of quiet rest. Additional measurements included state anxiety levels, trait anxiety levels, Short-Form McGill Pain Questionnaire, and Fibromyalgia Impact Questionnaire. Of the 14 subjects, 11 repeated the session due to differences in pain thresholds greater than 10 seconds and/or pain ratings greater than 2. RESULTS: (1) Following the first session, pain threshold and pain ratings were moderately reliable (intraclass correlation [ICC] = 0.632, P = .014 and ICC = 0.555, P = .016, respectively). (2) The pain threshold and pain ratings for the subjects who completed the first session only in addition to the subjects who completed the second session had higher reliability scores (ICC = 0.829, P = .0001 and ICC = 0.743, P = .001, respectively). (3) The pressure pain test did not influence state anxiety levels (time effect; P = .932) and (4) No associations were found between pain perception and state or trait anxiety levels, Short-Form McGill Pain Questionnaire, or the Fibromyalgia Impact Questionnaire.

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Physical Therapy, Armstrong Atlantic State University, Savannah, GA PURPOSE/HYPOTHESIS: Myofascial Trigger points (MTPs) are painful to touch and produce an area of referred pain when pressure is applied. MTPs commonly cause functional limitations secondary to pain and decrease ROM. The purpose of this study was to investigate the effectiveness of ischemic pressure with and without stretching in treating active MTPs. NUMBER OF SUBJECTS: Thirteen subjects with 40 active trigger points. MATERIALS/METHODS: Thirteen subjects with 40 MTPs were randomly assigned to the control, ischemic pressure, and ischemic pressure with stretch groups. Following the localization of the MTPs, their precise location was noted and pressure/pain threshold, maximal pressure tolerance, and pain referral patterns were assessed. Ischemic pressure was applied for 90 seconds. In the ischemic pressure plus stretch group, stretching was done for 30 seconds following the ischemic pressure application. This protocol was performed 2 times per week for 3 weeks. The control MPTs had only the prepost testing and received no treatments. Subjects were asked to maintain their current level of activity and to inform testers of any medication use. Analysis of variance (ANOVA) for repeated measures was performed followed by post hoc 2-tailed paired t tests with the alpha level set at .05. RESULTS: Ischemic pressure or ischemic pressure plus stretching produced significant increases in both the pressure/pain threshold and maximal pressure tolerance. There were no changes in the control MTPs. There were significant differences between the ischemic pressure intervention treatment and control and between the ischemic pressure and stretch treatment and control for both pressure/pain threshold and maximal tolerance. Of the 8 MTPs in the ischemic pressure group, all had decreased or completely eliminated referral patterns. Of the 15 MTPs treated with ischemic pressure plus stretch, 13 of those points had elimination of their referral pattern, while 2 had worsening of the referral pattern. Among the 17 control MTPs, 8 got worse, 7 were eliminated or improved, and 2 remained unchanged. CONCLUSIONS: When ischemic pressure and ischemic pressure with stretch were used to treat active MTPs there were significant increases in pressure/pain threshold and pressure tolerance levels and elimination or decreases in the referral pattern. These increases in pressure/ pain threshold and pressure tolerance and decreases in the referral pattern indicate improvement of the condition of the MTP following these interventions. CLINICAL RELEVANCE: Ischemic pressure or ischemic pressure with stretch is useful in treating the pain associated with MTPs.

weeks participants completed a visual analog stress scale (VASS), McGill pain questionnaire short form (SF-MPQ), and pain body diagram. Pain topography was quantified from daily pain body diagrams using the "rule of nines" modified for enhanced precision. Four independent raters determined all pain topography scores. Temporal relationships between stress and delayed changes in pain topography were analyzed using serial lag correlations. Daily stress scores were correlated with pain topography for same-day and each consecutive day's topography scores up to a 14-day lag. RESULTS: Serial lag comparisons revealed very weak correlations between stress and pain topography on the same day, ranging from r = ­0.05 to ­0.16. Two of the participants showed significant lag correlations between stress and topography of pain occurring 10 days later (r = +0.50 and +0.64), with secondary correlations between stress and pain 3 days later r = +0.35 and +0.29). Both participants displaying the 10-day delay were on consistent time-contingent pain medication dosing schedules, while the third participant was self-administering a pain cocktail, varying daily in composition and dosage prn. For the 2 participants showing episodic lags not all peak pain episodes were preceded by peak stress 10 days previously, but, every peak stress day was followed 10 days later by a marked pain topography increase. CONCLUSIONS: Two of the 3 participants with FS showed marked increases in pain topography 10 days after salient stressful events. For these participants delayed pain flares appear to impact not only the intensity but also topographic spread of perceived pain. CLINICAL RELEVANCE: Pain topography may have strong bearing on painrelated function and be an important indicator of disease severity, progress, or resolution. Knowledge of stress-related delayed pain topography changes may help patients and therapists better understand the seemingly inexplicable spread and retreat of painful symptoms over time, and discriminate between stress-related flares and those brought on by increases in home, work, or therapeutic activity.



Physical Therapy, University of Puget Sound, Tacoma, WA PURPOSE/HYPOTHESIS: This study's aim was to investigate a hypothesized mechanism for recent findings that delayed pain flares frequently occur 10 days after stressful events in patients with complex regional pain syndrome (CRPS). Specifically, this study assessed temporal relationships between daily stress, perceived pain intensity, pain-related function, and serum levels of the stress-related hormone thyroxine in a patient with CRPS. NUMBER OF SUBJECTS: The participant in this single-case design was a 54-year-old female with a 5-year history of right lower extremity CRPS, following first metatarsal spiral fracture. She had normal thyroid function, no history of thyroid-related disease, and was on stable time-contingent neurontin for pain. MATERIALS/METHODS: Each day, over 10 weeks, the participant completed a visual analog stress scale, visual analog pain scale, individualized visual analog function scale, the SF-MPQ, and submitted daily blood draws for thyroxine (T4) analysis. Free serum T4 levels were determined using microplate enzyme immunoassays, yielding a free T4 index (FTI) and 2 independent blind assessments of free T4. Relationships between stress, pain, and FTI were analyzed using serial lag correlations. Stress scores were correlated with pain and T4 for same-day as well as each consecutive day's pain and T4 scores up to a 14-day lag. Same-day Pearson product-moment correlation coefficients were calculated between pain and free T4. RESULTS: Over 10 weeks the participant experienced 4 peak stress episodes and 8 pain flares. Each stress episode was followed 10 days by peak free T4 exceeding the upper limit for normal adult range. Serial lag correlations yielded the strongest relationship for pain experienced 10 days



Physical Therapy, University of Puget Sound, Tacoma, WA PURPOSE/HYPOTHESIS: For patients with fibromyalgia syndrome (FS) recent literature established that psychogenic stress can trigger delayed pain intensity flares appearing 10 days after inciting events. A pain parameter not yet studied in this context is the extent of affected body regions perceived to be painful. The purpose of this study was to investigate delayed changes across time due to psychogenic stress in the topographic distribution of pain symptoms for patients with FS. NUMBER OF SUBJECTS: Participants included 1 male and 2 female patients with FS, ages 46, 60, and 67 years. Time since FS diagnosis ranged from 3 to 17 years. All subjects reported episodic variation in pain intensity and topography. MATERIALS/METHODS: This was a single subject design. Each day for 10

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after a stressor (r = +0.28, P<.05). FTI was correlated most highly with stress 10 days following stressful episodes (r = +0.43, P<.001). Same-day pain and FTI were correlated at r = +0.65, P<.001. Pain-related function was similarly influenced by this delay (r = ­0.88, P<.01). Each time the participant experienced a stressful episode a notable peak in free T4 followed 10 days later and was accompanied by a salient pain flare and drop in function. CONCLUSIONS: The temporal relationships observed in this study support the hypothesis that pain flares following 10 days after stressful events may be related to psychogenic release and activity of thyroxine, in a patient with CRPS. CLINICAL RELEVANCE: Elevated thyroxine can increase pain perception through direct effects on nociceptive axons and its activation coincides with the ten-day delay observed in patients with neuropathic pain. This study's findings support the hypothesis that psychogenic release of thyroxine may be a hormonal mechanism explaining some delayed pain flares, thereby helping patients and therapists discriminate stress-related flares from those caused by poor activity pacing or therapeutic activity intensity. jor stretching should be a treatment consideration prior to surgical intervention in males with orchialgia who have developed decreased hip flexor muscle length.



Department of Physical Therapy, Mount Saint Mary's College, Los Angeles, CA; Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA PURPOSE/HYPOTHESIS: Knee disorders are prevalent within the professional dance community. Although jumping activities have been associated with the development of patellar tendinopathy and other knee disorders, research examining the biomechanics of dance-specific jumping is sparse. Therefore, the purpose of this study was to examine vertical ground reaction forces and knee net joint moments during the takeoff and landing phases of grands jetés performed by elite dancers. We hypothesized that the vertical ground reaction forces during the landing phase would exceed those of the takeoff phase, and that this would be manifest as differences in peak knee net joint moments. NUMBER OF SUBJECTS: Eight dancers (6 female, 2 male; 18-24 years old; mean of 19.5 2.1 years) without known knee pathology, who were participating in a multidisciplinary preprofessional training program were recruited. MATERIALS/METHODS: Three-dimensional kinematics (8-camera Vicon system, 250 Hz) and ground reaction forces (AMTI, 1500 Hz) were collected while each dancer performed a minimum of 3 grands jetés. Lower extremity net joint moments were calculated using Visual 3-D software. Peak vertical ground reaction forces (GRFv) expressed in multiples of body weight (xBW), and peak sagittal plane knee net joint moments normalized to body mass, were analyzed during the takeoff and landing phases of the grand jeté. Data from all subjects are presented as means SD (range). Differences between the 2 phases for each variable were explored using a paired-samples t test with a significance level of = .05. RESULTS: Peak GRFv were significantly greater (P = .05) during the landing phase 4.88 1.36 xBW (2.92-8.28 xBW) than during the takeoff phase 3.59 0.75 xBW (2.52-5.35 xBW). However, there was no significant difference (P = .87) between the peak knee net joint extensor moments for the landing phase, 2.26 0.68 Nm/kg (0.95-3.90 Nm/kg), as compared to the takeoff phase, 2.41 0.48 Nm/kg (1.88-3.47 Nm/kg). CONCLUSIONS: Peak GRFv were greater during the landing phase than the takeoff phase of a grand jeté. This was not manifest as a significant difference in the peak knee net joint extensor moments. Future research exploring lower extremity joint kinematics, knee net joint moments in other planes, as well as net joint moments at the hip and ankle may provide additional insight into the biomechanics of jumping in dance. CLINICAL RELEVANCE: These preliminary findings indicate that neither the takeoff phase nor the landing phase of a grand jeté can be deemed potentially more injurious than the other, with respect to knee joint loading in the sagittal plane. Greater understanding of the kinetic characteristics of common jumping activities, as performed by healthy dancers, may lead to the identification of key modifiable factors in jump performance. The evolution of preventative interventions based upon such insights would greatly serve dancers, who are predisposed to the development of knee disorders.



Physical Therapy, University of Puget Sound, Tacoma, WA. BACKGROUND & PURPOSE: Orchialgia is persistent pain perceived as originating from the testicles, frequently treated via orchiectomy (surgical testicular resection). In some instances the site of pain generation may be neuropathic rather than testicular. The genitofemoral nerve is the source of somatosensory innervation to the region. As this nerve travels from its L1-2 spinal origins it pierces the psoas major muscle. Tightness of the psoas major muscle is hypothesized to impinge or irritate the genitofemoral nerve, thus generating perceived orchialgia via mechanical genitofemoral neuralgia. These two cases present results of a program of hip flexor stretching attempting to attenuate persistent phantom orchialgia in patients where prior orchiectomy failed to eliminate the pain. CASE DESCRIPTION: Two males, ages 79 and 67, with persistent orchialgia unrelieved by prior orchiectomy participated in this investigation. In the case of the younger participant a genitofemoral nerve block temporarily relieved the pain complaint, however, neural ablation surgery was refused by the patient. Both participants were introduced to physical therapy via involvement in a multidisciplinary pain program. Upon initial evaluation, both were found to have clinically significant hip flexor tightness on the involved side. Each patient then participated in 12 weeks of hip flexor stretching focused on easing psoas major impingement on the genitofemoral nerve. Treatment consisted of therapeutic ultrasound with passive cool-on-stretch to the distal psoas major tendon (BIW) and home stretches (BID). A visual analog pain scale assessed changes in orchialgia intensity. Goniometric assessment of hip flexion in the Thomas Test position quantified hip flexor length. Measures were made BIW and correlated across treatment sessions to determine the influence of hip flexor stretching on testicular pain intensity. OUTCOMES: Patient 1 reported pain intensity reduction from 7.2/10 pretreatment to 2.0/10 post-treatment. Patient 2 reported total elimination of pain from pretreatment average of 4.6/10. Pearson product moment correlation coefficients between hip flexor length and reported pain were r = ­0.63 and ­0.71 for the two patients respectively. Pain reductions were still evident at 3-month follow-up. DISCUSSION: In two patients with orchialgia, both previously treated unsuccessfully with orchiectomy, easing genitofemoral nerve irritation via hip flexor stretching produced notable orchialgia relief. For male patients with testicular pain if genitofemoral neuralgia is present and a Thomas Test provokes symptoms, initial conservative physical therapy treatment of hip flexor stretching may be indicated. Considering the major quality of life impact to the adult male of orchiectomy conservative psoas ma-



Department of Biokinesiology and Physical Therapy, University of South-

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ern California, Los Angeles, CA PURPOSE/HYPOTHESIS: Dancers formerly trained in jazz, modern, or ballet are prone to the development of knee pathology. The biomechanical factors associated with this development have not been rigorously explored within the context of dance-specific movements. A description of patterns within these movements is needed in order to create a baseline for comparing healthy dancers to those with pathology. Therefore, the purpose of this study was to describe lower extremity joint kinetics during the takeoff phase of a grand jeté performed by elite dancers. Specifically, peak hip, knee, and ankle net joint moments in the sagittal plane and the relative contribution of each joint to the support moment were examined. NUMBER OF SUBJECTS: Ten dancers (4 males, 6 females; age range, 18-24 years; mean, 19.6 1.6 years) without known knee pathology, trained in jazz, modern, and ballet, who were participating in a preprofessional dance training program. MATERIALS/METHODS: Three-dimensional kinematics (8-camera Vicon system, 250 Hz) and ground reaction forces (AMTI, 1500 Hz) were collected while each dancer performed a minimum of 3 grands jetés. Lower extremity kinematics and net joint moments were calculated using Visual 3-D software. The stance phase was divided into 3 subphases: initial transient phase, extensor phase, and terminal transient phase. The peak hip, knee, and ankle net joint moments (normalized to body mass) in the sagittal plane, and the support moments (sum of the averaged hip, knee, and ankle net joint moments) during the extensor phase were examined. Furthermore, each joint's contribution to the support moment across the extensor phase was calculated. Finally, the temporal characteristics of the peak net joint moments and each joint's contribution to the support moment were recorded. Data for all subjects were presented descriptively as means SD. RESULTS: The peak net joint moments experienced during the extensor phase of takeoff at the hip, knee, and ankle were extensor moments of 3.6 0.8 Nm/kg, 2.3 0.6 Nm/kg, and 4.0 0.6 Nm/kg, respectively. Each joint's contribution to the support moment during the extensor phase was 28.6% 5.0% from the hip, 22.2% 6.8% from the knee, and 49.2% 4.7% from the ankle. The peak net joint moments occurred earliest at the hip (26.0% 7.7% of takeoff ), followed by the knee (49.6% 4.8% of takeoff ), and the ankle (57.7% 3.8% of takeoff ). The same temporal pattern was observed for the maximal contributions to support moment, which were 54.4% 18.2% for the hip, 27.5% 6.8% for the knee, and 67.8% 20.1% for the ankle. CONCLUSIONS: The takeoff of a grand jeté is governed by the hip and ankle, as reflected by their net joint moments and the contributions of these joints to the support moment. CLINICAL RELEVANCE: Understanding the kinetics involved in the takeoff of a grand jeté provides a baseline for future comparisons between healthy and symptomatic dancers. This knowledge may also serve to enhance the teaching and training of this skill within the dance community.

3-minute step test using an accelerated step protocol. Resting and maximal heart rates were recorded at the start and end of each test and HRR was recorded 1-minute following test completion. Fitness rankings were assigned to each dancer based on age and HRR. Differences in HRR between companies were assessed with univariate ANOVA analyses (P<.05). RESULTS: Complete screens were obtained from 152 subjects (72 male, 80 female), age 24.7 ( 5.1) and 5.9 ( 5.0) years of professional experience. There were differences between companies in age and years of experience but not in gender. M1 dancers were older (28.3 5.6 years) than M2 (21.7 1.2), B2 (age 19.2 2.5), and B5 (age 22.9 4.9). M1 dancers had longer professional careers (9.0 5.0 years) than M2 (1.9 1.2), B2 (1.7 1.8, P = .14), B4 (5.0 6.3), and B5 (5.0 4.5). HRR of all participants averaged 87 bpm ( 14.5; range 54-131). One hundred thirty-one dancers (86%) were categorized as "fit" (excellent, good, or above average fitness categories). There was no effect of age, gender, years of experience, or cigarette smoking on the fitness categories of the participants. Pearson product moment calculations revealed no correlation between the subjects' resting systolic blood pressure, resting HR, or maximal HR and their fitness category. Ninety-two percent of modern dancers and 84% of ballet dancers were categorized as "fit." Post hoc comparisons revealed companies M1 and B1 had a greater number of "fit" dancers than B4 and B5, and company B3 had a greater number of "fit" dancers than company B5. CONCLUSIONS: Differences in CR fitness levels exist between modern and ballet dancers. Off-season exercise training or variations in performance seasons may influence these differences. In these companies, work weeks ranged from 33 to 47 and performances from 58 to 169. Repertory may also differ in length and aerobic challenge. Our accelerated step test uses methods that have been shown to accurately reflect an individual's CR fitness. These results support the inclusion of this step test as part of a comprehensive physical fitness screen to identify dancers who could benefit from aerobic conditioning to enhance overall performance ability. Further studies should investigate modifications of step test protocols for highly trained individuals. CLINICAL RELEVANCE: This accelerated step test is a safe and simple method for estimating CR fitness in dancers. A dancer who scores below fitness level `2' (`average') may benefit from additional CR training to better prepare them for performing various dance activities.



Physical Therapy, Virginia Commonwealth University, Richmond, VA PURPOSE/HYPOTHESIS: The purpose of this study was to determine values for lumbopelvic posture control of university modern dancers and determine its relationship to dancer skill level. NUMBER OF SUBJECTS: A convenience sample of 40 BFA dance majors at a university participated in the study. MATERIALS/METHODS: The equipment used was the Chattanooga pressure biofeedback unit. No available studies have reported data on the use of this equipment in dancers. Demographic information was collected on participants. Participants were tested on lumbopelvic control in up to 7 supine positions using the biofeedback unit. Each subsequent position becomes increasingly challenging to maintain neutral spine/core support. If a dancer was unable to maintain the pressure setting within 10 mmHG the trial was unsuccessful. Dancer skill level was observed in class and independently assessed by 2 faculty members. Correlations were completed for relationships between demographics, performance on the core testing, and skill level of the dancer (P<.05). RESULTS: Eleven students (27.5%) completed levels 6 and 7 of biofeedback testing. There were no significant differences between upper and lower classmen. There was no difference between any demographic variables



Dept of Rehabilitation and Movement Sciences, University of Medicine and Dentistry of New Jersey, Newark, NJ; ADAM Center, Long Island University, Brooklyn, NY PURPOSE/HYPOTHESIS: Several studies have investigated physical demands of dance in terms of cardiorespiratory (CR) fitness. None compare fitness levels in professional dancers of different genres. We investigated differences in heart rate recovery (HRR) between professional modern and ballet dancers with a standardized step test. NUMBER OF SUBJECTS: One hundred sixty-five professional dancers. MATERIALS/METHODS: Fifty-one modern dancers from 2 companies (M1, M2) and 101 ballet dancers from 5 companies (B1-B5) performed a

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and test performance. There was no significant correlation between biofeedback testing and skill level. CONCLUSIONS: The biofeedback unit may be used for testing core support in a screening. The test does not appear to correlate well with the dynamic core aspects of dancing. Additional dynamic measures of core support may better assess dancer abilities. CLINICAL RELEVANCE: Physical therapists working with dancers may conduct preseason screenings. Core support is usually included in the screening process. It is important to determine the most effective screening methods to assess core support and to determine which tests will best provide information related to the dynamic nature of dance so that the physical therapist can appropriately identify dancers with poor core support which may increase risk of injury.

PURPOSE/HYPOTHESIS: Hip Hop dance has exploded into a popular international art form. With the increasing rate of participation in hip hop dance, it is important for the medical community to understand injury rates and patterns in this population. There are several case reports on breaking injuries, but to our knowledge, there are no published studies on injury prevalence and patterns in this population. The purpose of this study was to determine injury incidence and patterns in hip hop dancers. NUMBER OF SUBJECTS: n = 312. MATERIALS/METHODS: Survey participants were recruited at dance events in the United States and internationally. Data were collected over a 6-month period using a Web-based survey. Inclusion criteria included intermediate and advanced level dancers over the age of 13. Dancers were divided into 2 main categories (Old School and New School). Old School dancers were further divided into 3 subcategories (Pure Breakers, Breakers-plus, Poppers/Lockers). Separate ANOVAs compared injury pattern differences between groups. Relative risks (RR) and odds ratios (OR) with 95% confidence intervals were calculated. RESULTS: Three hundred twelve dancers (143 M, 169 F), mean age 24 years (range, 13-44) completed the survey. Two hundred twenty-seven dancers (73%) reported a 5-year total of 922 injuries, with an average of 4.1 injuries per injured dancer. Cumulative injury incidence was 296% (231% for the most recent year of injury [Year 1]) with no differences due to age category, gender, or experience. There were, however, differences in injury rates by dance style (F1,3 = 6.13, P<.01). Breakers (Pure and Plus) had higher incidences of injuries (P<.01) compared to nonbreakers (Poppers/Lockers and New Schoolers). Lower extremity injuries accounted for more than half of the total injuries (55%), with foot and ankle (20%) the most commonly injured of all body areas. Forty-eight percent of all injuries to the foot and ankle were ankle sprains. Upper extremity injuries represented 29% of total injuries, with the majority of these occurring in the hand (10%). The most common injuries to the hand were finger dislocations (27%), fractures (22%), and ligament ruptures (12%). The most common tissues injured were muscle/tendon (29%), followed by joint (nonbone)/ligament (25%), and bone stress/fracture (11%). In terms of injury severity, most injuries (65%) were minor, involving less than 1 week of lost time. Moderate (8-28 days) and severe (>28 days) injuries were 19% and 14% of total injuries, respectively. The incidence of severe injuries was slightly higher in the lower extremity (7%) compared to the upper extremity (5%). CONCLUSIONS: These data suggest that hip hop dancers suffer injuries at alarming rates. There is an apparent need for education with respect to injury prevention and access to health care for musculoskeletal injuries. CLINICAL RELEVANCE: With the increasing rate of participation in hip hop dance, it is important for the medical community to understand injury rates and patterns in this population.



