Michael D. Ross

Effect of a 15-Day Pragmatic Hamstring Stretching Program on Hamstring Flexibility and Single Hop for Distance Test Performance

The purpose of this study was to determine the effects of a 15-day pragmatic hamstring stretching program on lower extremity performance as measured by the single hop for distance test (SHDT) in subjects with limited hamstring flexibility. Thirteen cadets enrolled at a military academy participated in the study. Subjects randomly were assigned to stretch the hamstrings of one lower extremity for 15 consecutive days (experimental lower extremity group) and not stretch the other (control lower extremity group). Pre- and post-test measurements showed significant improvements in the hamstring flexibility and SHDT scores for the experimental lower extremities. No significant change occurred for the control lower extremity group for the AKET and SHDT scores. The results suggest that in addition to a routine 15-day stretching program, a brief purposeful delay between stretching and performance testing may negate the detrimental effect on performance that may be caused by the acute effects of stretching. Because subjects also stretched on the day of the SHDT posttest, but with a purposeful delay of 10 minutes between stretching and testing, it is believed the design of this study more closely mimics stretching activities as commonly performed by athletes.

Red Flags: To Screen or Not to Screen?

The physical therapy profession has long recognized the importance of physical therapists determining whether a need for a patient referral to another healthcare practitioner exists. This clinical decision is based on physical therapists recognizing patient history and physical examination red flag findings consistent with pathology that requires physician consultation and examination. The challenge to physical therapists is the current lack of evidence describing what red flag findings are representative of specific pathological conditions. J Orthop Sports Phys Ther 2010;40(11):682–684. doi:10.2519/jospt.2010.0109

The effect of neuromuscular electrical stimulation during closed kinetic chain exercise on lower extremity performance following anterior cruciate ligament reconstruction

No studies have examined the effect of augmenting closed kinetic chain (CKCh) exercises with neuromuscular electrical stimulation (NMES) following anterior cruciate ligament (ACL) reconstruction. Therefore, the purpose of this study was to compare the effect of supplementing a CKCh training program with NMES during the initial six weeks following ACL reconstruction on anterior tibiofemoral joint laxity and the following CKCh performance activities: (1) unilateral squat, (2) 0.10 m lateral step‐up test and (3) anterior reach test. Twenty patients who underwent ACL reconstruction were randomly placed in two treatment groups post surgery: group 1 performed CKCh exercise with NMES applied to the quadriceps and hamstring musculature of the ACL reconstructed lower limb and group 2 performed CKCh exercise alone. Following five weeks of either CKCh training program, performance on the lower limb CKCh tests and knee arthrometry was compared between the two groups by multivariate analysis of variance. No significant difference was noted between the groups with respect to the non‐involved lower limbs performance. The ACL reconstructed lower limb in the combined CKCh and NMES group performed significantly better on the unilateral squat and lateral step‐up test than did the ACL reconstructed lower limb in the CKCh exercise alone group. It is concluded that augmenting CKCh training with NMES during the initial six weeks following ACL reconstruction produces a better lower limb performance effort than is attributable to a CKCh training program without NMES.

Manipulation and Back School in the Treatment of Low Back Pain

Low back pain (LBP) is one of the most common clinical disorders seen by health care practitioners today. While it is recognised that LBP is often chronic and recurrent in nature, no general consensus exists regarding the most effective treatment (Koes et al, 1994). Consequently, many approaches to treatment have been developed over the years. Two of the more common forms of treatment that have surfaced for LBP are manipulation and the ‘back school’. However, there is controversy about the indications and efficacy for both forms of treatment. Therefore, the purpose of this paper is briefly to examine both treatments and draw conclusions relative to their indications and efficacy.

