Norman W. Gill

Normative values for the unipedal stance test with eyes open and closed.

Purpose: Limited normative data are available for the unipedal stance test (UPST), making it difficult for clinicians to use it confidently to detect subtle balance impairments. The purpose of this study was to generate normative values for repeated trials of the UPST with eyes opened and eyes closed across age groups and gender. Methods: This prospective, mixed‐model design was set in a tertiary care medical center. Healthy subjects (n= 549), 18 years or older, performed the UPST with eyes open and closed. Mean and best of 3 UPST times for males and females of 6 age groups (18–39, 40–49, 50–59, 60–69, 70–79, and 80+) were documented and inter‐rater reliability was tested. Results: There was a significant age dependent decrease in UPST time during both conditions. Inter‐rater reliability for the best of 3 trials was determined to be excellent with an intra‐class correlation coefficient of 0.994 (95% confidence interval 0.989–0.996) for eyes open and 0.998 (95% confidence interval 0.996–0.999) for eyes closed. Conclusions: This study adds to the understanding of typical performance on the UPST. Performance is age‐specific and not related to gender. Clinicians now have more extensive normative values to which individuals can be compared.

Association between history and physical examination factors and change in lumbar multifidus muscle thickness after spinal manipulation in patients with low back pain

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

Short- and long-term clinical outcomes following a standardized protocol of orthopedic manual physical therapy and exercise in individuals with osteoarthritis of the hip: a case series

Abstract Objectives: Describe short- and long-term outcomes observed in individuals with hip osteoarthritis (OA) treated with a pre-selected, standardized set of best-evidence manual therapy and therapeutic exercise interventions. Methods: Fifteen consecutive subjects (9 males, 6 females; mean age: 52±7·5 years) with unilateral hip OA received an identical protocol of manual therapy and therapeutic exercise interventions. Subjects attended 10 treatment sessions over an 8-week period for manual therapy interventions and performed the therapeutic exercise as a home program. Results: Baseline to 8-week follow-up outcomes were as follows: Harris Hip Scale (HHS) scores improved from 60·3(±10·4) to 80·7(±10·5), Numerical Pain Rating Scale (NPRS) scores improved from 4·3(±1·9) to 2·0(±1·9), hip flexion range of motion (ROM) improved from 99 degrees (±10·6) to 127 degrees (±6·3) and hip internal rotation ROM improved from 19 degrees (±9·1) to 31 degrees (±11·5). Improvements in HHS, NPRS, and hip ROM measures reached statistical significance (P<0·05) at 8-weeks and remained significant at the 29-week follow-up. Mean changes in NPRS and HHS scores exceeded the minimal clinically important difference (MCID) at 8-weeks and for the HHS scores alone at 29 weeks. The 8 and 29 week mean Global Rating of Change scores were 5·1(±1·4) and 2·1(±4·2), respectively. Improved outcomes observed following a pre-selected, standardized treatment protocol were similar to those observed in previous studies involving impairment-based manual therapy and therapeutic exercise for hip OA. Future studies might directly compare the two approaches. Discussion:

Medical Screening and Evacuation: Cauda Equina Syndrome in a Combat Zone

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

Clinician Perception of the Impact of Deployed Physical Therapists as Physician Extenders in a Combat Environment

UNLABELLED Physical therapists (PTs) serve as physician extenders performing direct access evaluations for musculoskeletal conditions. The previous war-time mission of PTs was limited to level III medical care. Recently PTs began providing care at levels I/II with brigade combat teams (BCTs). PURPOSE Determine the sentiment of battlefield providers at levels I/II regarding the operational impact of PTs. METHODS Surveys were provided to BCT medical providers. RESULTS There were 107 responses (response rate of 51%). According to the responses, PTs made a significant impact on overall mission accomplishment (97%) and patient prognosis (83%) and were considered local experts in musculoskeletal pathology (92%), including the ordering of radiographs (79%). Their presence was thought to significantly decrease medical evacuations within theater (68%) and out of theater (73%). CONCLUSION There was a positive sentiment toward PTs in the BCT, suggesting they are highly valued. Future studies need to clarify further operational, medical, and fiscal implications.

Investigation of Abdominal Muscle Thickness Changes After Spinal Manipulation in Patients Who Meet a Clinical Prediction Rule for Lumbar Stabilization

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

Knee Extension and Stiffness in Osteoarthritic and Normal Knees: A Videofluoroscopic Analysis of the Effect of a Single Session of Manual Therapy

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

Manual Physical Therapy for Injection-Confirmed Nonacute Acromioclavicular Joint Pain

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

Hook of the Hamate Fracture

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

Clinical Reasoning and Advanced Practice Privileges Enable Physical Therapist Point-of-Care Decisions in the Military Health Care System: 3 Clinical Cases

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