ADAM Center, Long Island University, Brooklyn, NY PURPOSE/HYPOTHESIS: Hip Hop has many styles of dance including breaking, house, popping, and locking. Hip Hop dance movements combine the complexity of dance choreography and postures with the challenges of gymnastics and acrobatic movements. To date, there is no research concerning the biomechanics of Hip Hop dance. The purpose of this study was to analyze the kinematics and kinetics of selected choreographed sequences. NUMBER OF SUBJECTS: Six female dancers (B-girls), mean age 31 4.3 years (range, 25-35), with a mean of 13.5 6.6 years of Hip Hop dance experience. MATERIALS/METHODS: Three sequences were studied: Top Rock, More Breaking, and House. Each sequence had multiple steps. Kinematic data were collected with a 6-camera motion capture system (120 Hz) and 2 force platforms (1080 Hz). Hip, knee, and ankle peak angular displacement, moments, and vertical ground reaction forces (GRF) were determined. Repeated-measures MANOVA analyzed 2 factors: sequence and step (P<.05). RESULTS: There were differences between sequences and steps in hip, knee, and ankle angular displacement. The angular displacements of the More Breaking sequence, which included floorwork, exceeded the other 2 sequences. There were also differences between sequences in vertical GRF and knee internal rotation and ankle plantar flexion moments. CONCLUSIONS: Peak angular displacements suggest that B-girls work at weight bearing joint extremes where muscles are at a functional disadvantage. GRF were not excessive (range, 1.5 to 2.5 BW for each limb). The multi-directional movements resulted in joint moments in the frontal and transverse planes that exceed those in activities that are sagittal plane dominant. With several exceptions (hip and knee extension, hip adduction, and ankle plantar flexion), hip, knee, and ankle moments were 1.5 to 10 times those reported in running. Hip hop moment patterns were also very different from other nonsagittal plane dominant activities that include crossovers, cutting, pivots, and turns. Several factors may explain this finding: (1) rapid tempos and changes of directions, and (2) types of turns and pivots. Frontal and transverse plane moments may be more stressful to joints, particularly at the knee and ankle. These different moment patterns help to explain the high ankle and knee joint injury rates reported in a recent survey. CLINICAL RELEVANCE: Hip Hop dancers are a neglected population sustaining high injuries that may result from biomechanical stressors. They represent a culture with unmet training and medical needs.



Arizona Ortho Sports Physical Therapy, Peoria, AZ BACKGROUND AND PURPOSE: Use of the movement system impairment diagnosis system is effective in determining a musculoskeletal cause of a patient's complaints and guiding treatment specific to correct movement impairments related to the patient's complaints. CASE DESCRIPTION: Forty-six­year-old male presented to the clinic with an 8-month insidious onset of right superior/anterior shoulder pain. The patient reported 1/10 right shoulder pain at rest that increased to 8/10 pain with overhead lifting. The patient works as a communications technician where he was having difficulty lifting up to 25 lb. overhead with use of his right arm secondary to his symptoms. He also reports symptoms with lifting activities during performance of his hobby of repairing cars. The cervical region was cleared. The patient presented with a



ADAM Center at Long Island University, Brooklyn, NY; Nike Sports Research Laboratory, Beaverton, OR

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kyphotic posture, forward head, and bilateral scapular depression. He demonstrated insufficient elevation with performance of active shoulder flexion and abduction, which reproduced his superior/anterior shoulder pain. Manual scapular elevation was provided during performance of scapular flexion and abduction movements, which decreased his symptoms. Following evaluation, the patient was given a diagnosis of Right Scapular Depression Syndrome. A specific exercise program was prescribed to address the movement impairments that reproduced the patient's symptoms. These exercises addressed motor control changes as well as muscle length, strength, and stiffness deficits found to be contributing to the movement impairments and the patient's symptoms. OUTCOMES: The patient was seen for a total of 9 visits over a period of 6 weeks. Following the 6 weeks the patient was able to perform all job duties and car repair hobbies without shoulder symptoms. The patient met all functional goals that were set at initial evaluation. The visual analog pain scale decreased from a 1/10 at rest to 0/10 at rest and 8/10 with overhead movements to 0/10 with overhead movements. DISCUSSION: The use of movement system impairment diagnosis was effective in guiding treatment and intervention for a patient with right superior/anterior shoulder pain. Specific therapeutic exercises were proved to correct movement impairments that reproduced the patient's symptoms and correct muscle imbalances related to those movement impairments. Use of the movement system impairment diagnosis is effective in determining a musculoskeletal cause and implementing appropriate treatment in patient care. findings need to be confirmed in larger, more equivalent samples. CLINICAL RELEVANCE: A shortened pectoralis minor muscle has been hypothesized to lead to subacromial impingement although no data exists to support this hypothesis. Our data suggests that positive impingement findings are common in overhead athletes but are probably multifactorial and related to overuse. Pectoralis minor shortness may be 1 contributing factor and may be more prevalent in throwers.



Physical Therapy and Assistive Technology, National Yang-Ming University, Beitou District, Taipei, Taiwan; Rehabilitation Medicine, Cheng Hsin Rehabilitation Medicial Center, Taipei, Taiwan PURPOSE/HYPOTHESIS: Several studies have found the impaired proprioception and abnormal muscle recruitment patterns of the rotator cuff and scapular muscles in subjects with subacromial impingement syndrome (SAIS). Inadequate neuromuscular controls of shoulder girdle may influence the ability to perform a coordinated movement during a functional task of daily living, such as arm elevation. A novel machine Monitored Rehab Cable Column (MRCC) System allows for evaluating the proprioception and movement coordination of the upper extremity. Several trajectory-tracking tasks can be designed with the MRCC system to assess the reposition accuracy and motor coordination of a specific limb movement. The purpose of this study was to evaluate the reliability of the MRCC system in assessing proprioception and motor coordination in subjects with SAIS. NUMBER OF SUBJECTS: Twenty-eight subjects with SAIS (6 males, 22 females; mean age, 50.46 10.61 years) participated in this study. MATERIALS/METHODS: While observing the target trace on a monitor each participant was required to perform a series of shoulder abduction on the scapular plane by pulling up and down the cable which was connected to a 5-kg weight. In the proprioception test, subjects needed to remember a target position set by the machine and tried to reposition to that position. The coordination test consisted of 30 seconds of target tracking by controlling the arm movement. Three repetitions of the proprioception test and 2 repetitions of the coordination test were conducted. Only the affected arm was tested. Intra-session test-retest reliability was calculated for each test using the intraclass correlation coefficients (ICC). Standard error of mean (SEM) for each test was also calculated. RESULTS: Proprioception test demonstrated moderate reliability with the ICC = 0.73 and SEM = 0.98. Reliability of coordination tests were moderate to good (ICC = 0.66-0.83, SEM = 0.24-0.35). CONCLUSIONS: Upper-limb tracking-trajectory tests with the Monitored Rehab Cable Column System can be a reliable measurement to assess neuromuscular control ability in subjects with SAIS. CLINICAL RELEVANCE: This method of assessing the motor control ability may be sensitive to determine the movement impairments in subjects with SAIS.



Physical Therapy, Arcadia University, Glenside, PA PURPOSE/HYPOTHESIS: The purpose of this study was to determine the effects of shoulder dominance and the presence of subacromial impingement signs on pectoralis minor length in athletes involved in overhead intensive sports. A second purpose was to compare the findings in throwing athletes with swimmers. NUMBER OF SUBJECTS: Thirty-five collegiate throwing athletes (baseball, softball, water polo) and 22 high school swimming athletes. All athletes were actively participating in their sport and were not seeking medical care for shoulder symptoms. MATERIALS/METHODS: Athletes were examined for impingement symptoms (Neer, Hawkin's and Jobe tests) and any positive test was considered a sign of impingement. The lengths of the pectoralis minor muscle and clavicle were measured using an electromagnetic digitizer or a special caliper. Pectoralis minor length was measured as the distance from the coracoid process to the costochondral junction of the fourth rib. Clavicle length was measured as the distance from the sternoclavicular joint to the acromioclavicular joint. A Pectoralis Minor Index (PMI) was calculated in order to represent the pectoralis minor muscle length as a percentage of the clavicle length. t tests were performed to compare shoulders with and without impingement, as well as dominant shoulders to nondominant shoulders in both throwers and swimmers. RESULTS: Mean PMI values were not different between shoulders with and without impingement in either throwers (87.6 versus 89.6, P = .14) or swimmers (90.1 versus 91.5, P = .27). Mean PMI values revealed a shorter pectoralis minor muscle on the dominant side in throwers (87.2 versus 90.7, P<.001) but no difference between dominant/nondominant sides in swimmers (91.0 versus 90.7, P = .41). CONCLUSIONS: The presence of positive impingement signs was not associated with a shorter pectoralis minor in either group of athletes. Athletes involved in throwing sports show shorter pectoralis minor muscles on the dominant side while swimming athletes did not. Pectoralis minor shortness may be attributable to unilateral intensive shoulder use. These



Physical Therapy and Assistive Technology, National Yang-Ming University, Beitou District, Taipei, Taiwan PURPOSE/HYPOTHESIS: Subacromial impingement syndrome (SAIS) is the most commonly diagnosed condition involving the shoulder and is associated with pain and a loss of function. Because of the anatomic relationship, alignment of the cervical and thoracic spine can influence the static position and dynamic movement of the shoulder complex. Poor static posture of upper quarter (forward head posture and increased thoracic

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kyphotic posture) is considered one of the contributing factors to SAIS. However, no study was found in the literature examining the dynamic relationship between the arm movement and the dynamic posture of the spine for subjects with SAIS. The purpose of this study was to investigate whether changes of the upper quarter posture during the arm elevation were different between subjects with and without SAIS. NUMBER OF SUBJECTS: Participants included 22 subjects with SAIS (mean age, 47.1 13.5 years) and 22 age-, gender- and hand dominancematched control subjects (mean age, 47.6 14.1 years). MATERIALS/METHODS: An electromagnetic device (LIBERTY system) was used to measure the upper quarter alignment and movement. Seven electromagnetic sensors were fixed on the head, the sternum, the scapula, the posterior aspect of distal humerus, and the spinous processes of T1, T6, and T12 to capture the scapular kinematics, the cervical and thoracic spine static posture and dynamic movement during a unilateral arm elevation movement on the scapular plane. RESULTS: Subjects with or without SAIS demonstrated that heads moved to a more anterior and inferior position during the arm elevation movement. This resulted in decreasing the distance between the head and the trunk reference point. Subjects with SAIS demonstrated less distance than controls throughout the whole phases of arm movement. During arm elevation the control subjects extended their upper thoracic spine while subjects with SAIS flexed their upper thoracic spine. The difference between these 2 distinct movement patterns were statistically significant at most angles of the arm movement (P = .002-.027). However, no difference of the static upper quarter posture was found between the 2 groups. CONCLUSIONS: Compared to the control subjects, the posture of subjects with SAIS deviated to a more slouched position with more flexed upper thoracic spine and more head movement during the arm movement. We believe that the slouched posture was adapted by subjects with SAIS to set the stage for undue stress and strain on shoulder complex and could be a contributing factor in the development of shoulder pain. Aberration of the upper quarter posture in subjects with SAIS was not only observed in a static position, but occurred during the arm movement. CLINICAL RELEVANCE: Findings of this study highlight the importance of assessing and treating dynamic movement of the cervical and thoracic spine during arm elevation movement for subjects with SAIS. Retrain the correct movement pattern for the cervical and thoracic spine during the arm elevation needs to be considered when treating SAIS.

RESULTS: Fourteen examples of the spinoglenoid ligament were found. In

4 of the shoulders, the difference between the size of the neurovascular bundle and the space through which it traveled was less than 2.0 mm; in 6 others it was less than 5.0 mm. CONCLUSIONS: Combining our past and current findings, the incidence of the spinoglenoid ligament is 22/138 or 16%. This agrees most closely with Bektas et al who identified a spinoglenoid ligament in 5/32 shoulders (15.6%) and Cummins et al who noted the presence of a distinct ligament in 22/112 shoulders (20%). Other studies which cited a higher incidence used a less stringent definition of the ligament. The lack of consistent criteria in identifying the spinoglenoid ligament may account for the variability in its cited incidence. The small difference between the size of the neurovascular bundle and the space through which it travels, noted in several of the shoulders, suggests that perhaps these individuals might be more prone to nerve compression. CLINICAL RELEVANCE: The spinoglenoid ligament may compress the suprascapular nerve resulting in symptoms such as isolated infraspinatus weakness, atrophy and pain in the scapular region. This has previously been reported as a relatively rare occurrence. We found that the difference between the size of the neurovascular bundle and the space through which it traveled was less than 2.0 mm in 4 of the shoulders and less than 5.0 mm in 6 others. This lack of space suggests that nerve compression may be more likely to occur in these individuals, indicating the possibility of a much higher incidence than the 1% to 2% incidence that has been previously cited. This should be considered in cases when traditional therapy is not providing the expected results.



Physical Therapy, AT Still University, Arizona School of Health Sciences, Mesa, AZ; Athletic Training, AT Still University, Arizona School of Health Sciences, Mesa, AZ PURPOSE/HYPOTHESIS: The use of proprioceptive neuromuscular facilitation (PNF) for strengthening is a commonly used therapeutic intervention for patients with musculoskeletal and neuromuscular dysfunction. PNF is clinician-intensive due to the provision of manual resistance, thus resisting with elastic bands is also common in clinical practice. This lessens the burden on clinicians and allows patients to perform functional resistance training independently. It is not clear from previous studies whether the therapeutic benefits of PNF are similar when using resistive equipment and manual resistance. Therefore, the purpose of this study was to determine if upper extremity muscle activity differed when a PNF diagonal extension pattern (D2E) was resisted manually (MAN) or with an elastic band (BAND). NUMBER OF SUBJECTS: A convenience sample of 40 healthy subjects (age, 25.6 3.0 years; height, 68.5 4.1 in; weight, 166.3 35.6 lb), with no history of upper extremity injury within the previous 6 months, was recruited into the study. MATERIALS/METHODS: A randomized cross-over design was used to test for differences in shoulder muscle activity during D2E MAN and BAND resistance for all subjects. Surface electromyography (sEMG) measured muscle activation of anterior, middle, and posterior deltoids, biceps brachii, sternal portion of pectoralis major, and latissimus dorsi. Maximum voluntary isometric contraction for each muscle was obtained to normalize sEMG data. Subjects performed 10 repetitions of shoulder flexion, external rotation and abduction to shoulder extension, internal rotation, and adduction (D2E) for each condition. The same visual and auditory cues were provided in both conditions. Smoothed and rectified sEMG recordings from the middle 4 trials of each condition were analyzed. Repeated-measures ANOVA (hand dominance by condition by muscle) were performed for peak and mean muscle activation. Data were



University of Cincinnati, Cincinnati, OH PURPOSE/HYPOTHESIS: The spinoglenoid ligament is an inconsistent ligament originating on the scapular spine and attaching to the glenoid neck. In a previous study, we examined 48 cadavers (96 shoulders) and identified 8 spinoglenoid ligaments. The purpose of this study is to continue to establish the incidence of the spinoglenoid ligament and, when the ligament is present, to quantify the size of the space through which the suprascapular nerve and vessels travel. The size of the space may contribute to the incidence of nerve compression. NUMBER OF SUBJECTS: Twenty-one cadavers (42 shoulders). MATERIALS/METHODS: Twenty-one cadavers (42 shoulders) were examined for the presence of the spinoglenoid ligament which was defined as a dense fibrous band attached to the scapular spine and the glenoid neck and which was able to withstand moderate pulling with a probe. The width of the neurovascular bundle containing the suprascapular nerve, artery and vein was measured after it passed beneath the ligament. The space between the approximate midpoint of the ligament and a point on the scapular spine adjacent to the spinoglenoid notch was also measured using a Fisherbrand traceable digital carbon fiber calipers.

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normalized with a natural log transformation due to skewness. RESULTS: A significant interaction was found between condition and muscle (P<.05) for both peak and mean muscle activation. Follow-up comparisons using a Sidak correction (P = .009) revealed that anterior and posterior deltoid muscles were significantly more active in MAN than BAND condition. There was a significant main effect of condition (P<.01) for both peak and mean activation, with greater activation in the MAN condition. CONCLUSIONS: Manual resistance during a D2E PNF pattern produces greater activation of select shoulder muscles than elastic band resistance, suggesting an increased benefit of manual resistance over the use of elastic bands. However, it is unclear whether these statistical findings translate into a clinically meaningful difference. CLINICAL RELEVANCE: Manual contacts are beneficial for a variety of reasons when performing PNF resistance, and may optimize muscle activation during resisted diagonal patterns. Elastic bands for resistance in diagonal planes may be best utilized for strength training when a clinician is unavailable to provide manual resistance. neuromuscular compartments in muscle may have a direct influence on muscle function. Thus, compartmentalized muscles may serve multiple functions. The importance of the current finding may lie in providing a more accurate determination of infraspinatus function through the muscles anatomical description and motor innervation and thus will enable more effective rehabilitation of injuries involving the infraspinatus component of the rotator cuff.



Physical Therapy, University of Alabama at Birmingham, Birmingham, AL PURPOSE/HYPOTHESIS: The purpose of this study was to determine the reliability of the component measures of the Scapular Index (SI) to determine its clinical applicability. Our hypothesis was that the component measures of the SI would demonstrate good to excellent reliability. NUMBER OF SUBJECTS: Fifteen. MATERIALS/METHODS: Component measures of the SI were taken by 2 testers using a flexible tape measure. The component measures of the SI included the distance from the sternal notch to the coracoid process anteriorly and the thoracic spine to the posterolateral angle of the acromion posteriorly. Three measurements of each component were taken and averaged. Testers were blinded to each others measurements. Seven subjects returned on a second day to repeat the measurements. Intraclass correlation coefficients (ICCs) and standard error of the measurement (SEM) were calculated using a custom, web-based statistical program. The study was approved by the UAB Institutional Review Board and all subjects gave informed consent prior to participation. RESULTS: ICCs ranged from .520 to .941 demonstrating moderate to excellent reliability for the component measures. SEM ranged from 0.30 to 0.76 cm. CONCLUSIONS: The component measures of the SI were found to have a range of moderate to excellent reliability. Based on these results, further research is recommended to determine the validity of the Scapular Index based on the reliability of the component measurements. CLINICAL RELEVANCE: The SI, as a predictor of postural impairment at the shoulder, should be used with caution until further reliability and validity studies are performed.



Georgia State University, Atlanta, GA PURPOSE/HYPOTHESIS: Specific schemes of muscle architecture and motor innervations have been described for some human skeletal muscles. However, the architecture of the infraspinatus muscle has been described inconsistently. Current literature describes the arrangement of the infraspinatus muscle as multi-pennate, bipennate, or consisting of 2 separate muscle bellies. Further, the branching pattern of the suprascapular nerve distal to the scapular spine has not been addressed in the literature. The infraspinatus is critical to rotator cuff function. The function of the infraspinatus is dependent upon the muscle's architecture and subsequent innervation pattern. The objectives of the current study were to identify the architecture of the infraspinatus muscle, identify the branching pattern of the suprascapular nerve related to the infraspinatus muscle, and determine the presence or absence, on the gross anatomical level, of neuromuscular compartmentalization of the infraspinatus. NUMBER OF SUBJECTS: Seven. MATERIALS/METHODS: Seven, embalmed adult cadavers from the gross anatomy laboratory were examined. The infraspinatus muscles were exposed by removing all of the superficial soft tissues using standard dissection techniques. The muscles were then carefully reflected from the infraspinous fossa and the course of the suprascapular nerve was determined from a point just distal to the spine of the scapula to the point(s) at which the nerve or its branches entered the infraspinatus muscle. The nerves were dissected out carefully using fine dissection techniques under a magnified light for precise cleaning in order to accurately follow each nerve branch into the muscle. RESULTS: Results demonstrated that in 14 infraspinatus muscles (bilaterally from 7 cadavers) 13 muscles were comprised of 3 separate muscle bellies (93%) on the gross anatomical level. The muscle bellies were described with respect to the whole muscle configuration as superficial/superior, deep/middle, and superficial/ inferior. Each muscle belly resided within a separate fascial envelope though all were contained in the fascial envelope that overlies the complete infraspinatus. Additionally, the innervation to each muscle belly was demonstrated by either a first order branch of the suprascapular nerve or by a subsequent second order nerve. CONCLUSIONS: The results of our dissection appear to indicate that the infraspinatus muscle consists of 3 muscle bellies with an innervation pattern that appears to demonstrate neuromuscular compartmentalization, on the gross anatomical level. CLINICAL RELEVANCE: There is evidence to suggest that the presence of



Physical Therapy and Rehabilitation Sciences, Drexel University, Philadelphia, PA PURPOSE/HYPOTHESIS: Scapulothoracic (ST) muscle activity is essential for ST motion and upper extremity function. Much work has been done to further the understanding of ST motion and muscle activity during arm elevation; however, little research exists regarding arm lowering. Clinically abnormal ST motion tends to be more pronounced, and patients more painful during arm lowering. Studies that investigate differences in ST motion and muscle activity between arm elevation and lowering in healthy individuals would provide a foundation for better understanding abnormal ST motion in individuals with shoulder pain. The purpose of this study was to compare ST motion and ST muscle activity between arm elevation and lowering in a healthy population. NUMBER OF SUBJECTS: Nineteen healthy subjects (10 female, 9 male; ages, 18-30 years). MATERIALS/METHODS: Electromagnetic sensors on the scapula, humerus, and thorax were used to collect 3-D scapulothoracic and glenohumeral motion during scapular plane arm elevation and lowering. Surface electrodes simultaneously collected electromyographic (EMG) data from the upper trapezius, lower trapezius, and serratus anterior muscles. Scapu-

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lothoracic kinematic variables and EMG root mean square (RMS) values were the dependent variables. A 2-way repeated measures analysis of variance (ANOVA) with within factors of phase (elevation, lowering) and arm angle (30°, 50°, 90°, 130°) was performed on each dependent variable. Post hoc comparisons were conducted using paired t tests with Bonferonni correction (P = .01). RESULTS: Kinematics: Significant main effects of arm angle were noted for scapular upward rotation and clavicular retraction (P<.05) and a significant main effect of phase was noted for clavicular retraction (P<.05). Overall more clavicular retraction (1.7°) was noted during the lowering phase. Significant interactions were noted for scapular internal rotation, anterior tilt, and clavicular elevation (P<.05). Paired t tests revealed more scapular internal rotation (3.3°; P<.01) and clavicular elevation (1.7°; P<.01) at the 130° arm elevation position. EMG: Significant main effects of phase and arm angle were noted for EMG activity of all muscles. During the lowering phase there was a reduction in RMS EMG (40%-62%) across all muscles. CONCLUSIONS: Overall ST motion is similar during arm elevation and lowering. The small kinematic differences are on the order of measurement error. Despite these similar motion patterns, decreased amounts of ST muscle activity were found during the lowering phase. This likely reflects different neuromuscular control strategies between arm elevation and lowering. CLINICAL RELEVANCE: This information provides a more thorough understanding of ST motion and muscle activity associated with arm elevation and lowering in a healthy population. Furthermore, it suggests that measures of ST motion and muscle activity in individuals with shoulder pain should be performed for both arm elevation and lowering phases. symptoms in the left shoulder and achieved all functional goals set at her initial evaluation. The DASH outcome score decreased from a 33.25 to a 16.68, which is over the minimum clinically important difference needed to show significant change. The visual analog pain scale decreased from a 5/10 at rest and at 10/10 with movement overhead or behind the back to a 0/10 at rest and for all movements. DISCUSSION: The use of the movement impairment system was effective in determining a diagnosis and subsequent intervention for a patient with shoulder pain. A specific exercise routine was possible secondary to using a diagnostic system that allows for determination of the movement impairments that reproduce the patient's symptoms and the muscle imbalances related to those movement impairments. The importance of justification of physical therapy through diagnosis and specific intervention has never been more important. Further research is needed to determine successful diagnostic systems in physical therapy.