Undetected Hangman's Fracture in a Patient Referred for Physical Therapy for the Treatment of Neck Pain Following Trauma

Background and Purpose: This case report describes a patient referred for physical therapy treatment of neck pain who had an underlying hangmans fracture that precluded physical therapy intervention. Case Description: This case involved a 61-year-old man who had a sudden onset of neck pain after a motor vehicle accident 8 weeks before his initial physical therapy visit. Conventional radiographs of his cervical spine taken on the day of the accident did not reveal any abnormalities. Based on the findings at his initial physical therapy visit, the physical therapist ordered conventional radiographs of the cervical spine to rule out the possibility of an undetected fracture. Outcomes: The radiographs revealed bilateral C2 pars interarticularis defects consistent with a hangmans fracture. The patient was referred to a neurosurgeon for immediate review. Based on a normal neurological examination, a relatively low level of pain, and the results of radiographic flexion and extension views of the cervical spine (which revealed no evidence of instability), the neurosurgeon recommended that the patient continue with nonsurgical management. Discussion: In patients with neck pain caused by trauma, physical therapists should be alert for the presence of cervical spine fractures. Even if the initial radiographs are negative for a fracture, additional diagnostic imaging may be necessary for a small number of patients, because they may have undetected injuries that would necessitate medical referral and preclude physical therapy intervention.

Physical Therapist Practice and the Role of Diagnostic Imaging

SYNOPSIS For healthcare providers involved in the management of patients with musculoskeletal disorders, the ability to order diagnostic imaging is a beneficial adjunct to screening for medical referral and differential diagnosis. A trial of conservative treatment, such as physical therapy, is often recommended prior to the use of imaging in many treatment guidelines for the management of musculoskeletal conditions. In the United States, physical therapists are becoming more autonomous and can practice some degree of direct access in 48 states and Washington, DC. Referral for imaging privileges could increase the effectiveness and efficiency of healthcare delivery, particularly in combination with direct access management. This clinical commentary proposes that, given the American Physical Therapy Associations goal to have physical therapists as primary care musculoskeletal specialists of choice, it would be beneficial for physical therapists to have imaging privileges in their practice. The purpose of this commentary is 3-fold: (1) to make a case for the use of imaging privileges by physical therapists, using a historical perspective; (2) to discuss the barriers preventing physical therapists from having this privilege; and (3) to offer suggestions on strategies and guidelines to facilitate the appropriate inclusion of referral for imaging privileges in physical therapist practice. J Orthop Sports Phys Ther 2011;41(11):829-837. doi:10.2519/jospt.2011.3556.

Clinical Decision Making Associated With an Undetected Odontoid Fracture in an Older Individual Referred to Physical Therapy for the Treatment of Neck Pain

STUDY DESIGN Residents case problem. BACKGROUND The purpose of this paper is to provide the examination of and decision-making process for a patient referred to physical therapy for the treatment of neck pain following trauma. She was found to have an underlying odontoid fracture that precluded physical therapy intervention. DIAGNOSIS This case involved a 73-year-old woman who had a sudden onset of neck and left upper extremity pain after a fall 15 days prior to her initial physical therapy visit. Conventional cervical spine radiographs completed 1 day prior to her initial physical therapy visit were negative for a fracture. However, several components of this patients history and physical examination were consistent with a condition for which physical therapy intervention would not be indicated until more definitive cervical spine diagnostic imaging had been completed; more specifically, the physical therapist was primarily concerned about the possibility of an undetected fracture. The referring physician was contacted and immediate magnetic resonance imaging was requested, which revealed a type II fracture of the odontoid. Thirty-four days after her fall, the patient underwent a C1-C2 fusion. DISCUSSION When evaluating patients with neck pain who have a history of cervical spine trauma, it is important that physical therapists understand the clinical findings associated with cervical spine fractures, as these findings provide guidance for the use of cervical spine diagnostic imaging and medical referral prior to implementing physical therapy interventions. LEVEL OF EVIDENCE Diagnosis, level 4.