Armstrong Atlantic State University, Savannah, GA PURPOSE/HYPOTHESIS: To establish normative data of the rotator cuff musculature in a normal subject population using a hand-held dynamometer (HHD). NUMBER OF SUBJECTS: One hundred eighty-one subjects (18-39 years; 90 men, 90 women; height, 1.72 0.11 m; mass, 73.0 17.6) participated in the study, from a population of convenience consisting of students and faculty from the university and local area fitness centers. MATERIALS/METHODS: Four positions found in the literature were utilized for testing rotator cuff muscles with a HHD (Baseline hydraulic pushpull): Supine 90/90, Prone 90/90, Seated 0, Seated 30/30/30. Both internal (IR) and external (ER) rotation on the dominant (DOM) and nondominant (NDOM) arm were tested in each position. Prior to data collection, a pilot study (n = 16) was completed to establish intra- and interrater reliability. Bivariate correlation analysis was conducted between mass, height, body mass index (BMI) and strength in each position/direction. Separate 2-factor (limb by position) repeated measures analysis of variance (RMANOVA) was performed for each direction (IR,ER). ER/IR ratios were calculated for each limb and statistically compared between positions using separate 1-factor RMANOVA. RESULTS: Intraclass correlation coefficients (ICC3,1) and standard error of the measurement (SEM) revealed moderate relative (ICC = .673-.815) but small absolute (SEM, 1.85-2.56 kg) intrastester and intertester reliability. Strength was moderately related to height (r = .501-.637) and mass (r = .451-.572), but weakly related to BMI (r = .213-.339). For ER, significant differences were revealed between position (P<.001) and limb (DOM>NDOM, P = .007). Post hoc of the position effect yielded Supine 90/90 greater than Prone 90/90 greater than Seated 0 and seated 30/30/30. For IR, identical results were revealed for limb (P<.001) however post hoc of the significant position effect only yielded Supine 90/90 greater than seated 30/30/30. Unilateral ratios for both, DOM and NDOM, found the external rotators at 0.85 to 0.96 of the internal rotators, in all positions. For DOM Prone and Supine greater than Neutral and 30/30/30 (P<.001) and for NDOM Prone>Neutral (P<.010). CONCLUSIONS: Findings of the IRs' normative data suggest that positioning makes no clinically significant difference to the IR strength outcome, due to the significance being a difference of only 0.5 kg, which is not a significant enough amount to be useful clinically. However the ERs showed a significant ranking in the strength by position (supine90/90>prone90/90>seated 0 and 30/30/30). Findings of the ERs' normative data suggests that the tested positions have a strong clinical relevance and are pertinent to the rehabilitation of a patient with shoulder weakness. CLINICAL RELEVANCE: Findings of the ERs' normative data suggests that



Arizona OrthoSports Physical Therapy, Sun City, AZ BACKGROUND AND PURPOSE: Recent changes in reimbursement and our continued efforts to improve autonomy in physical therapy practice have made the justification of what we do as therapists more important than ever. The use of a diagnostic system not only assists in determining a neuromusculoskeletal cause of the patient's complaints, but it allows for specific intervention to be prescribed that is justified in its purpose by the diagnostic findings. CASE DESCRIPTION: Sixty-six­year-old female presented to the clinic with a 3-month insidious onset of left superior/anterior shoulder pain. The patient reported 5/10 pain of an achy quality that increased to a 10/10 with reaching overhead and reaching behind her back. Rest and antiinflammatories were the only treatments that decreased her symptoms. The patient worked as a librarian and was unable to lift and put away books with her left arm secondary to her symptoms. The cervical region was cleared. The empty can test was positive for symptom reproduction at the left shoulder, with all other special tests negative. Examination of the movement system revealed insufficient upward rotation of the scapula during glenohumeral elevation and excessive anterior glide of the humerus during glenohumeral medial rotation. The patient's symptoms were reproduced with these movements. Specific manual correction of these movement impairments decreased the patient's symptoms and improved her range of motion. Following evaluation the patient was given a diagnosis of Left Scapula Downward Rotation with Associated Humeral Anterior Glide. A specific exercise program was prescribed to address the movement impairments found to be reproducing the patient's symptoms. These exercises addressed motor control changes as well as muscle length, strength, and stiffness deficits found to be contributing to the movement impairments and to the patient's symptoms. OUTCOMES: The patient was seen for a total of 14 visits over 7 weeks. Following the 7 weeks the patient was able to perform all job duties without

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the tested positions have a strong clinical relevance and are pertinent to the rehabilitation of a patient with shoulder weakness. Working the ERs in the supine 90/90 position is more assistive to the weakened patient; while working in the seated 30/30/30 position is more challenging to the higher-functioning patient. ture, intervertebral joint mobility test and upper limb neural tension tests were associated with subacromial impingement syndrome. NUMBER OF SUBJECTS: Twenty-seven individuals with and 28 without subacromial impingement syndrome. MATERIALS/METHODS: We examined 2 posture variables (forward head and thoracic kyphosis angles) on digitized photo images, tested intervertebral joint mobility on 4 vertebral levels (C5/6, C6/7, C7/T1, T1/T2), and performed upper limb nerve (median, radial, and ulnar nerves) tension tests on all subjects. Independent-t tests were used to analyze group differences in the postural variables. Chi-square tests were used to analyze group differences in the passive intervertebral joint mobility and upper limb neural tension tests. Finally, logistic regression analysis was applied to all the significant variables to examine their association with the presence of subacromial impingement. RESULTS: All the examined variables on the cervico-thoracic posture, intervertebral joint mobility, and upper limb neural tension showed significant differences between those with and without subacromial impingement syndrome (P<.05). Significant association was observed between the presence of the subacromial impingement syndrome and positive radial nerve tension test, positive ulnar nerve tension test, restricted C5/6 and C6/7 intervertebral joint mobility as revealed by logistic regression analysis. CONCLUSIONS: Subacromial impingement syndrome was associated with forward head and kyphotic postures, restricted cervico-thoracic intervertebral joint mobility, and positive upper limb neural tension; with increased radial nerve tension, increased ulnar nerve tension, and restricted C5/6 and C6/7 intervertebral joint mobility showing the strongest association. CLINICAL RELEVANCE: The results supported a strong association between positive findings of the cervico-thoracic spinal examination and the presence of subacromial impingement syndrome. Clinicians need to thoroughly examine the cervico-thoracic spine when assessing patients with subacromial impingement syndrome.



Arizona OrthoSports Physical Therapy and InMotion Physical Therapy and Wellness, Surprise, AZ BACKGROUND AND PURPOSE: This case report is demonstrating the diagnosis and treatment of a patient presenting with subacromial bursitis. The patient was classified with scapular depression syndrome and tape (Leukotape) was applied to the patients right shoulder to correct this scapular impairment. The purpose is to demonstrate correction of scapular impairments with the use of tape to decrease symptoms and aid in physical therapy interventions. CASE DESCRIPTION: Fifty-year-old male, which presents with right lateral shoulder symptoms. The patient was referred to physical therapy for evaluation and treatment of right subacromial bursitis. The patient reports that approximately 3-5 years ago, while working as a mechanic, he began to experience right shoulder symptoms. He states that over the course of the past 2 years he has noticed a gradual increase in shoulder symptoms. He reports that currently, he is experiencing 3/10, but these symptoms can increase to a 10/10. These symptoms are elicited with performing activities above shoulder height; more specifically, reaching into kitchen cabinets, lifting any objects and donning and doffing a shirt. The patient is right hand dominant. He is unaware of any position changes which decrease his shoulder symptoms. The patients goal for physical therapy is to return to shooting guns and return to being a mechanic, both pain free. He continues to work as a mechanic and he states that he works through his symptoms. He denies any numbness and tingling symptoms of the upper extremity and the cervical region has been cleared. The patients standing alignment demonstrated right scapular depression. With manual correction of this scapular impairment the patient reported an abolishment of shoulder symptoms and an increase in glenohumeral ROM. Therefore, following the evaluation the patient was diagnosed with right scapular depression syndrome. The patients right scapula was taped into elevation and a home exercise program was issued to the patient. This home exercise program was specifically designed to aid in the correction of this scapular impairment. OUTCOMES: The patient was seen for a total of 5 treatment sessions over the course of 3 weeks. Following the course of treatment the patient was able to return to all activities and all functional goals were achieved. The DASH was administered prior and following the physical therapy intervention and had decreased from a 43.3 to a 5.83. DISCUSSION: Scapular depression was corrected in the intervention by elevating the scapula and maintaining this elevation with the assistance of tape. This was beneficial since the patient was able to perform his home exercise program, complete daily activities and earn trust and witness the benefit of physical therapy. Correcting scapular kinematics with the use of tape, can be an intervention, which provides relief to a patient with scapular depression.



Physical Therapy, Nova Southeastern University, Ft Lauderdale, FL PURPOSE/HYPOTHESIS: Shoulder disorders attributed to weight-training are well documented in the literature with prevalence rates of up to 36%. Aberrant joint and muscle characteristics such as strength and mobility imbalances have been identified in the recreational weighttraining (RWT) population, thus predisposing participants to disorders and injury. The purpose of this study was to investigate the effects of a 4-week educational intervention on shoulder joint and muscle characteristics in RWT participants. The investigators hypothesized that an educational intervention designed to address modifiable risk factors would lead to a statistically significant improvement in strength and mobility imbalances and a reduction in pain reported during RWT. NUMBER OF SUBJECTS: Fifteen male participants, ages 20 to 47 who participated in RWT at least 2 times a week and who have experienced shoulder pain during RWT in the past 6 months were recruited. MATERIALS/METHODS: A 1-group pretest-posttest design was used. Active range of motion (AROM), posterior shoulder tightness (PST), strength values, strength ratios and shoulder pain during RWT were measured at baseline and following a 4-week educational intervention. The educational intervention was provided to participants immediately following baseline data collection and consisted of a 10-page booklet with both text and illustrations addressing modifiable risk factors. Specifically, recommendations designed to improve strength and mobility imbalances along with instructions describing proper exercise technique were in-



Department of Physical Therapy and Assistive Technology, National Yang Ming University, Taipei, Taiwan; Department of Physical Medicine, Cheng Ching Hospital, Taichung, Taiwan PURPOSE/HYPOTHESIS: To investigate whether cervico-thoracic spinal pos-

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cluded. Participants were provided with an exercise log to document performance; however the investigator made no contact with participants during the intervention period. RESULTS: Significant pretest to posttest differences (P<.009) for AROM, PST, strength ratios, and pain during RWT were identified following the educational intervention using a paired t test for ratio data and a Wilcoxon signed-ranks test for ordinal data. Strength measurements showed no decline, however, strength ratios decreased significantly implying an improvement in strength imbalances. Decreased PST along with increased shoulder flexion, abduction, and internal rotation were identified implying improved mobility. Lastly, participants reported decreased shoulder pain during RWT upon posttest data collection. CONCLUSIONS: Shoulder joint and muscle characteristics significantly improved following a 4-week educational intervention. The preliminary efficacy of this educational intervention suggests that adaptive joint and muscle imbalances associated with RWT participation may be mitigated with proper education. CLINICAL RELEVANCE: Approximately 22% of the adult population participates in RWT. Although the health benefits are recognized, participation is not without risk and clinicians must identify risk factors a priori. An educational intervention designed to alleviate strength and mobility imbalances may prove useful and cost-effective as an injury prevention tool among RWT participants.

CONCLUSIONS: Our data indicates that external rotation during the middle

trapezius MMT is crucial. It was also shown that the resisted isometric hold test for the middle trapezius elicits greater muscle activation than the nonresisted isometric hold in external rotation. CLINICAL RELEVANCE: A common error during the performance of muscle testing for the middle and lower trapezius is in the lack of external rotation of the shoulder. This data supports the need for correct positioning of the upper extremity during the performance of the middle and lower trapezius muscle tests.



Rehabilitation Sciences, University of Kentucky, Lexington, KY; Orthopaedic and Sports Medicine, University of Kentucky, Lexington, KY PURPOSE/HYPOTHESIS: Knowledge is limited about the appropriate exercise program to follow surgery to gradually increase muscular demand and range of motion (ROM). The purpose of this study was to evaluate the muscular demand during 10 commonly prescribed passive, active assistive, and active ROM exercises following surgical repair of superior labral anteroposterior (SLAP) lesion. NUMBER OF SUBJECTS: Eight post-SLAP repair patients (age, 30 9 years), 4 to 6 weeks following surgery, and 5 noninjured volunteers (age, 28 6 years) were tested in this study. MATERIALS/METHODS: Ten rehabilitative exercises that would be used postoperatively to regain motion: (1) pendulum, (2) forward bow, (3) supported passive elevation with the upper extremity ranger (UER), (4) supported active elevation, (5) rope and pulley elevation, (6) t-bar assisted elevation, (7) UER assisted elevation, (8) wall walks, (9) UER active elevation, and (10) active forward elevation (AFE). Electromyographical (EMG) electrodes were applied with either fine-wire (supraspinatus, infraspinatus) or surface (upper trapezius, anterior deltoid, biceps brachii, and serratus anterior) electrodes to record muscular amplitudes. EMG root mean squared (RMS) amplitudes were normalized to a percentage of reference voluntary contraction (RVC). Maximal range of motion achieved was measured synchronously with video recording. Pain ratings (VAS scale) were also recorded following each exercise. All participants were asked to go through their maximal amount of motion without increasing their level of pain. This was confirmed statistically as there was no significant difference in pain between the exercises (P<.05). The dependent measures were muscular demand, (%RVC) and maximal range of motion (degrees) for each exercise. A mixed-model ANOVA considering group, exercise, and muscle was used for statistical analysis of each outcome measure with significance level set a priori at P<.05. RESULTS: The serratus anterior was more active in the post-SLAP group (72 5%) than in the noninjured group (36 6%) group (P<.05). The anterior deltoid was more active in the post-SLAP group (56 4%) than in the noninjured group (40 5%). There were several interactions between exercise and muscle, too many to report in this abstract. The greatest muscle activity was found in AFE and wall walks and the least muscular activity was recorded for all passive ROM exercises (P<.05). Pendulum (97 13°) and supported passive elevation (89 18°) exercises produced significantly lower peak motion than the forward bow exercise (137 11°) (P<.001). CONCLUSIONS: This is one of the first studies to evaluate PROM and AAROM exercises in an early postoperative patient group. The results support that a progression from passive to active assistive to active ROM exercises gradually increases muscular demands. CLINICAL RELEVANCE: This study provides electrophysiological evidence of muscular demand and ROM limits to help guide clinicians with an exercise selection following a postoperative SLAP repair.



Doctor of Physical Therapy Program, Des Moines University, Des Moines, IA PURPOSE/HYPOTHESIS: The manual muscle test for the lower trapezius (LT) and the middle trapezius (MT) can be a complicated test secondary to the cocontraction of additional muscles during the action of the middle and lower trapezius. The trapezius muscle acts as a scapular mover and stabilizer. The position of the glenohumeral joint indirectly influences the function of the trapezius. The most common manual muscle testing (MMT) procedures make use of this relationship. Placement of the shoulder in external rotation, positions the scapula into upward rotation and adduction. This decreases the activation of other scapulo-thoracic muscles during the testing procedure and facilitates the action of the trapezius. The primary aim of this study is to assess the influence of shoulder position on muscle activation amplitude of the middle trapezius and lower trapezius during a MMT. NUMBER OF SUBJECTS: Eight subjects (3 males, 5 females) ranging in ages from 20 to 28 years of age. MATERIALS/METHODS: Surface EMG electrodes were placed parallel to the fibers of the upper, middle, and lower trapezius, the posterior deltoid, and the teres major muscles. The subject was positioned in prone with the upper extremity abducted to either 90° (middle trapezius MMT) or approximately 135° (lower trapezius MMT). Three conditions were used for testing, glenohumeral internal rotation without resistance, and external rotation with resistance and without resistance. Each condition/ test was repeated 5 times, trials 2 to 4 were used for analysis. One experienced tester performed all the manual muscle tests. The testing order was randomized by test and condition, 2 × 2 repeated-measures analysis of variance (ANOVA) was used to determine the effect of test and condition on muscle activation. RESULTS: A significant interaction (P = .021) was found between the test and joint position in the activation of the middle trapezius. There was no such interaction found for the lower trapezius, but significant main effects were found (P = .043 and P = .044). When middle and lower trapezius data was combined, a significant interaction was found (P = .004) for test and joint position (P = .892). Additionally, it was found that the MT had significantly higher muscle activation during the externally rotated position (P<.01).

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CPRS Physical Therapy, Harrisburg, PA PURPOSE/HYPOTHESIS: Decreased glenohumeral joint ROM can be attributed to multiple etiologies including shoulder capsule tightness, muscular tightness, soft tissue dysfunction, boney abnormalities, and multiple pathologies affecting the contractile and noncontractile structures of the shoulder. One often overlooked area in treating and assessing glenohumeral ROM is thoracic spine mobility and the impact it has on scapula posturing. The aims of this study were: (1) to determine if increasing thoracic mobility and thoracic extension would increase glenohumeral ROM, (2) what planes of shoulder motion would be affected, and (3) to determine which technique (self thoracic extension stretch, manually assisted thoracic extension stretch, low load long duration passive thoracic extension stretch, or grade V thoracic spine mobilization) would change glenohumeral ROM to the greatest degree. NUMBER OF SUBJECTS: Eighty healthy human subjects between the ages of 18 to 60 without orthopedic or neurological pathologies affecting shoulder ROM, without prior cervical, thoracic, or ipsilateral shoulder surgery, and without current pain or discomfort in the cervical, thoracic, or ipsilateral shoulder were included in this study. MATERIALS/METHODS: Subjects were divided into 4 treatment groups with 20 subjects per group. Group 1 received the self thoracic extension stretch (SS), group 2 received the manually assisted thoracic extension stretch (MS), group 3 received the low load long duration passive thoracic extension stretch (PS), and group 4 received the grade V thoracic spine mobilization (TJM). Glenohumeral IR, ER, and flexion AROM and PROM were measured pre and post treatment on the subjects dominant side with a standard goniometer, and Beighton scores were recorded on all subjects. RESULTS: Improvements in AROM and PROM shoulder flexion, IR, and ER were demonstrated in all treatment groups with the most significant improvements being made in AROM and PROM shoulder IR. Group 1 (SS) AROM IR change in degrees, (mean SD) 4.2° 4.4°; PROM IR change in degrees, 6° 4°. Group 2 (MS) AROM IR change in degrees, 8.6° 6.5°; PROM IR change in degrees, 8.5° 6.9°. Group 3 (PS) AROM IR change in degrees, 5.2° 7°; PROM IR change in degrees, 6.3° 7.4°. Group 4 (TJM) AROM IR change in degrees, 10° 7.6°; PROM IR change in degrees, 5.8° 5.1°. CONCLUSIONS: Based on our findings, maneuvers for addressing thoracic mobility and thoracic ROM correlate with improvements in glenohumeral ROM in each plane, with the greatest changes being made in glenohumeral IR. The most significant gains in IR ROM were made after treatment with a grade V thoracic spine mobilization. Not all changes in ROM demonstrated statistically significant changes after 1 treatment, however 18% average improvements in IR ROM after 1 treatment demonstrate clinically significant changes and the need for further research. CLINICAL RELEVANCE: Assessment and treatment of thoracic spine mobility and thoracic extension should be considered in the evaluation and treatment of decreased glenohumeral joint ROM.

NUMBER OF SUBJECTS: Ten asymptomatic subjects (age 29.6 7.4 years). MATERIALS/METHODS: Three pins were inserted bicortically into the hu-

merus, clavicle, and scapula. Bone fixed tracking sensors determined positional data during active shoulder flexion, abduction, and scapular plane abduction. Joint positional data were extracted at minimum, 30°, 60°, 90°, and 120° of humerothoracic elevation and combined with scaled anatomical models to calculate moment arms for the levator and rhomboids. These values combined with physiologic cross sectional area data determined potential torque of the muscles for each acromioclavicular (AC) joint moment direction (external rotation, downward rotation, and tilting). Standard error of the measurement (SEM) and ICC values were calculated. A 2-factor (moment direction by humerothoracic elevation angle) repeated-measures ANOVA was run for each muscle for flexion, abduction and scapular plane abduction. Tukey-Kramer tests were used for post hoc pairwise comparisons. RESULTS: ICC and SEM values demonstrated excellent reliability (87% of ICCs greater than .75). Significant effects of moment direction were found for all muscles (P<.05). The levator demonstrated greatest AC torque capability for downward rotation (11 Nm), followed by external rotation and showed minimal anterior tilt capability (<2 Nm). The rhomboid minor demonstrated greatest torque capability for external rotation (~5 Nm), followed by downward rotation and showed no anterior tilt capability. The rhomboid major demonstrated greatest torque capability for external rotation at lower humerothoracic elevation (25 Nm), and greatest torque capability for downward rotation at higher angles (24 Nm). The rhomboid major demonstrated posterior tilting capability at all angles (~7 Nm). CONCLUSIONS: Our hypotheses were partially supported with some variation in primary and secondary roles. All muscles considered have substantive contributions (>5 Nm) to scapular external rotation. The rhomboid major is the only muscle investigated which produced posterior tilting. CLINICAL RELEVANCE: Knowing these muscles' functions across angles of humerothoracic elevation allows planning for targeted muscle strengthening when addressing shoulder pathology. Compared to past results for the trapezius, the rhomboids have similar torque capability for external rotation. Combined strengthening of the rhomboids and trapezius might aid in restoring normal scapular external rotation. The rhomboid major has the capability to produce >50% of the potential torque for posterior tilting as compared to past data for serratus anterior. Combined strengthening of the rhomboid major and serratus might aid in restoring normal scapular posterior tilting.



Physical Therapy, Governors State University, University Park, IL; School of Physical Therapy, Regis University, Denver, CO PURPOSE/HYPOTHESIS: Surgical techniques for rotator cuff repairs have become less invasive; however, research indicating recovery time changes is lacking. This study compared outcomes of patients undergoing early physical therapy (PT) following a rotator cuff repair to patients who were immobilized for at least 2 weeks. NUMBER OF SUBJECTS: Six patients (mean age 58 years 6.05) underwent rotator cuff repair surgery on their dominant arm and were referred for outpatient PT. Three were allowed to begin PT during the first 2 weeks (mean 7.3 days 1.5). The second group (n = 3) began PT after more than 2 weeks (mean 31.3 days 14.8). MATERIALS/METHODS: Data was collected every 2 to 4 weeks for the entire episode of treatment. Outcome measures included numerical pain rating scale (NPRS), range of motion (ROM) measurements, manual muscle testing (MMT) and short version of the Disabilities of the Arm, Shoul-



Physical Therapy, University of Minnesota, Minneapolis, MN PURPOSE/HYPOTHESIS: Limited data exists regarding levator and rhomboid torque capabilities. Our purpose was to quantify potential torque capabilities of these muscles in a 3-D shoulder model to gain more precise understanding of their actions. We hypothesized the levator primarily downwardly rotates, and secondarily anteriorly tilts. We hypothesized the rhomboids primarily downwardly rotate, and secondarily externally rotate.

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der and Hand (QDASH) scores. Each patient's intervention was individualized according to the surgeon's procedure, PT examination findings, and patient's recovery. RESULTS: Comparisons of early to late PT groups found no significant differences at initial examination or after discharge. Wilcoxon signed ranks test found significant differences for all subjects (n = 6) on initial values for pain (P = .027) and passive ROM: flexion (P = .028), abduction (P = .027), internal rotation (P = .042), and external rotation (P = .043) compared to measures taken 4 to 12 weeks later. Paired t test results for the entire group for QDASH scores at the beginning of PT (mean 76.32) and end of PT (mean 21.92) were significant (0.001). Analysis of variance comparing the 2 groups on total visits and QDASH scores were not significant. CONCLUSIONS: Although differences were not significant between groups, all subjects improved NPRS, PROM, and QDASH scores over the course of the study. All subjects underwent additional surgical procedures with the rotator cuff repair, which may lead to differences in recovery following surgery. A study with a larger sample size may detect differences between the groups, as trends in this study indicated that the early PT group started with higher pain levels and greater disability. CLINICAL RELEVANCE: Physical therapists working with patients after rotator cuff repair surgery should be prepared for significantly limited ROM and high pain levels. Further, the therapist should understand the surgical procedures and how these may influence healing tissues. weeks postop, AROM for FLX, ABD, HBB, and ER0 was 105°, 90°, T7, and 30° with no lag sign, respectively. PROM for FLX, GABD, ER90, and IR90 was 160°, 120°, 75°, and 60°, respectively. Muscle testing revealed 4/5 strength for ER0. ASES, SST, and DASH scores were 23/45, 6/12, and 35.8%, respectively. DISCUSSION: LDTT is a surgical procedure to help address massive irreparable rotator cuff tears, but can be difficult to rehabilitate due to several factors including altered glenohumeral and scapular biomechanics, challenges with latissimus dorsi neuromuscular activation patterns, and significant deltoid atrophy. With proper physical therapy intervention, significant improvement and satisfactory outcomes can be achieved in patient functional self-report measures, ROM, and strength.



Musculoskeletal Division, The George Institute for International Health, Sydney, NSW, Australia; South Eastern Sydney and Illawarra Health Service, Sydney, NSW, Australia PURPOSE/HYPOTHESIS: To establish the ability of the Orebro Musculoskeletal Pain Questionnaire (OMPQ) to predict outcome in patients with recent onset spinal pain. NUMBER OF SUBJECTS: 767. MATERIALS/METHODS: Searches of electronic databases were undertaken. Eligible studies were those which enrolled subjects with acute or subacute spinal pain, administered the OMPQ at baseline and measured outcomes in terms of pain, disability, sick leave and/or global recovery. Ratings of study quality and data extraction were conducted by 2 independent assessors. RESULTS: Seven publications (5 discrete data sets) of variable methodological quality were included. Baseline OMPQ scores were shown to have moderate ability in predicting long-term pain, disability and sick leave outcomes. For example, the area under the curve values for predicting persisting pain ranged from 0.62 to 0.75 and for persisting disability from 0.68 to 0.83. CONCLUSIONS: The OMPQ has moderate predictive ability in identifying patients with spinal pain at risk of persisting pain and disability. This evidence supports clinical guidelines recommending its use as an assessment tool for identifying psychosocial risk factors. Further research is needed to confirm the predictive ability of individual items in different populations and settings, to enhance its usefulness. CLINICAL RELEVANCE: The OMPQ can be readily used in the clinic to assist clinicians to estimate the likely clinical course of recent onset spinal pain.



Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA BACKGROUND AND PURPOSE: The role of a latissimus dorsi tendon transfer (LDTT) in individuals with massive irreparable rotator cuff tears is increasing. The purpose of this case study is to explore the indications and considerations for LDTT procedure, post operative guidelines and precautions, rehabilitative management, and expected outcomes. CASE DESCRIPTION: This patient is a 46-year-old left handed male who presented with a massive irreparable rotator cuff tear secondary to falling off his truck. This patient underwent a LDTT. The patient was placed in an abduction sling and immobilized for 1 week. Physical therapy was initiated 1.5 weeks following surgery, and included passive range of motion (PROM), scar mobilization, joint mobilizations, cardiovascular exercise, and modalities for pain control. From 6 weeks postop to discharge, progression of rehabilitation ranged from PROM to progressive active range of motion (AROM), neuromuscular facilitation for latissimus dorsi activation with external rotation (ER), scapular stabilization, and deltoid strengthening. Functional activities training was initiated once the patient was able to achieve at least 90° active flexion. OUTCOMES: On postop evaluation, the patient reported good pain control. AROM, PROM, rotational strength testing, and patient functional self-report measures were taken at 10, 14, 18, and 26 weeks postoperatively. PROM was limited to 75° on initial evaluation secondary to surgical precautions. At 10 weeks postop, AROM for flexion (FLX), abduction (ABD), and functional internal rotation (IR) measured by hand behind back (HBB) was 65°, 45°, and left posterior superior iliac spine, respectively. ER ROM at midline was not measured, and ER lag sign was not tested. PROM for FLX, glenohumeral abduction (GABD), ER at 90° in the scapular plane (ER90), and IR at 90° in the scapular plane (IR90) was 160°, 115°, 85°, and 55°, respectively. Muscle testing revealed 5/5 strength for IR at midline (IR0), and 3/5 strength for ER at midline (ER0). Modified American Shoulder and Elbow Surgeons Rating Scale (ASES), Simple Shoulder Test (SST), and Disabilities of the Arm, Shoulder and Hand (DASH) were 16/45, 2/12, and 49.2%, respectively. At 26



KORT, Louisville, KY BACKGROUND AND PURPOSE: To describe the examination, manual physical therapy interventions and clinical decision making for a patient with cervical pain utilizing thoracic thrust manipulation and mobilization with movement techniques. Currently there is a small amount of level 1B evidence for the use of thoracic manual therapy in the treatment of patients with neck pain. None describe the utilization of thoracic manual therapy for cervical spine post surgical pain. CASE DESCRIPTION: A 65-year-old male presented to physical therapy with a 6-month history of cervical pain after a C3-4 fusion. He also had a history of a C5-7 fusion 3 years earlier which was successful in pain relief. His pain was the worst with supine positioning and quick cervical movements, ranking a 6/10 on the Visual Analog Scale (VAS) and awaking him at night, and he had no formal physical therapy post operatively.

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Physical therapy examination revealed restricted, painful cervical AROM and significant thoracic AROM and PROM restrictions. Looking over his shoulder and looking up reproduced his pain scoring a 3/10 on the Patient-specific Functional Scale (PSFS) for both activities. He also had a Neck Disability Index (NDI) of 40%. Primary interventions included thrust manipulation of cervicothoracic, midthoracic, and thoracolumbar junctions, as well as mobilization with movement to the cervicothoracic spine. The patient was also given thoracic ROM exercises for a home exercise program (HEP). OUTCOMES: A 1/10 VAS, a 9.5 PSFS, a Global Rating of Change (GROC) of 6, and a NDI score of 4% followed 5 visits over 5 weeks. Improvements were also documented regarding cervical and thoracic AROM. A telephone follow-up at 7 months confirmed continued resolution of symptoms maintained by occasional self management strategies using his HEP. DISCUSSION: This patient experienced a rapid and clinically meaningful improvement in function with decreased pain after receiving thrust manipulation and mobilization with movement to the thoracic spine combined with thoracic ROM exercises. This case report is the first to describe the use of neurodynamic thoracic manual therapy techniques combined with thoracic ROM exercises in the management of a patient with a primary complaint of cervical pain post fusion. The treatment outlined may provide benefit for future patients with similar presentations. Future research should investigate the effects of this management strategy in a larger sample size and relative to standard care. the vibratory inhibition and control groups. An increase in function was found from pretreatment to the follow-up, regardless of group. CONCLUSIONS: This study demonstrated that pain decreased from pretreatment to posttreatment, regardless of group. Manipulation and vibratory inhibition were both beneficial in improving cervical sidebending and rotation ROM. Function improved over time, regardless of group. CLINICAL RELEVANCE: This study demonstrated that manipulation and vibratory inhibition both are viable treatment options for patients suffering from cervical spine dysfunction. Vibratory inhibition appears to be more beneficial than cervical spine manipulation with regards to ROM and functional increases, thus establishing it as a safe alternative or adjunct treatment for those suffering from cervical spine dysfunction.



Arizona OrthoSports Physical Therapy, Phoenix, AZ BACKGROUND AND PURPOSE: The purpose of the case study is to present a patient presenting with localized coccyx (tailbone) pain that, through a systematic movement evaluation and diagnosis, identified movement faults of rotation and extension in the lumbar spine that abolished symptoms with corrective exercise within 4 visits. Background: Typically, localized coccyx pain is a nonmechanical sign and symptom as identified by Waddell. Tailbone pain in isolation is not commonly considered to be a result of nerve impingement or as a component of radicular symptoms. CASE DESCRIPTION: A 48-year-old woman presenting with a history of 6 months of localized coccyx pain who underwent a series of tests, including a MRI and CT scan, which were negative for pathology or fracture. She underwent a series of 3 injections into the coccyx region with no change in her symptoms. Her subjective report indicated she was unable to drive or sit greater than 5 minutes (8/10 pain) and was unable to walking greater than 30 minutes (8/10 pain). She indicated that her symptoms were the result of pressure from the seat and her tendency was to arch her back into extension to decrease the pressure during sitting. A movement evaluation was performed that indicated movement faults in the lumbar spine of rotation and extension in sitting, standing, prone and supine. Forward bending in standing indicate no reversal of the lumbar curve. Standing lumbar extension did not change symptoms. Single-leg stance indicated lumbar extension and rotation bilaterally. In the seated position, a slumped position decreased, but did not abolish her symptoms. Supine lying with knees and hip extended increased symptoms. Supine hip and knee in flexion decreased symptoms. Prone testing indicated lumbar rotation/extension with knee and hip flexion. Accessory extension and rotation with lower quarter movement was noted in all test positions. Strength measurements indicated abdominal and pelvic stability weakness especially the obliques and gluteus medius bilaterally. No tenderness or symptom reproduction with palpation to coccyx region. Functional testing indicated her sitting posture as sitting on the edge of a chair with lumbar spine in extension. She reported maximizing the lumbar roll in her car during driving with the intent to take pressure off the coccyx region. The results of her examination indicated a Diagnosis of Lumbar Extension Rotation Syndrome. OUTCOMES: After 4 visits, with focus on modification of sitting posture and increasing the strength of the abdominals the patient's symptoms were abolished. Modification of her sitting posture included decreasing sternal elevation and modifying her seat position to produce lumbar flexion. Exercises to strengthen her abdominals while avoiding accessory lumbar extension and rotation were instructed. DISCUSSION: Localized coccyx pain, may be the only reported complaint in patients presenting with mechanical low back pain. A systematic movement evaluation that identifies movement faults at the lumbar spine can be useful in identifying the source of coccyx pain.



Texas Woman's University, Denton, TX PURPOSE/HYPOTHESIS: Manipulation for the treatment of dysfunction and pain of the cervical spine has been used as an effective treatment tool, but little information exists to definitively explain what structures are affected by this treatment. Limited research exists regarding the role of the facilitated segment in the biomechanically dysfunctional joint. The purpose of this study was to compare cervical spine manipulation as a biomechanical intervention to the vibratory technique designed to promote neural inhibition in treatment of patients with cervical spine dysfunction. NUMBER OF SUBJECTS: Twenty-nine participants with cervical spine pain were randomized into a manipulation group, a vibratory inhibition group, and a control group. MATERIALS/METHODS: Outcome measures collected were the Visual Analog Scale (VAS), the Neck Disability Index (NDI), and cervical spine sidebending and rotation range of motion (ROM). Participants were then treated with either manipulation, vibratory inhibition, or a placebo. Following treatment, each participant repeated the VAS and ROM measurements. Participants returned 1 to 2 days later for final measurement of all outcome measures. RESULTS: Four separate ANOVAs with repeated measures were used to compare the differences in all outcome measures. A significant reduction in pain was found from pretreatment to posttreatment, regardless of group. A significant increase in total sidebending ROM was found from pretreatment to posttreatment in both manipulation and vibratory inhibition groups, and a significant increase in total sidebending ROM was found from pretreatment to the follow-up in the vibratory inhibition group. A significant increase in total rotation ROM was found from pretreatment to posttreatment as well as from pretreatment to the followup in the vibratory inhibition group. Within the posttreatment measurement, a significant difference was found between the vibratory inhibition and control groups. Within the follow-up, a significant difference was found between the manipulation and control group, as well as between

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School of Physical Therapy, Ohio University, Athens, OH PURPOSE/HYPOTHESIS: Headache (HA) populations have been shown to exhibit reduced cervical spine range of motion (ROM) in the shoulder, TMJ, and neck. However, specific patterns of ROM related to HA patients have not been identified to date. ROM patterns could aid in the early detection of HA prone patients and could help guide treatments. The study purpose was to identify potential common motion patterns of restriction in neck, jaw or shoulder ranges in a HA population as compared to a HA-free population. It is expected that the HA population will exhibit a characteristic pattern of movement loss in the cervical and TMJ regions. NUMBER OF SUBJECTS: Patients with unilateral (n = 13) or bilateral (n = 16) HA were recruited from an outpatient PT clinic and compared to HAfree subjects (n = 29). MATERIALS/METHODS: ROMs of the cervical spine, shoulder, and temporomandibular joints (TMJ) were measured using a CROM device, goniometer, and ruler, respectively in both groups. All measurements were taken prior to the first treatment. Inter-rater reliability among the 4 raters was determined as good on all measurements (ICC>.88). Statistical analyses included t test, ANOVA with a post hoc Tukey, Pearson Product Correlation, and Mantel-Haenszel chi-square. RESULTS: Since there were no significant differences (P .05) between unilateral and bilateral HA groups, they were considered together for all subsequent analyses. A mild correlation between age and ROM was noted for shoulder flexion, internal rotation, cervical extension, rotation, and sidebending (.33-.44). All other motions or ranges exhibited no correlations with age. HA patients demonstrated significantly more ROM in cervical flexion and shoulder internal rotation (P<.05), and significantly less ROM in cervical extension and rotation, shoulder flexion and external rotation (P<.05). TMJ motions were not associated with the HA population (P .05). CONCLUSIONS: Loss of range in cervical (extension and rotation) and shoulder (flexion and external rotation) motions are characteristic of the sampled HA population. In contrast, no association between HA patients and any TMJ motions could be identified. CLINICAL RELEVANCE: Based on the findings of this study, clinical emphasis should be placed on cervical and shoulder motion losses rather than TMJ dysfunctions when working with a headache population. Future studies can assess the usage of these patterns for diagnostic and/or treatment considerations.

MATERIALS/METHODS: Kinematic data were collected using a 3-D motion capture system while subjects performed the rocking back. Angular measures of posterior pelvic tilt and knee flexion were calculated across time. The rocking back motion was indexed by knee flexion. The percent of posterior pelvic tilt was calculated at 10% increments of rocking back. A mixed model analysis of variance test followed by post hoc tests was conducted to test for the main and interaction effects of group and increment of motion. RESULTS: The interaction of group and increment was significant (P = .001). Compared to people without LBP who did not play RRS, the 2 groups who played RRS completed a greater percent of posterior pelvic tilt earlier in the rocking back motion (LBP, P = .002; No LBP, P = .032). Specifically, at the 30% increment of rocking back the people with LBP and people without LBP who played RRS began to move more than people with no LBP who did not play RRS. The interaction of group and increment for the 2 groups who played RRS was not significant (P = .052). There was a trend, however, for the people who had LBP and played RRS to complete a greater percent of their posterior pelvic tilt in the later range of the rocking back motion when compared to people without LBP who played RRS. CONCLUSIONS: Compared to the people without LBP who did not play RRS, people with and without LBP who played RRS displayed early lumbopelvic motion during the test movement. People who played RRS, irrespective of LBP history, displayed a similar movement pattern in the early range of the test movement but tended to differ in movement pattern in the later range of the test movement. CLINICAL RELEVANCE: Similar to our limb movement test findings, people with LBP display early lumbopelvic motion with a test that requires both trunk and limb movement for performance. Rocking back in quadruped is often given as an exercise for LBP. Our findings suggest that attention should be given to how the exercise is performed. Additionally, because the groups that participated in a repetitive activity displayed similar movements, the early movement of the lumbopelvic region (1) may reflect an adaptation driven by the repeated activity, and (2) increase a person's risk for development of a LBP problem with continued use of the activity. NIH K01 HD01226-05; 5R01 HD047709-02.



Physical Therapy, University of Tennessee Health Science Center, Memphis, TN PURPOSE/HYPOTHESIS: Physical therapists frequently prescribe core stabilization exercises to strengthen muscles and improve lumbar stability when treating back pain. The purpose of this study was to evaluate changes in abdominal strength and lumbar stability after a 6-week core stabilization exercise program. NUMBER OF SUBJECTS: Subjects were 28 women and 20 men age 22-65 years, alternately assigned into group. Inclusion criteria were: no history of abdominal or low back surgery; no low back pain requiring medical attention in past 3 months; no participation in other exercise program during this study. MATERIALS/METHODS: A quasi-experimental, 2-group pretest, post test design was used. Two examiners, blind to group assignment, performed all pretests and post tests. The leg lowering test was used to assess rectus abdominis strength. Lumbar stability was assessed using a pressure biofeedback unit with the bladder placed under the lumbar spine. A series of progressive exercises were performed. When a subject failed to complete 2 minutes of a given exercise while maintaining a pressure gauge reading of 40 to 50 mmHg, failure was recorded and a lumbar stability score was assigned. After completion of pretests, control group subjects were scheduled for the 6-week post tests. Experimental group subjects were



Clinical Medicine and Prevention, University of Milan, Bicocca, Italy; Program in Physical Therapy, Washington University School of Medicine, Saint Louis, MO PURPOSE/HYPOTHESIS: We have reported that early lumbopelvic motion during limb movement tests is important in people with low back pain (LBP). It is unknown if early lumbopelvic motion occurs with tests that require both trunk and limb movement for performance. A test commonly used in the examination of people with LBP is rocking back in quadruped. The purpose of this study was to examine lumbopelvic motion during the test. NUMBER OF SUBJECTS: The sample included 46 people with chronic LBP (28 M, 18 F; mean age, 28.5 8 years) and 62 people without LBP (37 M, 25 F; mean age, 27 8 years). No subjects were in an acute LBP flare-up. There were 3 groups: people without LBP who do not play rotation-related sports (RRS), people with LBP who play RRS and people without LBP who play RRS.

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given a home exercise program (HEP), completed 2 and 4-week followups for HEP progression, and completed 6-week post tests. RESULTS: Independent t tests for group comparisons on RAb and LSI at baseline and 6-weeks were significant for LSI only (P = .045). Paired t tests for within group differences revealed significance for LSI in the experimental group only (P = .016). A fair relationship between RAb strength and LSI score (r = .366) was found. CONCLUSIONS: A 6-week core stability exercise program improved LSI scores, but resulted in no significant change in RAb strength. Lumbar stability has been described as the ability to maintain a neutral spine through a dynamic process involving the interplay between the muscles and central nervous system to prevent excessive intersegmental movement but allow coordinated movement when needed. The neuromotor control system relies on a feed-forward strategy to maintain constant, low-level stiffness of local muscles, while using sensory-feedback and global muscles to respond to unexpected or large perturbations to stability. While many believe strength is the key to lumbar stabilization, motor learning involved with stabilization exercises may be the primary purpose. This could explain the significant change in LSI (an indicator of improved neuromotor control) and the lack of significant change in strength. Additionally, the RAb is considered a global muscle and these exercises may have been more specific for strengthening local muscles. CLINICAL RELEVANCE: Our results suggest that a 6-week core stability program is sufficient to improve LSI, possibly due to improved neuromotor control, but not sufficient to strengthen the RAb. Future research assessing the impact of this stability program on local muscle strength may yield different results.

CONCLUSIONS: Subjects with an increased kyphotic curve demonstrate a decrease in thoracic extensor muscle efficiency when tested in the shortened position. Results show a higher percentage EMG amplitude within the muscle and a lower force output when compared to age and gender matched controls. The positional change in force production is thought to result from a shift in the muscle length tension relationship. CLINICAL RELEVANCE: Increased thoracic kyphosis, or poor postural alignment, is an impairment often identified in patients with cervical, shoulder, and midscapular pain. Treatment interventions traditionally emphasize the restoration of balance between anterior and posterior trunk musculature. The study findings identify that subjects with an increased thoracic curvature demonstrate less muscle efficiency in a relatively extended position. Further investigation is needed to help determine if this inefficiency is due to positional weakness of the thoracic extensor group, or if the muscle group is inefficient independent of testing position.



Physical Therapy, University of Michigan - Flint, Flint, MI PURPOSE/HYPOTHESIS: The purpose of this pilot study was to examine the association between function and self-efficacy in a medically underserved population with chronic low back pain. NUMBER OF SUBJECTS: Ten subjects, 5 males and 5 females between the ages of 19 and 64, participated in the study. MATERIALS/METHODS: All subjects provided informed consent prior to participation in the study. Demographic data, pain level, the Oswestry Disability Index (ODI), and Pain Self-Efficacy Questionnaire (PSEQ) scores were collected using a computer-based survey method called Zoomerang. RESULTS: The mean score for the ODI was 53% 13%. The mean score for the PSEQ was 30.2 8.9. The range for the NRS was 4 to 9 with a mean of 7.2 1.4. A high, indirect correlation was found between the ODI and PSEQ (r = ­0.841). Seven of the 10 subjects were categorized as severely disabled or crippled by the ODI. CONCLUSIONS: Consistent with the literature for other populations, we found a high, inverse relationship between function and self-efficacy. Individuals rating themselves as having a high level of disability reported a low level of self-efficacy. We noted a discrepancy between high self-reported levels of disability and our observed levels of function. Although we noted an antalgic gait in several of our subjects, only 1 used an assistive device. CLINICAL RELEVANCE: The ODI and the PSEQ may not be the most valid tools for measuring functional disability and self-efficacy in a medically underserved population. A larger study needs to be conducted to validate these tools in this population.



Department of Physical Therapy, UTMB, Galveston, TX PURPOSE/HYPOTHESIS: The purpose of the study was to assess muscle efficiency of the thoracic extensors in subjects with and without hyperkyphosis. NUMBER OF SUBJECTS: Ten subjects participated in the pilot study (mean age, 39.4 18.6 years). The subjects were divided into 1 of 2 groups based on the sagittal Cobb angle of the thoracic spine. Subjects with an angle greater than 42° were assigned to the kyphotic group. Subjects with an angle less than 34.5° were assigned to the control group. Subjects were gender and age matched with no statistical difference between groups. MATERIALS/METHODS: Thoracic curvature measurements were taken to determine subject eligibility and group assignment. EMG amplitude, based on percentage of maximal isometric contraction, was recorded through surface electrodes. The EMG amplitude was recorded concurrently with isometric force production. Each subject was asked to perform 3 repetitions of a 6-second isometric contraction in 2 standardized positions. The flexion trial was performed at approximately 75% of the subject's thoracic flexion AROM. The extension trial was performed at 75% of the subject's thoracic extension AROM. The order of testing was randomized for each subject trial. Muscle efficiency was calculated by dividing the muscle EMG amplitude by the isometric muscle torque. The mean measure of muscle efficiency was calculated for both the flexed and extended position. Comparisons were made between groups using the MannWhitney U statistic. RESULTS: The kyphotic group demonstrated less thoracic extensor muscle efficiency in both the extended (3.8 0.9 versus 2.0 0.2) and flexed positions (2.9 1.0 versus 1.7 0.4) when compared to the control group. However, statistical significance was only noted in the extended position (P = .009) and not in the flexed position (P = .076) based on a 95% confidence interval.



Department of Physical Therapy and Rehabilitation Sciences, Drexel University, Philadelphia, PA PURPOSE/HYPOTHESIS: Aberrant lumbopelvic movement patterns are associated with mechanical low back pain (MLBP) and considered a key clinical sign for subclassifying MLBP patients. The purpose of this study was to qualitatively describe differences in lumbopelvic movement patterns in individuals with and without MLBP using kinematic data collected during a standing bilateral reach task. NUMBER OF SUBJECTS: n = 60 subjects. Twenty-eight subjects had chronic MLBP (10 female; 40 8 years) and 32 healthy controls (13 female; 39 9 years). MATERIALS/METHODS: Subjects performed 3 repetitions of a bilateral reach

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to a stationary target placed at a distance of 50% of their functional reach. The reaching task was performed with shoulders in 90° flexion, elbows extended and while holding 4.6 kg load. Kinematic data from the femur, pelvis and lumbar spine were collected (40 Hz) using an electromagnetic tracking device. Sagittal plane data trials for each subject were filtered at 5 Hz, time normalized, and averaged. Individual subject's pelvis and lumbar movement data were graphed using angle-angle plots to represent coordination of lumbopelvic movement and phase plane plots (segment motion versus velocity) to represent segment control. A rater, blinded to LBP status, categorized the angle-angle plots by coordination pattern. Mean angle-angle and phase plane plots were constructed from the categorized groups, then coordination and control patterns described. RESULTS: Four distinct categories of lumbopelvic coordination patterns were determined: shared pattern demonstrating relatively equal inphase movement of the pelvis and lumbar spine (n = 36; 60%); lumbar pattern consisting of predominantly lumbar motion (n = 5; 8.3%); pelvic pattern consisting of predominantly pelvic motion (n = 11; 18.3%); and restricted pattern demonstrating limited motion in both segments (n = 8; 13.3%). Twenty-four (67%) of the 36 individuals in the shared pattern were from the control group. Individuals in the MLBP group were distributed across the 4 patterns and dominated the lumbar (80%), pelvic (64%) and restricted (62%) movement patterns. Twelve of 28 MLBP subjects (43%) were placed in the shared pattern. Phase plane plots for the pelvis and lumbar spine segments demonstrated relatively smooth control by subjects in the shared pattern group. Segment motion was not as smoothly controlled in the lumbar, pelvic and restricted pattern groups, which had greater numbers of subjects with MLBP. CONCLUSIONS: Individuals with MLBP appear to adopt altered movement strategies that could be a result of, or contributing factor to, their symptoms. In addition, they also demonstrate impaired control of their lumbar spine and pelvic segments during this reaching task. CLINICAL RELEVANCE: A qualitative approach to describing movement impairments of the trunk may provide a basis for clinical movement assessments that assist with identification of patients with MLBP with poor trunk control. Therapists should consider assessing these characteristics and implement treatment plans that address these impairments.