Acute Knee Haemarthrosis: A Case Report Describing Diagnosis and Management for a Patient on Anticoagulation Medication

BACKGROUND AND PURPOSE A 63-year-old woman was referred to physical therapy with a 3 day history of constant anterior left knee pain that was atraumatic in nature. The patient was taking anticoagulation medication for chronic atrial fibrillation. Her international normalized ratio (INR) was within normal limits when assessed 3 weeks prior to her initial physical therapy evaluation. METHOD Physical examination revealed an antalgic gait, moderate left knee effusion, limited painful knee range of motion, normal ligamentous testing and negative joint line or patellofemoral joint palpation. The patient was instructed in the use of a single-point cane, use of ice, positional comfort and relative rest from weight-bearing activities. Upon re-assessment 2 days later, the patients knee pain and effusion had worsened despite compliance with day 1 instructions. Given that there was no clear mechanism of injury and the worsening nature of the disorder, the physical therapist discussed the case with the patients physician, and immediate appointments for laboratory testing and potential knee aspiration were obtained. RESULTS Laboratory testing demonstrated that INR values had elevated to a supratherapeutic level of anticoagulation. Fluid from the patients left knee was aspirated, revealing a haemarthrosis. The patients symptoms immediately improved following aspiration. After suspending her anticoagulation medication dose for 1 day, her INR value returned to therapeutic range. She was symptom free within 3 weeks with physical therapy intervention and had remained symptom free at 1 year following the knee haemarthrosis. CONCLUSION We recommend that physical therapists screen all patients for whether or not they are taking anticoagulation medications, especially before implementation of manual therapy or therapeutic exercise interventions.

Abdominal Aortic Aneurysm in a Patient With Low Back Pain

STUDY DESIGN Residents case problem. BACKGROUND The purpose of this report was to describe (1) the clinical reasoning that led a clinician to identify an abdominal aortic aneurysm (AAA) in a patient with low back pain requiring immediate medical referral, and (2) an evidence-based approach to clinical evaluation of patients with suspected AAA. DIAGNOSIS The patient was unable to identify a specific mechanism of injury for his low back pain, lacked aggravating/easing factors for his symptoms, and complained of night pain and an inability to ease his symptoms with position changes. While the patients symptoms remained unchanged during physical examination of the lumbar spine and hip, abdominal palpation revealed a strong, nontender pulsation over the midline of the upper and lower abdominal quadrants. Due to concern for an AAA, the patient was immediately referred to his physician. Subsequent computed tomography imaging revealed a prominent AAA, which measured up to 5.5 cm in greatest dimension and extended from below the renal arteries to the bifurcation of the iliac arteries. The patient initially deferred surgical intervention but eventually consented 6 months later, after repeat computed tomography imaging revealed that the AAA had progressed to 6.7 cm in greatest dimension. DISCUSSION It is essential for physical therapists to be familiar with a diagnostic pathway to help identify AAA in patients presenting with apparent musculoskeletal complaints. Knowledge of the risk factors for AAA, understanding how to screen for nonmusculoskeletal symptoms, and a basic competence in abdominal palpation and how to interpret findings will help with the clinicians clinical decision making. LEVEL OF EVIDENCE Differential diagnosis, level 4. J Orthop Sports Phys Ther 2014;44(7):500-507. Epub 25 April 2014. doi:10.2519/jospt.2014.4935.

Metastatic cancer mimicking mechanical low back pain: a case report

Abstract Objective and Importance: The purpose of this report is to describe the clinical course of a patient referred to physiotherapy (PT) for the treatment of low back pain who was subsequently diagnosed with metastatic non-small cell carcinoma of the lung. Clinical Presentation: A 48-year old woman was referred to PT for the evaluation and treatment of an insidious onset of low back pain of 2 month duration. The patient did not have a history of cancer, recent weight changes, or general health concerns. The patient’s history and physical examination were consistent with a mechanical neuromusculoskeletal dysfunction and no red flag findings were present that warranted immediate medical referral. Intervention: Short-term symptomatic improvements were achieved using the treatment-based classification approach. However, despite five PT sessions over the course of 5 weeks, the patient did not experience long-term symptomatic improvement. On the sixth session, the patient reported a 2-day history of left hand weakness and headaches. This prompted the physiotherapist to refer the patient to the emergency department where she was diagnosed with lung cancer. Conclusion: Differential diagnosis is a key component of PT practice. The ability to reproduce symptoms or achieve short-term symptomatic gains is not sufficient to rule out sinister pathology. This case demonstrates how extra caution should be taken in patients who are smokers with thoracolumbar region pain of unknown origin. The need for caution is magnified when one can achieve no more than short-term improvements in the patient’s symptoms.