RESULTS: In lordosis the mean angle at L4-5 was 10.6° (SD, 4.4) and at L5-S1 was 17° (SD, 7.0) of extension. In the full kyphosis position of the device the mean angle at L4-5 was 6.1° (SD, 4.5) and at L5-S1 13.8° (SD, 6.5) of extension. Both L4-5 and L5-S1 showed statistically significant (P<.001) changes with increased segmental flexion in the kyphotic position. At L4-5 the mean increase in flexion was 4.5° (95% CI: 2.9°, 6.0°) representing an average 47% change. The mean increase in flexion at L5-S1 was 3.2° (95% CI: 2.3°, 4.2°) representing an average 20.8% change. Additionally, there was a statistically significant difference (P<.05) in percent change between the 2 levels with L4-5 showing a larger change (27% more flexion) between positions. CONCLUSIONS: With the use of an external device to preposition the prone patient into kyphosis, we observed statistically and clinically significant increases in segmental flexion at the targeted L4-5 and L5-S1 levels. CLINICAL RELEVANCE: The results obtained with this device should be compared directly to devices and procedures used by physical therapists who aim to provide joint mobilization or manipulation with the lumbar spine prepositioned in kyphosis. The degree to which increased segmental flexion may allow for increased posterior to anterior translation of the vertebrae during spinal mobilization is a future investigation.



Program of Physical Therapy, University of Wisconsin - La Crosse, La Crosse, WI BACKGROUND AND PURPOSE: Cervical radiculopathy caused by a cervical disc herniation is a common diagnosis that clinicians treat. An early and thorough examination is critical for the clinician to determine the most appropriate intervention to address the patient's functional limitations. In the presence of a cervical disc herniation, the nerve root in close proximity to the disc is susceptible to inflammation due to the effect of the enzyme phospholipase A2 (PLA2) which is present in the nucleus pulposus. In the presence of disc herniations, PLA2 leaks into the epidural space in the vicinity of the nerve roots potentially creating the radicular symptoms associated with a disc herniation. This case study is intended to describe the physical therapy and medical management of a patient with symptoms associated with C6 radiculopathy being seen in a direct access environment of physical therapy. CASE DESCRIPTION: A 46-year-old female sought physical therapy services via direct access 1 week post acute onset of left neck pain and radicular pain down the left upper extremity. Her symptoms gradually progressed to the point of influencing her ability to perform necessary tasks associated with her occupation as a nurse practitioner. A physical therapy examination revealed pain in the C6 dermatome of the left upper extremity which was not affected by a mechanical evaluation, manual traction or positional traction of the cervical spine. Results of special tests included a positive Spurling's tests and shoulder abduction test. Additional symptoms included left-sided weakness of the wrist extensors and diminished grip strength. The examining therapist referred the patient for a medical consultation due to a strong suspicion of a herniated nucleus pulposus that was unresponsive to mechanical means of symptom relief. An MRI was performed which revealed a large left-sided disc herniation at C5-6 resulting in extrinsic mass effect on the cervical cord and on the exiting left C6 nerve root. The individual was prescribed an oral burst of prednisone with a tapering dose over a 12-day time frame while physical therapy intervention was continued. OUTCOMES: Physical therapy was resumed 2 days following the initial dose of prednisone to address the patient's impairments and functional limitations. Four weeks from the initial physical therapy visit, the patient achieved a significant decrease in her average pain (from 7/10 to 0-1/10), a significant improvement in her functional rating (from 55% to 98%



US Army-Baylor University Postprofessional Doctoral Program in Orthopaedic Manual Physical Therapy, Brooke Army Medical Center, Fort Sam Houston, TX; Spine Research Center and Biomechanics Lab, Walter Reed Army Medical Center, Washington, DC PURPOSE/HYPOTHESIS: Surgical techniques for minimally invasive lumbar fusions describe prepositioning the prone patient in maximal kyphosis to optimize visualization of the disc space and prevent retraction of neural structures. Manual therapists often use similar prepositioning techniques with table breaks and pillows to induce segmental flexion prior to joint mobilization/manipulation. The purpose of this study was to present validating observations of an external device (Wilson frame) to induce kyphosis and quantify angular changes. NUMBER OF SUBJECTS: Twenty subjects. MATERIALS/METHODS: Twenty consecutive patients (40 total levels) undergoing minimally invasive transforaminal lumbar interbody fusion received preincision intraoperative radiographs at L4-5 and L5-S1 with the device in maximal lordosis followed by kyphosis. Descriptive statistics were calculated for sagittal plane angular measures at L4-5 and L5-S1 in lordosis and kyphosis, including absolute differences and percent change between positions. Inferential statistics were calculated using paired t tests with an alpha of .05.

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score on the Functional Rating Index) and normalization of her cervical spine AROM and upper extremity strength. DISCUSSION: This case illustrates the importance of an early and thorough examination that led to a referral for a MRI evaluation and pharmacological intervention in a direct access physical therapy setting. An early burst dose of prednisone is intended to address the effects of PLA2 on the cervical nerve root and enhance the outcome of physical therapy intervention.



Lakeland HealthCare, Saint Joseph, MI; Department of Physical Therapy, Andrews University, Berrien Springs, MI PURPOSE/HYPOTHESIS: Neck pain is a common problem treated by physical therapists. Often, patients with similar pathoanatomical diagnoses receive considerably different treatment approaches. In an effort to standardize treatment and improve outcomes for neck pain patients, it has been proposed that physical therapy management would be more effective if they were classified into subgroups based on treatment goals, rather than on pathology or symptom location. NUMBER OF SUBJECTS: A case series of 92 patients referred to physical therapy. MATERIALS/METHODS: Patients with neck pain referred by physicians were placed at initial visit by their evaluating physical therapist into 1 of 5 treatment based classifications; reduce headache, improve mobility, centralize symptoms, pain relief or exercise/conditioning. Outcomes measured (initial evaluation and discharge) were numeric pain rating scale (NPRS), Neck Disability Index (NDI) scores and number of treatments. RESULTS: A total of 92 patients were included in this study (64% women; age, 52.9 16.2 years). The most common classifications were centralization (30.4%), mobility (29.3%) and pain control (28.3%). A repeatedmeasures ANOVA revealed improvement in NDI and NPRS scores over time for all groups (P<.05). Though there were trends for higher NDI and NPRS scores in the pain relief group a Bonferroni post hoc analysis showed no differences between groups except for NDI scores between the pain and mobility groups. Of the interventions used 58.7% of patients received a combination of manual therapy and exercise with chisquare analysis showing significant (P<.05) increased use of this intervention for both the pain relief and mobility groups. Mechanical traction was used significantly more often for the centralization group (82.1%). Manipulation with thrust was used with 4 patients. Mean ( SD) number of treatments was 9.5 ( 5.8) with no differences between groups. CONCLUSIONS: Though there were trends showing differences in outcome for different groups, the treatment based classification scheme as used in this case series does not seem to have substantial prognostic ability for the physical therapist. The combined use of manual therapy and exercise in more than half of patients seen is consistent with current evidence but the low use of thrust manipulation is not. CLINICAL RELEVANCE: Identification of clinically meaningful subgroups of patients with neck pain is an important research priority. More study needs to be undertaken on the treatment based classification scheme to establish its validity.



Physical Therapy, Washington University, St Louis, MO PURPOSE/HYPOTHESIS: Previously, we have reported that people with low back pain (LBP) who regularly play rotation-related sports (RRS) demonstrate earlier lumbopelvic motion during 2 lower limb movement tests than people without LBP who do not regularly play RRS. However, it is unclear if early lumbopelvic motion is an adaptation to participation in RRS that is related to the LBP problem. The purpose of the current study is to examine a variety of variables that may contribute to LBP in people who regularly play RRS. We hypothesize that people with and people without LBP who regularly play RRS will demonstrate similar lumbopelvic movement patterns during lower limb movement tests, but will differ on other variables. NUMBER OF SUBJECTS: Two groups of people who regularly play RRS participated: people with LBP (n = 54; age, 28.3 8.2 years; 63% male) and people without LBP (n = 26; age, 26.3 7.8 years; 73% male). MATERIALS/METHODS: Kinematic data were collected using a 3-D motion capture system during 2 lower limb movement tests. Self-report measures were used to collect information on subject characteristics and activity levels. The Baecke Questionnaire was used to measure activity levels during work, leisure, and sport. To examine differences in activity levels during the majority of the day versus during sport participation, the work and leisure subscores were averaged and compared to the sport subscore. Independent sample t tests were conducted to test for differences between groups on subject characteristics and movement variables. A mixed-model analysis of variance test was conducted to test for the main and interaction effects of group and activity level. RESULTS: There were no differences between groups in subject characteristics or movement variables (P>.05 for all comparisons). There was a significant interaction of group and activity level (P = .04). Both groups reported similar sport activity levels (No LBP, 3.59/5; LBP, 3.68/5; P = .53) but people with LBP reported a lower combined work and leisure activity level than people without LBP (No LBP, 2.63/5; LBP, 2.35/5; P = .02). CONCLUSIONS: People with and people without LBP who play RRS demonstrate similar movement patterns during 2 lower limb movement tests. Compared to people without LBP, people with LBP reported lower combined work and leisure levels, but similar sport activity levels. CLINICAL RELEVANCE: Clinical data reporting decreased LBP symptoms with modification of lumbopelvic motion during limb movements suggests that early lumbopelvic motion may contribute to a LBP problem. The findings of the current study suggest that people who regularly play RRS develop movement patterns in which the lumbopelvic region moves early during limb movements. Because not all people who play RRS develop a LBP problem, additional factors may contribute. Our results suggest that the imbalance between routine, daily activities (work and leisure) and higher intensity activities (sport) may be an important factor contributing to the development or persistence of LBP in people who play RRS. NIH Grant #K01 HD01226-05.



Institute for Physical Therapy Education, Widener University, Chester, PA; Physical Therapy, Arcadia University, Glenside, PA; Phoenix Rehabilitation, Royersford, PA PURPOSE/HYPOTHESIS: To quantify the interrater reliability of a newly-proposed system for classification of cervical spine disorders that is based on an individual's symptomatic response to active movement. NUMBER OF SUBJECTS: Eleven subjects (10 female, 1 male); mean age, 40.5 years; height, 65.9 in; weight, 172 lb; mean Neck Disability Index score, 33; Northwick Park Questionnaire score, 38; Average Numeric Pain Rating Scale, 4/10. MATERIALS/METHODS: A complete history was obtained and the Neck Disability Index (NDI) and Northwicke Park Disability Questionnaire (NPQ) were administered as per standard protocol. Two cervical spine examinations were performed consecutively by 2 trained examiners with

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specialist certification (OCS) followed by classification into 1 of 6 newly proposed cervical spine movement impairment syndromes. Each subject performed 1 repetition of cervical active movement in sitting in a specific sequence. Pain levels were recorded using the Numeric Pain Rating Scale (NPRS). If the subject's primary symptoms were reproduced with single plane movement, Forward Bending (FB) followed by Backward Bending (BB) was added to the direction of movement in which the primary symptoms were reproduced and the subject's symptomatic response to these combined movements were recorded. Bilateral Rotation was tested post classification. Assessment of motion quantity using visual estimation and level of reactivity was also recorded. RESULTS: This newly-proposed impairment-based system of classification for disorders of the cervical spine demonstrated Fair to Good interrater reliability (kappa = .49 [95% CI], po = .64, pc = .29). 7/11 subjects in which agreement was established demonstrated lower levels of self-assessed disability (NDI = 29.14, NPQ = 32.28) compared to 4/11 in which agreement was not established (NDI = 42, NPQ = 46). NDI and NPQ agreed on level of reactivity in 10/11 subjects. There was no relationship between the level of reactivity and the time since onset or limitation of ADL. CONCLUSIONS: The Fair to Good interrater reliability of this newly proposed classification system warrants further investigation. This impairment-based system may be most reliable for classifying patients with neck-related disorders that are considered to possess low to moderate levels of reactivity. Self-assessed disability, as determined by the NDI and NPQ appear to be reliable methods for determining reactivity levels in this population. CLINICAL RELEVANCE: The classification of spinal disorders has been deemed as one of the most important research initiatives related to the care of the spine in order to guide intervention and improve outcomes. Several authors have proposed impairment-based models of classification for the management of neck-related disorders. This pilot study introduces a new model of impairment-based classification that may be useful in guiding intervention and directing research initiatives. Further evidence is needed to support the relevance of this classification system. of the swing analysis, thoracolumbar rotation and hamstring flexibility were assessed using clinical measures. Three of the 5 swings were randomly chosen for data analysis. 3-D data were exported to Microsoft Excel and processed using a macro program to determine the maximum transverse plane rotations of the trunk and pelvis at peak backswing. Descriptive statistics were calculated for demographic and dependent variables. Bivariate scatterplots were analyzed to check for the presence of linear relationships and influential observations. Pearson moment correlations were conducted to examine for significant relationships. RESULTS: The Pearson r for the correlation between the X-factor and thoracolumbar rotation was 0.01 (P = .99). Pearson r for the correlation between X-factor and hamstring flexibility was ­0.73 (P = .02), and the Pearson r for correlation between the maximum pelvis rotation and hamstring flexibility was 0.53 (P = .11). CONCLUSIONS: The results of this study suggest an indirect relationship between the X-factor and hamstring flexibility. The results do not support a relationship between the X-factor and thoracolumbar rotation. CLINICAL RELEVANCE: Hamstring and trunk flexibility exercises may not result in an increase in X-factor in young, skilled golfers.



Rehabilitation and Movement Science, University of Vermont, Burlington, VT; Division of Physical Therapy, University of Utah, Salt Lake City, UT; Mathematics and Statistics, University of Vermont, Burlington, VT PURPOSE/HYPOTHESIS: Classification of patients with low back pain (LBP) is an important step for improving clinical decision-making by distinguishing subgroups of patients with certain characteristics who are most likely to respond to a particular treatment approach. Numerous systems have been described for patients with LBP and the TreatmentBased Classification (TBC) system uses data gathered from the history and physical examination to place a patient into 1 of 4 basic classification categories (Delitto et al, 1995). The purpose of this study was to examine the interrater reliability of classification decisions made by raters who had minimal to no prior experience using the TBC system using a published decision-making algorithm (Fritz 2007). NUMBER OF SUBJECTS: Subjects for this reliability analysis were 24 randomly selected patients with LBP from a previously-published randomized clinical trial (Brennan et al, 2006; n = 123). The characteristics of the 24 selected patients were a mean age of 39.2 years ( 11.4), a mean Oswestry of 40.2% ( 11.5) and a Numeric Rating Scale of 5.6 ( 1.5). MATERIALS/METHODS: Using the written cases of patients' history and physical exam data only, 12 raters, 11 of whom were physical therapists, independently classified the 24 selected cases using the published algorithm (Fritz 2007). RESULTS: Of the possible 288 classifications (24 cases × 12 raters), there were a total of 277 classifications available for analysis and thus 1464 pairs of comparisons among the 12 raters' chosen classification. There was 81% agreement in the pairs of classification and an overall 79% agreement with the more experienced examiners who previously rated each case also independently (Brennan et al 2006). When examining agreement by a particular classification category, there was 94% agreement between the 12 raters and the more experienced examiners for the "Specific Exercise" category; 82% agreement for the "Manipulation/Mobilization" category; and 64% agreement for the "Stabilization" category. The overall kappa for the 12 raters was 0.60 (CI: .56-.63; P<.01). The "Traction" category was not included. CONCLUSIONS: Our results are similar to (Brennan et al 2006) that report an overall agreement among raters of 76% and a kappa value of 0.60 (CI: 0.56, 0.64), and no differences in reliability based on experience. The raters had minimal to no prior experience with the TBC, supporting prior results that experience does not influence reliability. While the interrat-



Physical Therapy, University of Tennessee at Chattanooga, Chattanooga, TN PURPOSE/HYPOTHESIS: The term X-factor was first described by Mclean in 1992. Mclean described the X-factor as the relative disassociation between the trunk and pelvis that occurs during peak backswing. Mclean demonstrated that a greater X-factor was related to longer driving distances in professional golfers. The purpose of this study was to examine the relationships between lower extremity flexibility measurements and the X-factor during a golf swing in young, skilled golfers. NUMBER OF SUBJECTS: Ten healthy (2 males, 8 females) golfers (mean age, 18.9 3.0 years) were recruited to participate in the study. All participants were right-handed golfers and were injury-free. The mean self-reported handicap was 0.7 ( 1.0) strokes. MATERIALS/METHODS: All participants performed a self-selected warmup routine. Upon completion of the warm-up, 6 reflective markers were placed on the following anatomical locations: right and left acromion processes, seventh cervical spinous process, right and left anterior superior iliac spines, and second sacral process. After the placement of the reflective markers, participants were allowed to take additional practice swings with a 7-iron into a framed net until the subject reported that they were producing their most optimal swing. The motion of the swing was captured using an 8-camera Vicon MX motion analysis system at 120 Hz. Data were collected for 5 acceptable swings as determined by data quality and verbal feedback from the participant. After completion

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er reliability of the classification judgments made based on written cases using the TBC system are moderate to good, it is clear that some degree of error persists in the classification decision-making associated with the TBC system, especially for the "Stabilization" category. CLINICAL RELEVANCE: The reliability of the TBC system is moderate to good even for raters with minimal experience with this schema. However, a degree of error persists in the TBC classification algorithm and future studies should study the mutual exclusivity of the classification categories as one potential source of error. ences exist using 3 common exercise formats: Pilates (P), floor (F), and physioball (B) in supine and prone positions. NUMBER OF SUBJECTS: Fourteen recreationally active subjects (7 male, 7 female) were recruited between the ages of 35 and 50 years of age with no history of current musculoskeletal or balance pathologies. These subjects were novice to the exercise formats. MATERIALS/METHODS: Electromyographic activity (EMG) was recorded over rectus femoris, rectus abdominis, external oblique, internal oblique, biceps femoris, gluteus medius, paraspinals, and latissimus dorsi muscles on the subject's dominant lower extremity. Subjects were randomly assigned an order for P, F, and B and asked to perform 3 repetitions of supine oblique crunch and prone quadruped arm and lower extremity lift. EMG was recorded for each repetition and analyzed using the middle 2 seconds of each muscle contraction. EMG activity was normalized and expressed as %MVC. One-way ANOVA was performed to compare gender differences among the 8 muscles during 3 exercise formats (P = .05). RESULTS: Higher rectus femoris EMG activity was observed during supine B (P = .006). Prone B found greater rectus femoris (P = .01), external oblique (P = .03), and biceps femoris (P = .006) in women. Supine F displayed higher rectus femoris (P = .02), external oblique (P = .02), and in prone, paraspinals were higher (P = .02) in women. Women demonstrated greater rectus femoris (P = .03), rectus abdominis (P = .02), internal oblique (P = .01), and biceps femoris (P = .001) during supine P. CONCLUSIONS: Women exhibited greater rectus femoris EMG activity during supine oblique crunch for all 3 core programs. Women displayed higher rectus abdominis, internal oblique, and biceps femoris EMG activity during supine Pilates and greater external oblique EMG activity for supine Floor. The prone position using the Physioball resulted in higher biceps femoris and external oblique EMG activity versus floor exercises caused greater paraspinals EMG activity in women. CLINICAL RELEVANCE: The use of rectus and biceps femoris muscles by women who are novice to various core exercises should be considered when designing stabilization programs. Gender differences may exist among current core exercises, however differences are dependent upon body position and core program.



Physical Therapy, Wichita State University, Wichita, KS PURPOSE/HYPOTHESIS: The abdominal hollow and abdominal brace muscle contractions are 2 types of muscle contractions commonly prescribed to increase spinal stability and trunk strength. Our purpose is to quantify the immediate change in lumbo-pelvic-hip complex/lower trunk strength produced by these 2 different types of abdominal muscle contraction techniques. Our hypothesis is that there will be no significant difference in lower trunk strength with respect to the 2 types of muscle contractions utilized in this study. NUMBER OF SUBJECTS: Thirty-five asymptomatic subjects (27 females and 8 males) with a mean age of 44.0 8.9 years were used as a sample of convenience. Subjects were randomly assigned into either a bracing or hollowing abdominal muscle contraction group. MATERIALS/METHODS: Subjects' lower trunk strength was tested in the supine hooklying position with force applied via dynamometer from lateral to medial at mid thigh of bilateral lower extremities. Subjects were then taught either the abdominal bracing contraction or the abdominal hollowing contraction as per established instructions. Ultrasound imaging was utilized for feedback training and assurance of proper performance of the respective technique. Subjects were then tested for lower trunk strength again in the same position with the instruction of performing the specified technique (bracing or hollowing contraction) prior to force application for strength assessment. RESULTS: Intraclass correlation coefficient of test-retest reliability for lower trunk strength testing was established at 0.996 with pilot testing (n = 17) prior to this study. Strength increased significantly in the bracing group after the training session but not in the hollowing group (P = .039). CONCLUSIONS: In asymptomatic subjects, performing the abdominal brace contraction provided an immediate increase in lower trunk strength as compared with performing the abdominal hollowing contraction. CLINICAL RELEVANCE: These findings may allow clinicians to accurately prescribe abdominal contraction techniques with stabilization exercises commonly utilized in the clinic as a means of increasing trunk strength and ability to resist transverse plane forces. With subjects who need to improve lower trunk stabilization/strength, it may be more beneficial to prescribe the abdominal bracing contraction technique as compared to the abdominal hollowing contraction technique. Further studies are warranted with an emphasis on long-term benefit of such exercise prescription, specifically with subjects with low back pain.



University of Delaware, Newark, DE BACKGROUND AND PURPOSE: Acute low back pain (LBP) may be categorized into 1 of 4 treatment classifications as defined by Fritz and George (2000): mobilization, immobilization, specific exercise, and traction. Patient evaluation provides information necessary to assist with allocation to the appropriate treatment group and prediction of potential success with a given intervention. The purpose of this case is to describe an acute exacerbation of a patient with chronic LBP who fits criterion for both mobilization and immobilization categories. Treatment was based on treatment classification and corresponding clinical prediction rules (Childs 2004, Cibulka 1999, and Hicks 2005). CASE DESCRIPTION: A 32-year-old male manufacturer warehouse worker with a 6-year history of chronic LBP experienced an exacerbation performing yard work resulting in 9/10 pain with ambulation. He was unable to squat, lift from the floor, or twist as required by his job. Recreationally, he was unable to golf, run, or perform his daily lifting routine. His Oswestry was 14% and his Fear-Avoidance Beliefs Questionnairework (FABQ-W) was 0. He presented with asymmetry with seated PSIS palpation, and changes in the relationship between the malleoli from a supine to long-sitting position and leg length with prone knee flexion (positive prediction for lumbopelvic manipulation). Hip internal rotation on the right was 46° and left 35°. Posterior-anterior joint mobil-



University of Findlay, Findlay, OH PURPOSE/HYPOTHESIS: Studies have reported males and females respond differently to core exercises. Greater abdominal activity during a crunch has been found in males while others reported no gender differences in trunk flexors. The purpose of this study was to determine if gender differ-

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ity assessment revealed hypomobility at L1, L2, and L5 with hypermobility of L3. Aberrant movement with lumbar flexion and extension was present. He received a lumbopelvic manipulation secondary to 3/4 positive tests described by Cibulka as well as 5/5 criterion for success with a manipulation (lumbar joint hypomobility: pain less than 16 days, hip IR greater than 35°; no symptoms distal to the knee, and FABQ-W<19) by Childs, which indicates greater than a 95% chance of a 50% Oswestry improvement. A lumbar stabilization program was implemented since he met 3/4 criterion established by Hicks et al (age less than 40 years, aberrant movements, and a hypermobile lumbar segment), for a 67% chance of success after 8 weeks. Stabilization program exercises were those described by Hicks. OUTCOMES: A lumbopelvic manipulation was performed on the evaluation day and improved his lumbar flexion and extension by 50 percent; pain with ambulation reduced from 2 to 0/10. After 4 visits his Oswestry was 8%. After 10 visits, he noted 0/10 pain with ADLs but intermittent LBP at L3; he reported noncompliance with his home program. He received re-education on core exercises and at a 6-week follow-up had 0/10 pain with all activities including squatting, lifting, and twisting at work. He had resumed all recreational activities without limitations. DISCUSSION: Ten visits of physical therapy using Clinical Prediction Rules guided selection of successful intervention strategies of mobilization and immobilization in a patient with an acute exacerbation of chronic low back pain. back (afferent and efferent) related to tinnitus pathways. Since tinnitus is a potentially debilitating condition with limited treatment success, it is imperative to identify any effective therapeutic interventions.



Rehabilitation and Movement Science, University of Vermont, Burlington, VT; Neurology, University of Vermont, Burlington, VT PURPOSE/HYPOTHESIS: To determine if changes in central motor control associate with chronic low back pain. We hypothesized that people with chronic low back pain would exhibit changes in central motor neurophysiology associated with delayed anticipatory postural adjustments. NUMBER OF SUBJECTS: Ten participants with chronic, recurrent low back pain and 10 participants without low back pain matched for sex and of similar age, height and weight. MATERIALS/METHODS: Participants performed rapid, self-initiated arm raises with their dominant arm. We recorded the electromyographic onset latencies of the internal oblique and erector spinae muscles relative to the onset of the moving arm's anterior deltoid as measures of the participants' anticipatory postural adjustments. We also recorded the participants' electroencephalographic premovement potentials as a measure of the participants' cerebrocortical motor preparation. RESULTS: The onset latencies of anticipatory postural adjustments were asymmetric, with the following order of activation: contralateral internal oblique, contralateral erector spinae, ipsilateral erector spinae, and ipsilateral internal oblique. There was a trend for the group with low back pain to exhibit larger premovement cortical potentials and delayed onset latencies of their anticipatory postural adjustments, but these differences were not statistically significant. The onset latencies of the anticipatory postural adjustments were significantly associated with the amplitudes of the participants' cortical premovement potentials for only the group with low back pain. CONCLUSIONS: The results suggest that people with chronic low back pain exhibit an increased contribution of the cerebral cortex to coordinating their anticipatory postural adjustments. CLINICAL RELEVANCE: Changes in motor neurophysiology and postural coordination with chronic low back pain suggest a need for rehabilitation to address these motor impairments through movement re-education.



Rehabilitation Institute, Cleveland Clinic, Cleveland, OH; Neurological Institute, Cleveland Clinic, Cleveland, OH BACKGROUND AND PURPOSE: Approximately 50 million people in the US experience tinnitus, with up to 10 to 12 million actually seeking medical care. Over 2 million of these people cannot perform their daily activities due to tinnitus. A review by Dobie of 69 randomized trials indicated that "no single treatment can be considered effective for long-term relief " of tinnitus. Levine (2003) demonstrated that approximately 75% of patients can temporarily modulate their tinnitus (intensity and/or character) with contractions of the neck and/or jaw. There is limited literature on the long-term effects of physical therapy in the treatment of tinnitus. CASE DESCRIPTION: The patient is a 42-year-old male with bilateral, intermittent tinnitus, headaches, blurry vision, and neck tightness. Evaluation identified decreased cervical range of motion as measured by CROM. Resisted muscle contraction of the neck in flexion, extension and rotation increased the intensity of tinnitus. Jaw contractions had no effect on his symptoms. Additional findings included: tenderness of cervical and jaw musculature, neck disability score of 24%, tinnitus handicap inventory score of 62/100, headache disability inventory of 38/100 and dizziness handicap inventory of 40/100. Physical therapy focused on normalizing cervical spine mechanics via repeated movements assessment and treatment per Robin McKenzie's protocol. This patient was able to progress easily from repeated retraction to extension while showing improvement in his overall cervical motion and symptoms. Joint mobilizations were also performed by using Brian Mulligan's towel technique for increased motion at the C1-2 level. Soft tissue massage was completed for the cervical spine and jaw musculature that associated with symptoms. OUTCOMES: The patient demonstrated significant improvement in the intensity of his tinnitus. This improvement was demonstrated by decreased disability scores in the THI, NDI, HDI and DHI. The patient also demonstrated increased cervical range of motion as measured by the CROM. DISCUSSION: Treatment success was likely due to improving cervical spine biomechanics, along with focus on ergonomics and posture. Normalizing mechanics may facilitate normal muscle tone thereby influencing feed-



Des Moines University, Des Moines, IA PURPOSE/HYPOTHESIS: Upper extremity neural tissue provocation tests (NTPTs) are used to examine neural tissue in patients with neuromusculoskeletal disorders. Although comparisons between involved and uninvolved limbs are made clinically, no data exists reflecting the normal variation between limbs for upper extremity neural tissue provocation tests. The purpose of this study was to determine if within subject differences exist between limbs for the upper extremity NTPT. Our hypothesis was that there would be no within subject difference between limbs for the NTPT. NUMBER OF SUBJECTS: Sixty-one healthy volunteers (44 females, 17 males) with a mean age of 29.7 9.0 years participated in the study. MATERIALS/METHODS: Each subject's upper extremity was passively moved through the NTPT for median, radial, and ulnar nerves. A uniaxial electrogoniometer was used to measure the elbow in the end position of the NTPT for each nerve. The procedure was repeated on both upper extremities for each subject. Differences between limbs for each nerve were examined using paired t tests while the relationships between limbs were quantified with Pearson correlation coefficients. The alpha level was set

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at 0.05 for all analyses. RESULTS: The mean difference between limbs for the median nerve was significant (right, 16.4° 11.4°; left, 20.1° 13.7°; P = .045). There was a trend for a difference between limbs for the ulnar nerve (right, 146.9° 7.3°; left, 144.4° 10.5°; P = .057) while the inter-limb differences for the radial nerve were not significant (right, 8.1° 9.4°; left, 9.6° 10.5°; P = .3). The correlation analyses showed that while the relationships between limbs were statistically significant, the magnitude of the relationships was quite small (median nerve: r2 = 0.14, P = .001; radial nerve: r2 = 0.20, P<.001; ulnar nerve: r2 = 0.13, P = .002). CONCLUSIONS: The results of this study show that it is normal for an individual to have differences between limbs for the NTPT for median and ulnar nerves. The small relationship found between limbs cannot be used to predict NTPT motion available in 1 limb based on the motion available in the other. Right and left extremities are independent of each other in elbow ROM values for NTPT. CLINICAL RELEVANCE: Within subject comparisons for the NTPT cannot be used clinically to determine the presence of limitations since between limb values are independent of each other. Patient outcome goals should not be developed around comparisons of elbow ROM between limbs. adaptive protective response. CLINICAL RELEVANCE: These findings indicate that chronic low back pain leads to a shift in trunk muscle activation strategies that should be addressed as part of the rehabilitation care plan.



Washington University, St Louis, MO PURPOSE/HYPOTHESIS: Early lumbopelvic motion during active limb movement tests has been associated with an increase in symptoms in people with low back pain (LBP). Clinically, people report a decrease in LBP symptoms when the lumbopelvic motion is manually restricted by the therapist. However, it is unclear whether people are able to modify lumbopelvic motion without manual restriction. The purpose of this study was to examine the effect of instruction within a single session on patterns of movement during the lower limb movement test of active hip lateral rotation in prone. We hypothesized that, compared to their preferred movement patterns, people would demonstrate decreased and later onset of lumbopelvic motion during active hip lateral rotation in prone following standardized instruction to modify the movement. NUMBER OF SUBJECTS: The sample included 13 people with LBP (mean age, 28.7; 5 men, 8 women) and 6 people without LBP (mean age, 26.7; 3 men, 3 women). MATERIALS/METHODS: Kinematic data were collected using a 3-D motion capture system while subjects performed active hip lateral rotation in prone. Subjects completed 5 trials using their preferred method of performing hip lateral rotation and 10 trials following verbal and tactile instruction intended to modify lumbopelvic motion during hip lateral rotation. Angular measures of hip lateral rotation and lumbopelvic rotation were calculated across time. Variables of interest were (1) magnitude of lumbopelvic rotation relative to the magnitude of hip rotation, and (2) timing of lumbopelvic rotation relative to hip rotation. Averaged data for the preferred and modified trials were used for analyses. Separate paired t tests were performed to examine the effect of instruction on maximal lumbopelvic rotation angle and timing of lumbopelvic rotation during active hip lateral rotation in prone. RESULTS: Compared to their preferred movement patterns, subjects demonstrated decreased maximal lumbopelvic rotation (P<.001) and later onset of lumbopelvic rotation (P = .002) during hip lateral rotation following instruction. CONCLUSIONS: Within a single session, people were able to modify their lumbopelvic motion during hip lateral rotation following verbal and tactile instruction. CLINICAL RELEVANCE: The preliminary results of this study suggest that people are able to readily modify performance of a movement pattern within a single session following a minimal amount of instruction. These findings are important because they suggest modification of a movement pattern during higher level activities may also be possible. Further study is necessary to identify (1) whether people with LBP are able to learn to modify movement patterns during exercises as well as functional activities, and (2) factors that contribute to why some people are better able to modify movement patterns following instruction than others. Knowledge of such factors is potentially important for specifying treatment and prognosis.



Physical Therapy, Ohio University, Athens, OH PURPOSE/HYPOTHESIS: To determine if trunk muscle activation is altered in participants with chronic low back pain when compared to healthy matched controls. NUMBER OF SUBJECTS: Twenty individuals with chronic low back pain and 20 individuals with no history of low back pain. MATERIALS/METHODS: Participants reached with their right hand to 2 targets located in a mid-sagittal plane starting from a standing posture, paused at the target for 2 seconds, and then returned to an upright posture. Participants were paced to reach for the targets at 2 speeds (comfortable and fast) and were given no instructions on limb segment geometry. Kinematic data were measured using a Vicon Mx-13 system. Using a Delsys Bagnoli system, surface EMG data were collected from the right deltoid and bilaterally from the following trunk muscles: external oblique, rectus abdominus, internal oblique, erector spinae, and multifidus. We defined movement onset (t0) as the point where fingertip velocity exceeds 2.5% of peak velocity and movement offset (t1) as the point where fingertip velocity dropped below 2.5% peak velocity. Movement time was calculated as t1-t0. Onset of EMG activity was, defined as the point where EMG signal is greater than or equal to baseline 4 SD (baseline and SD was calculated from 100 data points beginning 200 milliseconds prior to t0). The latencies were calculated as the difference between onset of the trunk muscles and the onset of the deltoid. RESULTS: Movement time for reaches at the comfortable pace was, on average, 1090 milliseconds (SD, 57) and for fast pace reaches the movement time was 527 milliseconds (SD, 24). There was no significant effect of group on movement time. However, for the fast paced movement trials, there was a significant effect of group on the onset latency of the left (P<.019) and right (P<.03) erector spinae. For the comfortable paced movement trials, there was only a group effect for the left erector spinae (P<.1). On average, for fast-paced movement trials, healthy controls had a latency of the erector spinae muscles of 191 milliseconds (SD, 39) while those with chronic low back pain had a latency of 344 milliseconds (SD, 48). Finally, there was no effect of group on latencies of the trunk agonists. CONCLUSIONS: Thus, both groups turned on their antagonist trunk muscles late into the movement; but there was a much larger delay for those with chronic low back pain. Further research is needed to determine if these latencies contribute to continued low back pain or serve as an



Physical Therapy, East Tennessee State University, Johnson City, TN PURPOSE/HYPOTHESIS: The purpose of this study was (1) to determine the content of patient education programs provided by physical therapists

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for the management of an acute low back derangement syndrome, and (2) to compare study results with the literature recommendations. NUMBER OF SUBJECTS: Six hundred (600) survey questionnaires were mailed to a national sample of physical therapists: 300 were mailed to physical therapists who were employed in an outpatient orthopaedic setting; and 300 to ABPTS-certified orthopaedic clinical specialists. Study samples were drawn from a mailing list provided by the APTA. MATERIALS/METHODS: The survey instruments consisted of a written description of a sample patient case study and a questionnaire. After content validity was established, pilot testing of the survey instruments was conducted prior to survey administration. The survey questionnaire included items on the provision of patient education, patient instructions, resources, and demographics. Descriptive statistics were used to analyze the survey data. RESULTS: Two hundred and 64 (264) completed questionnaires were returned, resulting in a 44% response rate. Of the 264 completed questionnaires, 43% were completed by males and 55% by females. Fortyone percent of respondents were under age 40, while approximately 58% were age 40 and above. Fifty-five percent of respondents indicated they were Board Certified Specialists in Orthopaedic Physical Therapy, while 45% did not indicate this certification. The most frequently provided patient education topics (95% or more of respondents) were as follows: the plan of care; therapeutic exercises; current condition/risk factors; posture/positioning; body mechanics; and instructions on altering the amount of loads/forces acting on the lumbar spine. Slightly less frequently provided topics (90%-94% of respondents) were: the self limiting nature of low back pain/importance of resuming normal activities; use of rest periods during activities; resuming patient's personal goal of playing tennis; patient participation in setting goals; health/wellness/ fitness; and altering the rate or pace of performing activities. The least frequently provided topics were: use of physical agents to control pain (86%), role of imaging studies (80%), use of devices/equipment (70%), and stress management (69%). CONCLUSIONS: Specific to a low back derangement syndrome, physical therapists provide a broad-based patient education program that draws on principles from the adult education literature as well as the orthopaedic literature. CLINICAL RELEVANCE: Principles from adult education may prove beneficial to the patient education program. Among these is the development of a collaborative relationship between the physical therapist and patient. Also important is to dispel patients' fears and misconceptions, and to promote self-care. the ankle, knee, hip, lumbar spine, and thoracic spine were calculated as the difference between the joint angles in upright standing posture and maximum trunk flexion. Spine-hip ratios as well as the onset latencies for spine and hip joint motions were also calculated. RESULTS: Discrete versus cyclic movements significantly influenced joint excursions of the ankle, hip, and thoracic spine as well as the spine/hip ratio (P<.05). Joint excursions increased from discrete to cyclic, ­10.7 (SD, 0.89) to ­13.5 (SD, 1.32) for the ankle joint, and from 48.2 (SD, 2.15) to 54.13 (SD, 2.21) for the hip joint. For the thoracic spine, the joint excursion decreased, from 4.33 (SD, 2.58) of flexion with discrete movements to 2.58 (SD, 2.52) of extension with cyclic movements. Additionally, the spine hip ratio decreased from 1.47 to 1.3 in discrete versus cyclic movements. However, excursion of the lumbar spine was not affected by discrete versus cyclic movements. Finally, there was no effect of movement condition (ie, cyclic versus discrete) on the timing of spine and hip joint motion. For both discrete and cyclic movements, spine motion preceded hip motion by 30 milliseconds when initiating forward bending movement, but hip joint motion preceded spine joint motion by 9.5 milliseconds when initiating return to an upright posture. CONCLUSIONS: While the excursions of the postural joints used to perform forward bending are influenced by the task condition of discrete versus cyclic movements, the excursion of the lumbar spine and the timing of the spine and hip joint motion remain invariant. CLINICAL RELEVANCE: Therapists often have patients perform single (discrete) and repeated (ie, cyclic) during an examination, yet there are no studies that have examined the effect of this manipulation on motor behavior. Our findings indicate that lumbar spine excursions and the timing of the spine and hip remain invariant to this manipulation. This experiment needs to be repeated with a cohort of back pain patients to determine how back pain will influence coordination in these 2 tasks.



Arizona OrthoSports Physical Therapy, Phoenix, AZ BACKGROUND AND PURPOSE: The purpose is to describe the use of the Movement Systems Impairment diagnostic system to evaluate, diagnose, and treat a patient with low back pain. This diagnostic system allowed for an exercise program to be developed that focused on addressing specific movement impairments to decrease pain. CASE DESCRIPTION: A 56-year-old female presented to the clinic with leftsided low back pain. The pain had been present for 6 weeks and began with an insidious onset. She was unable to walk greater than 5 minutes before having to sit down due to pain. She was retired and cared for 3 young grandchildren daily. Her goals were to stand to wash dishes, walk for exercise, and lift her grandchildren without back pain. The patient stood with an anterior pelvic tilt. The evaluation revealed that she demonstrated excessive lumbar rotation and extension with lower extremity movements. Her pain was reproduced with positions that put her lumbar spine into an extended position and abolished when her lumbar spine was in a flexed position. Her symptoms were also reproduced with rotation of her lumbar spine. The patient had weak lower abdominals and had poor recruitment of her abdominals with lower extremity movements. Following the evaluation the patient was given a Diagnosis of Lumbar Extension-Rotation Syndrome. The patient was instructed in specific exercises designed to increase lower abdominal strength and improve motor control to correct movement faults in the lumbar spine. OUTCOMES: This patient was seen for 5 visits over the course of 4 weeks. The Back Index score decreased from 40% disability, or moderate disability at the initial visit to 4% disability, or minimal disability at time of discharge. Her score on the visual analog pain scale decreased from 8/10 with activity initially to 0/10 at the final visit. At the time of discharge, the patient was able to walk 2 miles, lift her grandchildren, and perform



Physical Therapy, Ohio University, Athens, OH PURPOSE/HYPOTHESIS: To examine the influence of discrete versus cyclic task conditions on the timing and excursions of the spine and hip joints in healthy participants performing forward bending movements. NUMBER OF SUBJECTS: Twenty four healthy participants (14 women, 12 men) with no history of back pain. MATERIALS/METHODS: As part of a larger experiment, participants performed a series of discrete and cyclic forward bending movements. For the discrete movement task, participants were instructed to bend as far forward as possible while keeping their legs straight and to stay in that position until they received the signal to return to an upright posture (ie, 2 seconds after achieving full trunk flexion). After 2 discrete trials participants were asked to perform a cyclic bending task. Participants would perform repeated maximum trunk flexion at a comfortable pace (with no pause at upright posture or full trunk flexion) for 10 seconds. Kinematic data were recorded using a Vicon MX 13 system. Joint excursions of

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all daily activities without low back pain. DISCUSSION: The use of diagnostic systems is beneficial for evaluating and classifying patients. The Movement Systems Impairment diagnostic system was successfully used to evaluate and treat a patient with low back pain. Specific movement impairments in the lumbar spine were identified and the results of the evaluation were used to design an intervention to specifically correct movement faults.

Cooper Institute, Dallas, TX PURPOSE/HYPOTHESIS: The first purpose was to determine intrarater and interrater reliability using a single electronic goniometer for measuring lumbar flexion and extension range of motion (ROM) in women. The second purpose was to compare a single electronic goniometer to a single bubble inclinometer for measurement of lumbar flexion and extension ROM. NUMBER OF SUBJECTS: Forty women (mean age, 35.9 years) were recruited among university students and employees from the Dallas/Ft Worth Metroplex for the reliability study. An additional 39 women (mean age, 37.7 years) were recruited for the concurrent validity study. MATERIALS/METHODS: Two raters, (A and B) measured lumbar flexion and extension using a single electronic goniometer to estimate interrater reliability. Rater A always measured ROM twice to establish intrarater reliability, while rater B measured once to establish interrater reliability. Each rater independently palpated and marked the T12 and S2 spinous processes with a round sticker. In order to determine concurrent validity, lumbar flexion and extension ROM was assessed using a single electronic goniometer and a single bubble inclinometer. The tester used a pen to mark the palpated spinous processes of T12 and S2. The average of 2 trials for lumbar flexion and extension was used for data analysis. The data were analyzed using ICC, dependent t test, and Pearson correlation coefficient. RESULTS: Intrarater reliability of lumbar flexion and extension was good with an ICC3,2 of 0.97 and 0.94, respectively. Interrater reliability of lumbar flexion and extension was also good with an ICC2,2 of 0.90 and 0.78, respectively. The results of the dependent t tests revealed no significant difference between lumbar ROM measurements with the single electronic goniometer and the single bubble inclinometer. The Pearson r coefficient revealed a strong positive relationship between the single electronic goniometer and single bubble inclinometer with r = 0.95 for lumbar flexion and r = 0.84 for lumbar extension. CONCLUSIONS: The single electronic goniometer demonstrated good intrarater and interrater reliability when measuring lumbar flexion and extension ROM. Good concurrent validity exists between the single electronic goniometer and the single bubble inclinometer. CLINICAL RELEVANCE: Lumbar ROM is often measured using dual inclinometer with intrarater and interrater reliability varying from poor to good. Single inclinometer measurements of lumbar ROM have been determined to have better reliability than the dual inclinometer but reliability has still been poor to good. The current study demonstrated good intrarater and interrater reliability using a single electronic goniometer and standardized tests procedures for measurements of lumbar flexion and extension. In addition, when using the same test procedures, good concurrent validity was found between the single electronic goniometer and the single bubble inclinometer. Based on this finding, the single bubble inclinometer provides an inexpensive and valid alternative for measuring lumbar ROM in the clinical setting.



Biokinesiology and PT, USC, Los Angeles, CA BACKGROUND AND PURPOSE: Purpose: To describe the improvement in posturography after cervical spine manipulation. Background: Patients with dizziness and neck disorders can exhibit impaired postural performance, which improves following nonspecific physical therapy to the neck. Spinal manipulation has been advocated to improve cervicogenic dizziness. This case illustrates the immediate improvement of postural performance following each of 2 bouts of cervical spine manipulation. CASE DESCRIPTION: A 68-year-old woman complained of insidious onset decreased balance, "wooziness," and neck stiffness starting 5 months prior to her initial exam. She denied true vertigo and headaches. Her oculomotor and neurologic exams were normal. She had a positive right head thrust, a dynamic gait index of 17/24, and single limb balance under 10 seconds bilaterally. Cervical ROM was decreased and painful, and eyes closed joint repositioning appeared compromised. Prior to the episode of care described here, she received soft tissue and joint mobilization, and dynamic balance and cervical kinesthesia exercises. She improved, was able to return to golf, and was discharged. Three weeks later her symptoms had returned to their original levels despite a faithful home program. The standard Smart Balance Master sensory organization test (SOT) protocol was performed 4 times: once prior to and again immediately after a single cervical manipulation to each side, repeated again a week later. She received a high velocity low amplitude thrust in the cephalic direction, in sidelying via unilateral occiput contact. Prior to manipulation she was cleared for contraindications and verbal consent was obtained. During the intervening week her activity levels were unchanged. OUTCOMES: Initial standard SOT results were below-normal on conditions 5 and 6, including 1 fall in each condition. The composite SOT score was 60 (below normal). Immediately after the first manipulation the composite score increased to 65 (still below normal), condition 5 normalized, but condition 6 was still below normal (2 falls). One week later, the premanipulation SOT composite score was 71 (normal for age), with condition 5 still normal and 1 abnormal trial in condition 6. The immediate postmanipulation composite score was 76, normal in all trials. Her symptoms and ROM were improved; she was able to return to golf. DISCUSSION: The immediate symptom and SOT improvements following a week of stable symptoms suggest that the traction manipulation was responsible for the change. A study on young healthy adults suggested an 8-point difference in test-retest SOT composite scores is needed to discount change due to a learning effect. The ability to generalize this difference to a 68-yearold patient is unknown. Despite only 5-point immediate changes, the 16-point overall improvement in 1 week is well beyond the 8-point minimal necessary change. Further studies are needed on the mechanism of improving postural control via spinal manipulation, particularly in someone with a positive head thrust, and who may best benefit from this intervention.



Physical Therapy Department, Nazareth College, Rochester, NY; Program in Physical Therapy, Washington University in St Louis School of Medicine, St Louis, MO PURPOSE/HYPOTHESIS: Prior data suggest that people in the Rotation with Extension (RotExt) low back pain (LBP) subgroup display greater asymmetry of lumbar region passive elastic energy than people without LBP during trunk lateral bending (TLB). Our purpose was to examine whether characteristics of the individual and of the trunk muscles are related to measurements of passive elastic energy in the RotExt subgroup and people without LBP. We hypothesized that anthropometric characteristics such as BMI, waist and hip circumference, and spine length would



School of Physical Therapy, Texas Woman's University, Dallas, TX; The

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be related to passive elastic energy in both groups, but that trunk muscle characteristics may be related to the asymmetry of passive elastic energy in the RotExt subgroup. NUMBER OF SUBJECTS: Twenty-two people with LBP in the RotExt subgroup, and 19 people without a history of LBP. MATERIALS/METHODS: A movement device measured torque during passive and isometric resisted TLB. A motion capture system measured lumbar region kinematics. A surface EMG system measured muscle activity of the lumbar erector spinae and external oblique muscles during passive and resisted TLB. For passive TLB, torque-lumbar region angle curves were generated and passive elastic energy was defined as the area under the curve. For resisted TLB, peak torque and normalized average EMG were calculated. A principal components analysis was conducted to develop an anthropometric factor and a factor for trunk muscle characteristics to each side. To examine whether the derived factors were related to passive elastic energy, 2 separate multiple regression analyses were conducted for each direction of passive TLB. The independent variables included were: group (RotExt, no LBP), anthropometric factor, trunk muscle factor in the direction opposite the passive movement, and an interaction factor of group and trunk muscle characteristics. RESULTS: The anthropometric factor was a significant predictor of passive elastic energy with left TLB for both the RotExt and no LBP groups (P<.01). The anthropometric factor (P<.01) and the interaction factor of group and trunk muscle characteristics (P<.01) were significant predictors of passive elastic energy with right TLB. Separate analyses then were conducted for each group. For people in the RotExt subgroup, 50% of the variance in passive elastic energy with right TLB was accounted for by the trunk muscle factor with resisted left TLB, compared to 2% in the no LBP group. CONCLUSIONS: Anthropometric characteristics predicted lumbar region passive elastic energy with TLB to both sides, in both groups. For people in the RotExt subgroup, trunk muscle characteristics with resisted TLB to the left predicted lumbar region passive elastic energy with passive TLB to the right. CLINICAL RELEVANCE: Trunk muscle characteristics are significant factors that predict asymmetry of passive elastic energy in the RotExt subgroup. Intervention for LBP that focuses on reducing the asymmetry in the RotExt subgroup should address the differential effect of trunk muscle characteristics on passive elastic energy between sides. and postexercise H-reflex responses were obtained. If patients were not able to ambulate for a full 10-minute period, they were retested as soon as they developed symptoms of burning, numbness and pain in their legs that were not tolerable. Statistical analysis consisted of repeated-measures, paired-sample t tests. RESULTS: Group I (n = 25; 24 2 years old) normal subjects demonstrated H-reflex latency of 30.1 3.58 milliseconds prior to exercise and 29.89 3.24 milliseconds following TM testing (P>.05). Group II (n = 20; ages 50-70) data collection is incomplete, but preliminary analysis reveals H-reflex responses of 31.5 milliseconds before exercise and 31.9 milliseconds following TM testing. Patients with LSS are currently being recruited to participate in the study and their responses to H-reflex testing are being analyzed. CONCLUSIONS: Tibial H-reflex responses do not appear to change as a result of an endurance exercise bout in young or older normal individuals. H-reflex values are likely to be responsive to TM exercise in patients who describe sensory symptoms with ambulation. This information provides useful information for documenting the diagnosis of LSS in patients for whom the remainder of the electrophysiologic testing may be normal. CLINICAL RELEVANCE: This study provides supporting evidence that simple electrophysiologic measures (H-reflex) combined with ambulation stress may provide useful diagnostic information in patients with subtle LSS, long before motor changes occur.



Physical Therapy Program, University of Colorado Denver, Aurora, CO BACKGROUND AND PURPOSE: Little evidence exists to guide clinicians in selecting patients with low back pain (LBP) that will benefit from mechanical traction. Clinical experience suggests that sciatica is a primary indication for the use of traction in patients with LBP. The treatment based classification suggests that patients with LBP and radiating leg pain that does not centralize with active movements may be candidates for mechanical traction. A recent report identified several examination findings that predicted a short term improvement in disability with the use of mechanical traction: the presence of sciatica, signs of nerve root compression, and either a positive crossed straight leg raise (SLR) or peripheralization of symptoms with extension. The purpose of this case series is to describe the examination findings, interventions and outcomes for 3 patients who were candidates for traction based on these criteria. CASE DESCRIPTION: Patient number 1 presented with a 2 week history of right sided LBP with sciatica into the calf. His initial disability level, as measured by the Oswestry Disability Questionnaire (ODQ), was 60%. He presented with a positive SLR at 37° and crossed SLR at 41°, absent Achilles reflex, weakness in the L5 and S1 myotomes, and peripheralization of symptoms with extension. Patient 2 presented with a 4 week history of left sided LBP and sciatica into the medial left foot. His initial ODQ was 46%. He had a positive SLR at 20° and crossed SLR at 45°, absent Achilles reflex, weakness in the S1 myotome, and peripheralization with extension. Patient 3 presented with a 3-month history of left LBP with sciatica radiating into the left hip and lateral thigh. Her initial ODQ was 61%. She had a positive SLR at 50° and crossed SLR at 55°, diminished patellar tendon reflex on the left, weakness in the L4 myotome, and peripheralization with extension. All patients received 6 to 8 sessions of static prone traction for 12 minutes at 40% to 60% subject's body weight, manual therapy focusing on centralization of symptoms, and extensionoriented exercises when tolerated. OUTCOMES: All 3 patients made significant improvements in impairments and disability, including a 50% decrease in ODQ scores at 6 weeks. Two of 3 patients had complete resolution of sciatica. Six month follow-up



Rehab Sciences, University of Kentucky, Lexington, KY PURPOSE/HYPOTHESIS: The purpose of this prospective cohort study was to initially establish that the H-reflex is a stable electrophysiologic parameter in normal subjects following endurance stress testing (exercise treadmill [TM]). Further, it is believed that patients with neurogenic claudication (NC) associated with lumbar spinal stenosis (LSS) will demonstrate identifiable changes in H-reflex latency and/or amplitude with TM stress testing. NUMBER OF SUBJECTS: Two groups of normal subjects volunteered to participate in this study. Group I consisted of 25 individuals (16 females, 9 males) 22 to 26 years of age. Group II was composed of 20 pain free, normal volunteers aged 50 to 70. A third group of 10 patients with symptoms and signs of LSS were also included in this study. MATERIALS/METHODS: Following familiarization with the testing protocol, standard tibial H-reflexes were obtained from the right lower extremity of all subjects and patients. Immediately after H-reflexes were obtained the subjects began ambulating on a standard TM at a final speed of 3.6 mph with the incline at 0.5° for 10 minutes. At the end of the 10-minute exercise period the subject was immediately placed in the prone position

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scores on the ODQ were 8% for patient 1, 16% for patient 2, and 28% for patient 3. DISCUSSION: The findings of this small, retrospective case series support the existence of a subgroup of patients likely to respond to mechanical traction. All 3 patients presented with sciatica, signs of nerve root compression, a positive crossed SLR, and the peripheralization of symptoms with extension. Additionally, this case series demonstrates the long-term efficacy of this intervention. Further research is needed to validate this subgroup.



Physical Therapy Division, The Ohio State University, Columbus, OH PURPOSE/HYPOTHESIS: Previous research by Kiesel et al (2007) indicates change in lumbar multifidus (LM) thickness, as measured with rehabilitative ultrasound imaging (RUSI), is highly correlated with fine wire electromyography (fwEMG) activity when asymptomatic controls perform a prone upper extremity (UE) lifting test. This study examined this relationship in subjects with low back pain (LBP). NUMBER OF SUBJECTS: Subjects (n = 15, age = 34.6 10.05 years) with subacute, recurrent LBP and 5 asymptomatic controls (27.4 5.03 years) participated. MATERIALS/METHODS: LM activity at S1 was recorded bilaterally using fwEMG while sagittal plane LM thickness at each L5/S1 facet was measured using RUSI. Activity of LM was recorded with the subject in prone during 3 conditions: (1) rest, (2) lifting the contralateral arm with no weight (LIFT-NO), and (3) lifting the contralateral arm with a weight (LIFT-WT) graded based on the subject's body weight (Kiesel, 2008). fwEMG was normalized to the maximal activity during the Biering-Sorensen test (McGill, 1999). RESULTS: A linear mixed-effects model indicated no difference between the subjects with LBP and the asymptomatic controls (P>.05). The relationship between changes in LM thickness and fwEMG were not significant at the P<.05 level (P = .076) across the 3 conditions. However, for every 1 unit change in percent fwEMG, LM thickness increased by 0.17 cm. This suggests a potential linked relationship. fwEMG could discriminate between each condition (P<.05) with a progressive increase in activity from REST to LIFT-NO to LIFT-WT. RUSI discriminated differences in LM thickness changes between REST and LIFT-NO (P<.0001) and REST and LIFT-WT (P<.0001) but not between LIFT-NO and LIFTWT (P = .2622). CONCLUSIONS: fwEMG was more sensitive than RUSI for detecting changes in the demands on the LM under the 3 UE lifting conditions. In a small sample of subjects with and without LBP, changes in LM fwEMG showed a poor relationship to changes in muscle thickness with RUSI. CLINICAL RELEVANCE: These findings suggest that RUSI may not discern precise changes in activation levels of the LM in persons with LBP and there may be no benefit to testing 2 levels of resistance with the prone UE lifting test. If the goal is to detect differences in LM activation across tasks, then fwEMG is superior to RUSI.



Faculty of Applied Health Sciences, Department of Kinesiology, University of Waterloo, Kitchener, ON, Canada PURPOSE/HYPOTHESIS: Previous work has shown that LBP can be induced in previously asymptomatic individuals during prolonged standing (Gregory et al, 2007). Attempts have been made to use biomechanical factors to predict LBP-developers a priori with moderate success (Nelson-Wong et al, 2008). The purpose of this study was to determine whether performance on active hip abduction in sidelying (AHAbd) is useful in discriminating between LBP developers and nondevelopers. It was hypothesized that LBP developers would have greater difficulty performing AHAbd than nonLBP developers. NUMBER OF SUBJECTS: Thirty, gender balanced. MATERIALS/METHODS: Participants underwent a clinical examination followed by 2-hours of standing. Participants completed a visual analog scale (VAS) every 15-minute during the 2 hours. Examination consisted of: lumbar and hip range of motion, lumbar segmental mobility, prone instability test, passive and active straight leg raise, time to fatigue in side-bridge support, and AHAbd. For the AHAbd test, the subject was placed in sidelying, both legs extended and pelvis aligned in the frontal plane. The subject was asked to lift the top leg approximately 30°, maintain the position of the pelvis, and rate the difficulty on a 0-to-5 scale (0, not difficult; 5, unable to perform). The test was scored by summing the ratings for each leg, with a score greater than 0 indicating a positive test. The examiner observed whether the subject was able to maintain the pelvis position and assigned a score from 0 to 3, with 0 indicating no loss and 3 indicating severe loss of frontal plane position. Self-reported and examiner rated AHAbd scores were entered into 2-factor ANOVAs with group and gender as between-subjects factors. RESULTS: Forty-seven percent of the participants developed LBP during the standing period. For self-reported scores, there were significant main effects of group (P = .009) and gender (P = .009) with mean scores of 2.61 (SE = .60) and .97 (SE = .30) for LBP and non-LBP groups respectively. Males had lower scores than females (.93, SE = .83 and 2.53, SE = .55 respectively). For the examiner scored test, there was a main effect of group only (P = .004). Mean examiner scores were 1.43 (SE = .27) and .50 (SE = .16) for LBP and non-LBP groups respectively. Sensitivity and specificity were similar for the 2 scoring methods, with Sn = .79 for both, SP = .56 and SP = .50 for the self-reported and examiner scored tests respectively. CONCLUSIONS: There were significant differences between LBP and nonLBP groups on the AHAbd test. When self-reporting, males scored lower than females, however there were no gender differences when the examiner scored the test. CLINICAL RELEVANCE: Active hip abduction in sidelying appears to be a promising screening tool for early identification of patients at risk for development of LBP during standing. Inclusion of examiner rating does not appear to improve the sensitivity or specificity of the test. Further work is required to objectively quantify frontal plane loss during the test, investigate gender differences, and examine reliability and validity issues particularly in clinical populations.



Physical Therapy, Oakland University, Rochester, MI PURPOSE/HYPOTHESIS: The purpose of this study was to determine if 4 different low velocity (LV) Translatoric Spinal Manipulation (TSM) techniques caused statistically significant changes in vertebral artery (VA) blood flow velocity or lumen diameter (LD) at the C5-C6 spinal level. NUMBER OF SUBJECTS: Thirty subjects (36.6 9.9 years; 21-57 years) participated in this study. MATERIALS/METHODS: Duplex Doppler ultrasound was used to measure VA blood flow velocity and LD at the C5-C6 inter-transverse segment. Peak systolic (PS), end diastolic (ED), and arterial LD measurements were taken of both VAs with the subjects cervical spine in the neutral position and during 4 different LV TSM techniques. RESULTS: There was no statistically significant change in LD or in PS or ED velocity. Paired t tests (P<.05) compared LD, PS, and ED pre- and post-TSM application. A Bonferoni procedure was used to control for family-wise type I error. The False Discovery Rate procedure recon-

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firmed the Bonferoni results. CONCLUSIONS: These 4 translational manipulative techniques provide a means to stretch cervical segmental motion restrictions. There were no statistically significant effects on VA LD or blood flow velocity during the performance of these 4 manipulation techniques. CLINICAL RELEVANCE: Results demonstrate that this form of manipulation may provide an increased degree of safety for the VA.

City, UT; Intermountain Healthcare, Salt Lake City, UT PURPOSE/HYPOTHESIS: Physical therapists often attend continuing education (CE) courses to improve their overall clinical performance and patient outcomes. The purpose of this study was to investigate the effectiveness of an ongoing educational intervention for improving therapists' outcomes in the management of patients with neck pain. NUMBER OF SUBJECTS: Nineteen physical therapists who attended a 2-day CE course focusing on the management of neck pain. MATERIALS/METHODS: Therapists from 11 clinics were invited to attend a 2-day CE course on the management of neck pain. Following the CE course therapists were randomly assigned to receive either ongoing education consisting of small group sessions and an educational outreach session or no further education. Clinical outcomes including the Neck Disability Index (NDI) and pain were compared between therapists who received ongoing education and those that did not for both pre and posttraining periods. The effects of receiving ongoing education were examined using linear mixed model analyses with time period and group as fixed factors, improvements in disability and pain were used as the dependent variable. RESULTS: During the pretraining period there was no difference in outcomes for patients between groups for change in NDI or pain (P>.05). However, therapists in the ongoing education group experienced significantly greater improvements in disability (mean difference 4.2; 95% CI: 1.7, 6.6; P = .001) during the posttraining period. The linear mixed model analysis examining improvements in NDI scores revealed a significant interaction between time and group (P = .019). Pair-wise comparisons revealed that during the posttraining period, therapists in the ongoing education group had higher improvements of NDI scores than therapists in the control group (adjusted mean difference = 3.7; 95% CI: 0.84, 6.5; P = .013). There was no difference in the improvements in the NDI between the pretraining and posttraining periods for therapists in the control group (P = .31). There was a difference in the improvements in NDI scores between the pretraining and posttraining periods for therapists in the ongoing education group (adjusted mean difference = 2.8; 95% CI: 0.54, 5.1; P = .015). CONCLUSIONS: The results of our study demonstrate that the ongoing education on the management of neck pain was beneficial in improving therapists outcome scores for disability. Future research is necessary to continue to evaluate other educational implementation strategies to determine the most clinically and cost effective interventions. CLINICAL RELEVANCE: Awareness of the lack of translation of evidence to clinical practice has resulted in a search for more effective strategies for moving evidence into practice and improving patient care. The results of our study that an education strategy involving a combination of individual and group sessions with ongoing outreach and feedback may be beneficial in improving therapists outcomes in the management of patients with neck pain.



Department of Physical Therapy and Rehabilitation Sciences, Drexel University, Philadelphia, PA PURPOSE/HYPOTHESIS: Reliable measurements of trunk postural control are crucial not only for identifying the role of poor trunk control in patients with low back pain (LBP) and extremity injuries, but also in determining the efficacy of core stabilization interventions widely used in clinical practice. The purpose of this pilot study was to begin to document test-retest reliability of trunk postural stability parameters obtained during volitional control of seated balance on an unstable surface. We hypothesized that center of pressure (CP) parameters would have adequate test-retest reliability in this testing paradigm. NUMBER OF SUBJECTS: Six subjects (1 LBP, 5 healthy with no LBP history) were tested. Mean age 26 5.7 years, height 175 14 cm, and weight 75 13 kg. MATERIALS/METHODS: Trunk postural control was tested while seated on an unstable surface. The testing apparatus was designed to isolate trunk control by minimizing the contribution of the lower extremity. Subjects sat on a seat with an adjustable foot rest allowing positioning of the subjects at 90° of hip and knee flexion. The seat was constructed with a 44 cm diameter hemisphere at the bottom to create an unstable surface there by requiring active trunk control to maintain an upright seated posture. The seat was placed on a force plate at the edge of a raised platform. For the test, the subjects were instructed to cross their arms over their chest and maintain their balance. One practice trial (30-sec) with eyes open (EO) was permitted prior to recording 3 consecutive 60-second trials. The same protocol was then completed with eyes closed (EC). Retest was performed with 48 hours under the same conditions. CP coordinates were calculated from force plate data that was low pass filtered (10 Hz, fourth-order zero-lag Butterworth). CP trajectories were quantified as maximal (MAX) and root mean square (RMS) displacements in the lateral (x) and anterior-posterior (y) directions, and path length (PATH) traveled per second. Trials were averaged and measures of reliability calculated: ICC2,k, standard error of measurement (SEM), and minimal detectable change (MDC, 95% CI). RESULTS: All but 1 of the measurements (MAXy EO) showed good to excellent test-retest reliability with ICCs ranging from .35 to .99. The SEMs ranged from .25 to 7.25 mm and the MDC (95) scores ranged from to 0.7 to 20.1 mm. CONCLUSIONS: In this testing paradigm, CP trajectories appear to reliably measure volitional trunk postural control. The SEM and MDC (95) scores from this pilot study imply that measurement error is small and that these postural control parameters should be further investigated in a patient population for reliability and responsiveness. CLINICAL RELEVANCE: This may be a viable method for assessing seated postural control in patients with LBP and may be useful in monitoring their progress with treatment.



University of Florida, Gainesville, FL PURPOSE/HYPOTHESIS: Research suggests the flexion relaxation ratio (FRR), determined using surface electromyography (EMG) of trunk muscles, is decreased in patients with chronic low back pain (LBP). More recently, this ratio has been suggested as a clinical tool to discriminate between individuals with acute LBP and those without. The objective of this study was to determine whether FRR discriminates between individuals with and without acute onset LBP. NUMBER OF SUBJECTS: Forty participants (22.5 3.9) volunteered for this study. Each signed a consent form endorsed by the local IRB. MATERIALS/METHODS: Subjects filled out a pain visual analogue scale (VAS), underwent surface EMG recording during trunk flexion and extension



Franklin Pierce University, Concord, NH; University of Utah, Salt Lake

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on the regions of the fifth lumbar vertebrae and 12th thoracic vertebrae and pressure pain threshold (PPT) testing at these same points using a handheld dynamometer. Comparison of EMG during full trunk flexion and concentric trunk extension phase determined the FRR. Subjects underwent a back exercise protocol to induce DOMS by doing repeated bouts of dynamic, fatiguing trunk exercises. Measures of FRR, ROM and pain were collected at baseline, 24, 48, 96 hours and 1 week. Bivariate correlations were calculated to determine the association among ROM, pain and FRR. Additionally, subjects were split into groups based on peak pain report: a low pain group of subjects who reported 0 or 1 using a 100-mm VAS; high pain group reported greater than 20. Groups were compared on FRR, trunk range of motion and PPT using separate mixed model analyses of variance (between-group, within-time). Type 1 error was set at 5%. RESULTS: Low correlations were observed between FRR and change in total trunk flexion (r = ­0.01, P = .94) and between change in FRR and change in total trunk flexion (r = ­0.01, P = .94). No interactions were noted for total trunk flexion; however, there was a main effect for group (F1,34 = 8.21, P = .010) in which the group reporting high pain had significantly less total trunk flexion. Comparison of these groups on mechanical threshold yielded a main effect for time in which thresholds were reduced after exercise (F1,20 = 11.16, P = .003) and the group with low pain reports tended to have higher threshold measurements (F1,20 = 3.51, P = .076). A significant interaction for pain rating in the group reporting high pain was found; ratings at threshold increased after exercise indicating mechanical hyperalgesia while the low pain group's rating decreased (F1,20 = 5.496, P = .029). CONCLUSIONS: Although FRR is useful in discriminating those individuals with chronic LBP, these results indicate FRR is not responsive to acute onset experimental LBP. Mechanical hyperalgesia occurred in the trunk muscles of subjects reporting high pain which suggests a muscular involvement in those subjects. FRR was reduced during the 48hours after induction of pain for all subjects. The FRR reduction was not associated with peak pain report or changes in trunk ROM. CLINICAL RELEVANCE: This study suggests that FRR may not be an effective diagnostic tool of muscle performance in acute onset muscular LBP. traction (normalized to standard task). Latency was defined as the time difference between deltoid muscle onset and trunk muscle onset and offset. Group comparisons were performed using MANOVA and ANOVA statistics, alpha set to .05. RESULTS: Patients with MLBP demonstrated significantly delayed trunk muscle onset (P<.01) in all the muscle groups. However, offset latency was not significantly different between the groups (P = .42). This resulted in significantly shorter burst durations (P = .04) for all muscles and a shorter duration of abdominal-extensor cocontraction (P<.01) as compared to asymptomatic individuals. In contrast, the MLBP subjects used a strategy that included significantly greater activation of the IO/TrA muscles (P<.01). CONCLUSIONS: These results indicate an altered feedforward control strategy, suggesting patients with MLBP might be inefficient in regulating posture and may be prone to periods of dynamic trunk instability and potential tissue injury during voluntary tasks. The increased activation response of the IO/TrA could be the consequence of pain or a compensatory "safety-catch" imposed by the CNS to enhance trunk stability. CLINICAL RELEVANCE: Maintaining dynamic trunk stability while performing rapid voluntary extremity movements could be a challenging task for the postural control system in patients with MLBP. Therefore, postural control exercises should be integrated into day-to-day functional activities during spinal rehabilitation of patients with MLBP.



Human Performance, West Virginia University, Morgantown, WV PURPOSE/HYPOTHESIS: To identify physical and psychosocial predictors of disability in working nonacute subjects with lower back pain. NUMBER OF SUBJECTS: Fifty-one subjects (25 women and 26 men) participated in the research investigation. The mean age was 28.9 years with a range of 19 to 50 years. MATERIALS/METHODS: This data represents preliminary results from an ongoing research project funded by National Institute for Occupational Safety and Health. Subjects were recruited from the local community to participate in the investigation based on the following inclusion criteria: age 18 to 50 years, greater than 3 weeks of lower back pain in the last year, currently working at least part-time outside the home, low back pain that is affected by occupational exposure, back pain less than 7/10 at the time of the testing session, back pain not related to a motor vehicle accident, and no associated radicular symptoms below the knee. Data analysis consisted of multiple linear regression using a stepwise approach to identify the best model. The response variable was Oswestry Disability Questionnaire (ODQ) and the regressor variables included: age, current pain, worst pain, FABQ-Physical Activity (FABQ-PA), FABQ-Work (FABQ-W), hip internal rotation ROM, straight leg raise, normalized and nonnormalized gait velocity (GAITRite), step length, and cadence, lumbar flexion ROM, and limits of stability balance measures (Balance Master) in the forward, backwards, left and right directions. The chosen model was then checked for assumption of normality and multicollinearity. RESULTS: Mean ODQ was 16.9% using a 100 point scale. The ODQ range was 2% to 34%. Multiple linear regression revealed current pain (P<.0001), FABQ-PA (P = .01), gait velocity (P = .007), and limits of stability (MLV) in the backward direction (P = .013) predicted 59% of the variability in ODQ. Examination of the residuals revealed a normal distribution based on the Shapiro-Wilk test. The model was found to have no significant multicollinearity. Examination of the coefficients revealed that ODQ increased as current pain, FABQ-PA, and backward movement velocity increased, while ODQ decreased as gait velocity increased. A restricted model with current pain and FABQ removed resulted in a



Department of Physical Therapy and Rehabilitation Sciences, Drexel University, Philadelphia, PA PURPOSE/HYPOTHESIS: To investigate differences in trunk muscle timing (onset, offset, burst duration, cocontraction duration) and amplitude of bilateral trunk muscle between patients with mechanical low back pain (MLBP) and asymptomatic controls in response to a known self-initiated postural challenge. Based upon previous work and biomechanical theories of spinal stabilization, we hypothesized that the MLBP group would demonstrate delayed muscle onset and offset, longer burst duration, and increased muscle activation and cocontraction. NUMBER OF SUBJECTS: Thirty subjects with MLBP (16 female, 14 male; 41.4 8 years) were compared to 30 asymptomatic controls (21 female, 9 male; 39.6 9.5 years). MATERIALS/METHODS: Surface EMG data were collected from bilateral internal oblique/transversus abdominus (IO/TrA), external oblique (EO), rectus abdominus (RA), superficial lumbar multifidus (sLM) and dominant arm anterior deltoid. Subjects stood in a relaxed standing posture and completed 3 repetitions of rapid unilateral shoulder flexion in response to an auditory stimulus. EMG data had heart rate eliminated and were RMS filtered. Onset and offset times were determined using a computer algorithm. Dependent variables were trunk muscle onset and offset latency (milliseconds), burst duration (milliseconds), duration of abdominal-extensor cocontraction (milliseconds) and amplitude of muscle con-

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decrease in R-square from 0.59 to 0.21, suggesting that the physical measures are contributing 36% of the explained variability, while pain and FABQ-PA are contributing 64% of the explained variability. CONCLUSIONS: Low back disability in nonacute working subjects can be moderately predicted by examining current pain, FABQ-PA, gait velocity, and limits of stability movement velocity. CLINICAL RELEVANCE: While this investigation is not designed to examine cause and effect relationships, the results support a moderate relationship between pain level, FABQ-PA, gait velocity, limits of stability velocity and low back disability. Further research in this area focused on gait and limits of stability is warranted to determine if manipulation of these physical performance variables is capable of improving low back disability in this population.

PURPOSE/HYPOTHESIS: Beneficial effects of conservative treatments for low back pain (LBP) are inconsistent, perhaps due to the absence of a specific diagnosis. Thus, a system for classifying LBP based on relevant variables to direct conservative treatment is needed (Croft 1997; Borkan and Cherkin, 1996). One such system is the Movement System Impairment (MSI)-based classification system, designed specifically to direct rehabilitation and assist in prognosis (Sahrmann 2002). The MSI system includes 5 classifications of LBP named for the specific direction(s) of movements and alignments associated with the person's LBP. The purpose of this study was to examine the interrater reliability of classification decisions made by raters who had moderate to no prior experience using the MSI system. NUMBER OF SUBJECTS: Thirteen raters, 12 of whom were physical therapists, independently reviewed 21 written cases of history and physical exam data collected from people with LBP. MATERIALS/METHODS: Following a 2-day workshop on the MSI classification system, the raters classified each case using decision rules currently being used to classify participants (n = 75) of an ongoing clinical trial (R01 HD047709). RESULTS: There were a total of 269 of the possible 273 classifications available for analysis (21 cases × 13 raters). Thus, there were 1590 pairs of comparisons among the 13 raters' chosen classification. There was 87.4% agreement in the pairs of classification and an overall 90.0% agreement with classifications based on the current rules. When examining agreement by a particular classification category, there was 83.8% agreement between the 13 raters and the expert opinion for the "Lumbar Rotation" category; 90.1% agreement for the "Lumbar Extension" and 100% agreement for the "Lumbar Flexion" and 96.9% agreement for the "Lumbar Rotation with Extension" and 100% agreement for the "Lumbar Rotation with Flexion." Only 2 raters (15.4%) agreed with the expert opinion for single subject who could not be classified based on the current rules. The overall kappa for the 13 raters was 0.81 (CI: 0.78-0.83; P<.01). CONCLUSIONS: With training, the interrater reliability to classify written patient cases was excellent. The reliability was similar to, or better than previously reported studies (Norton et al 2004; Jackson et al 2008). A degree of error persists in the classification decision-making associated with the MSI system, pointing to the need for additional elucidation of the classification rules. CLINICAL RELEVANCE: The findings from the current study suggest that the decision-making to classify people with LBP using the MSI system is generalizable, an important feature of any classification system. With excellent agreement in classifying written cases of patients with LBP, future studies will examine the reliability of raters in examining and then classifying patients as well as the efficacy of MSI-directed treatment in the management of LBP.



Physical Therapy, Oakland University, Rochester, MI PURPOSE/HYPOTHESIS: Previous studies show that excessive joint stiffness and muscle guarding contribute to limitations in thoracic spine mobility and impairments in function. Although management of joint stiffness using manipulation and exercise techniques has been documented in the literature, few studies address the use of manual muscle stretching to improve spinal active range of motion (AROM). Several studies have demonstrated the effectiveness of "Hold-Relax" (HR) to increase hamstring length and 1 for increasing cervical ROM. The success of HR in these studies leads the researchers to anticipate similar benefits in the thoracic spine. The purpose of this study is to investigate the effectiveness of "Hold-Relax" compared to active movements to improve thoracic flexion and extension AROM in healthy individuals. NUMBER OF SUBJECTS: Thirty. MATERIALS/METHODS: A convenience sample of 30 healthy physical therapy students between the ages of 22 to 38 participated in this study. Participants were randomly assigned to either initial treatment group A or B. Group A received 3 repetitions of `Hold-Relax' of the thoracic spine flexors. Group B performed 3 repetitions of active flexion and extension of the thoracic spine. At least 7 days later, all participants returned to receive the intervention they did not receive the previous week. Thoracic flexion and extension AROM were measured pre and post each intervention using the double inclinometer method for all subjects. RESULTS: A paired samples t test was used to compare values pre and post intervention for both groups. Subjects in Group A (HR group) had a significant increase in active thoracic extension ROM (P<.006) following intervention. There were no significant changes in thoracic flexion following HR or with the AROM intervention. CONCLUSIONS: Performing HR on the trunk flexors resulted in a statistically significant increase in thoracic extension AROM in this group of participants. CLINICAL RELEVANCE: The results of this study suggest that HR of the trunk flexors may be an effective method for increasing thoracic spine extension in asymptomatic individuals. Physical therapists may want to consider HR as a potential intervention for improving thoracic mobility when designing spine intervention programs. The effect of HR in patients with impaired movement due to pain or spinal pathology needs to be investigated further.



CIRRIS research centre, Quebec City, QC, Canada; Rehabilitation, Laval University, Quebec City, QC, Canada PURPOSE/HYPOTHESIS: Persons with shoulder impingement syndrome (SIS) present movement deficits during arm movements. It has been shown that repeated movement training contributes to the improvement of motor performances in persons with peripheral impairments. However, it is still unknown how movement deficits of persons with SIS are influenced by movement training. The aim of this study was to evaluate the immediate and short-term effects of movement training with feedback on the kinematic patterns of persons with SIS. We think that movement training with feedback will help reduce the movement deficits of persons with SIS. NUMBER OF SUBJECTS: Thirty-three subjects with SIS and 20 healthy



Rehabilitation and Movement Science, University of Vermont, Burlington, VT; Program in Physical Therapy, Washington University, St Louis, MO; Mathematics and Statistics, University of Vermont, Burlington, VT

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MATERIALS/METHODS: Subjects with SIS participated in 2 visits, 1 day apart.

During the first visit, they performed movement training with feedback. Kinematic patterns of trunk, clavicle, shoulder, elbow and wrist were evaluated before, during, immediately after and 24 hours after movement training. These patterns were characterized during reaching movements in the frontal plane by total excursion and position at the end of reaching of these joints. Movement training consisted of reaching movements performed under the supervision of a physiotherapist who gave feedback (visual, manual, and verbal) aimed at restoring proper shoulder control. Healthy subjects participated in 1 visit in order to assess normal kinematic patterns. t tests were used to compare kinematic patterns of the subjects with and without SIS before training. Then, 1-way repeatedmeasures ANOVAs were run to analyze the effect of movement training in subjects with SIS. An alpha level of .05 was used for all tests. RESULTS: Before training, subjects with SIS performed reaching with larger trunk and shoulder rotation (total excursion), and finished reaching with the clavicle more elevated, the trunk more rotated and the shoulder in a more anterior plane of elevation as compared to the healthy subjects. During and immediately after movement training, total excursion of the trunk and final position of the trunk, shoulder and clavicle were significantly improved. However, 24 hours after, the kinematics of these joints were back to the baseline level. CONCLUSIONS: Movement training with feedback led to immediate benefits during reaching with respect to upper limb kinematic patterns, but to minimal or no retention 24 hours after. One session, therefore, was not enough to bring permanent changes in kinematic patterns, and as expected, movement training has to be repeated in time. Our results support the need to evaluate this approach during a longer and more intensive training program. CLINICAL RELEVANCE: This study is the first to look at the effect of movement training with feedback on persons with SIS. It shows that supervised training, aimed at improving specific deficits observed in persons with SIS, leads to short-term improvement on upper limb kinematic patterns. These results demonstrate the potential of movement training in the rehabilitation of movement deficits associated with SIS.

anal sphincter tone was decreased. OUTCOMES: Due to suspected CES, the patient was evacuated to a military neurosurgeon in country and within 48 hours underwent an emergent L4-5 laminectomy and decompression secondary to a large midline disc herniation with an extruded fragment in the epidural space. He was returned to full military duties 18 weeks after surgery without back or leg symptoms, and with normal strength, reflexes, sensation and bowel/bladder function. DISCUSSION: This case demonstrates the importance of continual medical screening for physical therapists in direct-access settings. It further demonstrates the importance of immediate referral to surgical specialists when CES is suspected as rapid intervention offers the best prognosis for recovery.



Physical Therapy Program, Nova Southeastern University, Fort Lauderdale, FL BACKGROUND AND PURPOSE: The use of high velocity low amplitude (HVLA) spine manipulation is recommended for treatment of patients without radiculopathy. This is based primarily on studies for the lumbar spine, where clinical prediction rules and practice guidelines recommend against the use of HVLA manipulation for patients with lower limb radiculopathy. This trend not to use HVLA manipulation for patients with radiculopathy is now recommended for patients with neck pain and radiculopathy in the upper limb (Childs et al, 2004; Fritz and Brennan, 2007). The purpose of the present case report is to describe the successful treatment of a patient with shoulder pain and radiculopathy with cervical HVLA manipulation and exercises that falls outside the recommendations of the literature. CASE DESCRIPTION: The patient was a 29-year-old female who complained about right shoulder pain (5/10 in a 0-10 scale) and tingling/numbness on the right fourth and fifth fingers. Her symptoms were aggravated by playing tennis or lying on the right shoulder at night. Left neck side flexion reproduced symptoms. Light touch tested with Semmes-Weinstein monofilaments (SWM) was reduced on the right median (0.1720.217 g) and ulnar (0.445-2.350 g) nerve distributions; left side sensation was normal (0.008-0.080 g). Motor conduction response without facilitation (tested by an independent neurophysiologist) was 80% for the right median and 15% for the right ulnar nerves versus the left median (100%) and ulnar (90%) nerves. Right C5-6 accessory motion testing reproduced the patient's right hand tingling and numbness. The patient was treated for 6 weeks (12 visits after the initial evaluation), twice per week with HVLA manipulation (cervical), mobilization (cervical and right first rib) and stretching/strengthening of the shoulder and neck muscles. OUTCOMES: After 6 weeks of intervention, the patient was discharged because she achieved her functional goals (sleep and play recreational tennis pain free). She still complained about 1/10 shoulder pain when lying on the right shoulder. Right sensory impairment had completely recovered (SWM, 0.008-0.080 g). Right median and ulnar nerve motor response without facilitation improved to 100% and 40%, respectively. Left neck side flexion no longer reproduced symptoms. Three months after PT intervention, she stated that she maintained her functional level she obtained when she was discharged. DISCUSSION: Cleland et al (2005) and Browder et al (2004) reported on patients with upper extremity radiculopathy who benefited from thoracic HVLA manipulation. This report illustrates a case where cervical HVLA manipulation was used to successfully treat a patient with upper extremity radiculopathy. Sensory impairment assessed with SWM was consistent with motor nerve response findings assessed by an indepen-



Physical Therapy and Sports Medicine, Riva Ridge Troop Medical Clinic, Camp Liberty, Iraq; Physical Therapy Service, Brooke Army Medical Center, Fort Sam Houston, TX BACKGROUND AND PURPOSE: Cauda equina syndrome (CES) is a rare, but potentially devastating disorder, which is considered a true neurologic emergency. This condition often has a rapid clinical progression from other presentations of low back pain. Timely recognition of CES and surgical referral are essential to maximize functional outcomes and reduce potential long-standing neurological deficits. CASE DESCRIPTION: A 32-year-old male, US Army officer, presented to a Troop Medical Clinic in Iraq with a complaint of insidious onset low back, left buttock, and posterior thigh pain. Symptoms had started 4 weeks prior with a recent, significant increase in pain level without any known injury or cause. He denied pain, numbness, or tingling distal to the knee, saddle anesthesia, or bowel and bladder changes. On exam the patient was neurologically intact throughout all lumbosacral levels with a negative straight leg raise, severely limited in lumbar flexion active range of motion, and demonstrated initial reduction of symptoms with repeated extension. He was re-evaluated day 3 and day 7 for increasing pain but was neurologically stable. On day 10 follow-up, he reported a new, sudden onset of saddle anesthesia, constipation, urinary hesitancy, and right leg weakness. On exam, sensation was intact bilaterally, plantar flexion was 3­/5 on the right, the right ankle reflex was absent, and

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dent neurophysiologist before and after PT intervention, which validates radiculopathy improvement for this patient. ability and responsiveness of the GAITRite (GR) as a measure of gait in patients with lower back pain (LBP). The GR is a computer assisted device which measures temporal and spatial gait parameters. To date, no reliability or responsiveness studies have been performed with the GR on people with LBP. NUMBER OF SUBJECTS: Twenty-six subjects (17 male, 9 female) with a mean age of 40.23 and with acute or chronic low back pain volunteered to participate in the study. MATERIALS/METHODS: Each subject completed 2 back pain questionnaires before completing 3 walking trials with the GR. Ten subjects completed 3 trials 15 minutes following their first measurement. All subjects underwent physical therapy treatment for 3 to 5 weeks. Following this treatment period, subjects once again completed both questionnaires and performed walking trials on the GR. Reliability for 2 temporal (velocity and cadence) and 2 spatial (step length and base of support) gait parameters was estimated. Additionally, temporal (velocity and cadence) and spatial (step length, base of support, and step length symmetry) changes in subjects were compared with changes on the questionnaires, to estimate responsiveness of the GR. RESULTS: The GR provided excellent reliability for temporal measures and acceptable reliability for spatial measures (ICC range, 0.70-0.98). Additionally, positive changes in velocity, cadence (temporal variables) were seen in subjects measured after 24 days of treatment, which agreed with the self-report measures. CONCLUSIONS: The GR provides reliable data for temporal and spatial gait parameters in persons with LBP. It demonstrated responsiveness for temporal variables of gait, in persons with lower back pain. Question remains as to whether or not the GR is a responsive instrument to spatial measures in persons with LBP. CLINICAL RELEVANCE: The GAITRite is commonly used to measure gait parameters in the clinical setting. It has been tested on various neurological populations (eg, Parkinson's, Cerebral Palsy), however there is little evidence of its usefulness in the orthopaedic setting. While the GR yields reliable data in persons with LBP, the changes in gait associated with LBP may be too subtle for the GR to detect.



Department of Physical Medicine and Rehabilitation, Kaiser Permanente, Downey, CA; Centre for Clinical Research Excellence in Spinal Pain, Injury, and Health; Centre of National Research on Disability and Rehabilitative Medicine, University of Queensland, Herston, QLD, Australia BACKGROUND AND PURPOSE: Whiplash associated disorder (WAD) is a multifactorial condition involving both physical and psychosocial components. It has been reported 60% of those persons who have suffered a motor vehicle crash (MVC) continue to have mild residual pain after `recovering' from their original injury. Currently no published literature exists describing an assessment and treatment strategy for a subgroup of patients presenting with nontraumatic mechanical neck pain and signs and symptoms of posttraumatic stress that may be due to what was considered a recovered WAD. The purpose of this case is 2-fold; (1) to describe the multimodal assessment and treatment approach for an individual presenting with what appeared to be an insidious onset of neck pain, and (2) to establish preliminary methods aimed at identifying a potential subgroup of patients with a previous history of whiplash presenting with what may be considered a recurrence of their original whiplash symptoms (eg, mechanical neck pain, motor control impairment and psychological distress). CASE DESCRIPTION: A 37-year-old female with insidious onset neck pain and persistent symptoms for 21 days. Self-reported measures indicated the presence of elevated psychosocial variables and further questioning revealed a previous history of a traumatically induced WAD 18 years ago. An impairment based musculoskeletal examination was performed and the following self-reported measures were recorded at baseline: Numeric Pain Rating Scale (NPRS) 6.3/10, Neck Disability Index (NDI) 56% (56/100), Impact of Events Scale (IES) 34/75, Fear-Avoidance Belief Questionnaire (FABQ-PA) 21/24, and the Patient-specific Functional Scale (PSFS) 6.3/10. Primary interventions included thrust and nonthrust mobilizations to the thoracic and cervical spine in addition to therapeutic exercise. Secondary interventions included a pain neurophysiological based education approach and graded movement. OUTCOMES: Following 7 treatments over 12 weeks the following changes were reported: NPRS 6.3/10 to 1.7/10, NDI 56% to 0%, IES 34/75 to 5/75, FABQ-PA 21/24 to 0/24, and the PSFS 6.3/10 to 9.7/10. She continued to be relatively symptom free at a 4- month follow-up. DISCUSSION: Manual therapy and a pain educational treatment approach with graded movement appeared to be effective in resolving her symptoms. This case report is the first to use the IES as a screening tool for an individual with a nontraumatic neck pain episode that may have been influenced from a previous history of WAD. Clinical examination of patients with mechanical nontraumatic neck pain should aim to identify any previous history of traumatic neck injury (such as MVC) including the use of the IES aimed at the identification of psychosocial variables that have shown to impact outcomes. Future research should investigate the potential existence of a subgroup of patients presenting with nontraumatic mechanical neck pain with a previous history of head and or neck trauma.



Physical Therapy Program, Nova Southeastern University, Fort Lauderdale, FL PURPOSE/HYPOTHESIS: Low back pain (LBP) is the most common diagnosis seen by physical therapists (PT) in the United States (US). Effective management of LBP is essential and may vary based on PT nationality. This study investigated whether PT nationality affected LBP management in the US. LBP management effectiveness was based on adherence to Evidence Based Practice (EBP) guidelines for management of LBP. We tested 2 hypotheses: (H01) there is no association between PT nationality and adherence to EBP guidelines for management of acute LBP; (H02) there is no association between PT nationality and adherence to EBP guidelines for management of chronic LBP. NUMBER OF SUBJECTS: We surveyed 2800 physical therapists that had an email listed with the Florida Department of Health to participate in an electronic survey. MATERIALS/METHODS: The study was exploratory and descriptive with a cross-sectional design. The survey included acute and chronic low back pain vignettes. EBP adherence level was based on guidelines published over the last 6 years in the US and abroad. For acute LBP, high level was management with spinal manipulation (SM) and patient education, moderate was either SM or education, and low was neither SM nor education. For chronic LBP, high was management with exercises in the clinic and no use of physical agents in the clinic (excluding ice or heat), moderate was exercises with physical agents in the clinic, and low was



Exercise and Nutritional Sciences, San Diego State University, San Diego, CA PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate the reli-

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no exercise in the clinic. RESULTS: We had 327 respondents, 276 were Americans, 16 were LatinAmericans, 12 were from British Commonwealth (BCW) countries, 12 were from Asia, and 9 were from other countries. We tested our hypotheses with the Fisher exact test. PTs from BCW countries had higher adherence to EBP for management of acute LBP than Latin-Americans (P = .044). Americans had higher adherence to EBP guidelines for chronic LBP than Latin Americans (P = .001) and Asians (P = .001). CONCLUSIONS: The finding that Latin and Asian PTs had lower adherence to EPB guidelines for chronic LBP than American PTs may be cultural. Brazilian PT students believe that LBP justifies disability more so than North-American health care providers, which may explain why Latin PTs were less likely to exercise patients with chronic LBP. Chinese people tend to confuse work with exercise, which may explain why Asian PTs were less likely to exercise a working patient with chronic LBP. However, these findings need further investigation because of our small sample size of Latin and Asian therapists. The fact that PTs with BCW nationalities had higher adherence to EBP guidelines for acute LBP than Latin Americans needs further exploration. CLINICAL RELEVANCE: Minority health care (Latin/Asian) workers tend to care for minority patients. Minority patients usually have the most demanding physical jobs in the US. Heavy labor is the most important risk factor for a first episode of LBP. It is important that PTs with Latin and Asian nationalities be educated to provide active rehabilitation protocols with exercise for chronic LBP rather than passive intervention with physical agents without exercise. ynx (P<.001) in the whiplash subjects, but only 20% to 30% of the variance could be explained by these factors. CONCLUSIONS: Conventional MRI can be used to reliably measure the size and shape of the oropharynx in patients with chronic whiplash and healthy controls. There are significant differences in the size and shape of the oropharynx in the upper cervical region in subjects with chronic whiplash when compared to healthy controls. CLINICAL RELEVANCE: Identifying changes in the CSA of the oropharynx with MRI provides a quantifiable representation of altered oropharyngeal size and shape in those patients with chronic whiplash. It is yet to be determined whether these changes could be related to specific symptoms (eg, dysarthria, dysphagia and/or dysphonia) or mechanisms.


MRI ANALYSIS OF THE SIZE AND SHAPE OF THE OROPHARYNX IN CHRONIC WHIPLASH Elliott J, Cannata E, Christensen E, DeMaris J, Kummrow J, Manning E, Nielsen E, Romero T, Barnes C, Noteboom T, Jull G

Division of Physiotherapy, University of Queensland, Brisbane, QLD, Australia; Department of Physical Therapy, Regis University, Denver, CO PURPOSE/HYPOTHESIS: In our previous MRI research investigating cervical extensor muscular degeneration in chronic whiplash subjects, we observed, by chance, that there were apparent morphometric changes in the oropharynx in the upper cervical region (C1-C2) in these subjects. The purpose of this study was to undertake an initial retrospective analysis to determine whether MRI measures of (1) oropharynx size (crosssectional area- CSA) and (2) shape-ratio (anterior-posterior/lateral) of the oropharynx in patients with chronic whiplash were different to those of healthy controls. It was hypothesized that chronic whiplash subjects would demonstrate decreased oropharynx CSA and shape-ratio when compared to healthy controls. NUMBER OF SUBJECTS: Seventy-nine chronic whiplash subjects (age, 29.75 7.8 years) and 34 healthy control subjects (age, 27.0 5.6 years) within the age range of 18 to 45 years. MATERIALS/METHODS: Conventional T1-weighted MRI was used to measure (1) the cross-sectional area (CSA-mm2) and (2) shape-ratio for the oropharynx by taking a linear measurement from the anterior-posterior (AP) midline margins versus the lateral margins of the oropharynx at the C1-2 segmental level. The repeatability of the MRI measures for CSA and shape-ratio were established. RESULTS: Multiple ANOVAs were performed to determine if MRI CSA changes were different by group, age, body mass index (BMI), pain, disability and duration of symptoms. The whiplash subjects had significantly smaller oropharynx CSA (P<.001) and shape-ratio (P<.001) compared to healthy controls. The oropharynx shape-ratio (AP/lateral) for the whiplash subjects revealed a `collapsed' appearance with reduced linear measures for the AP margins. Self-reported levels of pain and disability and duration of symptoms were not associated with size and shape of the oropharynx in whiplash subjects (P = .75 and P = .99, respectively). Age and BMI did influence the size (P = .01) and shape of the orophar-

a100 | january 2009 | volume 39 | number 1 | journal of orthopaedic & sports physical therapy



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