Ableism to Empowerment: Navigating School Structures When Working With Students Who Stutter.

PURPOSE: School-based speech-language pathologists (SLPs) face uniquely complex webs of guidelines and criteria that can undermine their ability to move toward disability-affirming practices. The purpose of this clinical focus article is to present a contrast between ableist and disability-affirming practices in school-based stuttering therapy while highlighting the critical perspectives of students who stutter. Practical examples of disability-affirming stuttering therapy in public school settings are provided. CONCLUSIONS: This clinical focus article outlines practical guidelines and specific examples of affirming collaboration, eligibility decisions, goal choice, and accommodations for students who stutter. These discussions demonstrate how SLPs can adopt updated assessment therapy planning and institutional practices to affirm students who stutter while informing school cultures and society about the dignity and value of stuttered voices. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.21818028.

Leveraging the Short-Term Benefits of Manual Therapy which Includes Exercise Over Exercise Therapy Alone Appears Justified for Knee Osteoarthritis.

Letter to the Editor-in-Chief in response to JOSPT article "The Benefits of Adding Manual Therapy to Exercise Therapy for Improving Pain and Function in Patients with Knee or Hip Osteoarthritis: A Systematic Review with Meta-analysis" by Runge et al. J Orthop Sports Phys Ther 2023;53(1):49-50. doi:10.2519/jospt.2023.0201.

It Would Take Combat Relevance to Put a Chiropractor in Khakis- This Is Why That Has Not Happened.

The purpose of this article is to challenge the premise of a recent commentary suggesting that chiropractors should become commissioned officers. An overview of the early practice guidelines and current scientific evidence for the use of spine and peripheral manipulation is provided. The Military Health System is designed to support military operations and currently includes a large contingent of active duty musculoskeletal healthcare experts to include sports medicine-trained family physicians, orthopedic surgeons, physician assistants/associates, doctors of physical therapy/physical therapists, occupational therapists, and podiatrists. The evidence is clear that it is not in the best interest of our military services to commission alternative practitioners whose practices are out of step with the rest of medicine.

Physical therapist decision-making in managing plantar heel pain: cases from a pragmatic randomized clinical trial.

INTRODUCTION: Plantar heel pain (PHP) is a common condition managed by physical therapists that can, at times, be difficult to treat. Management of PHP is complicated by a variety of pathoanatomic features associated with PHP in addition to several treatment approaches with varying efficacy. Although clinical guidelines and clinical trial data support a general approach to management, the current literature is limited in case-specific descriptions of PHP management that addresses unique combinations of pathoanatomical, physical, and psychosocial factors that are associated with PHP. Purpose: The purpose of this case series is to describe physical therapist decision-making of individualized multimodal treatment for PHP cases presenting with varied clinical presentations. Treatment incorporated clinical guidelines and recent evidence including a combination of manual therapy, patient education, stretching, resistance training, and neurodynamic interventions. A common clinical decision-making framework was used to progress individualized treatment from a focus on symptom modulation initially to increased load tolerance of involved tissues and graded activity. In each case, patients met their individual goals and demonstrated clinically meaningful improvements in pain, function, and global rating of change that were maintained at the 1-2-year follow-up. Implications: This case series provides details of physical therapist management of a variety of PHP clinical presentations that can be used to complement clinical practice guidelines in the management of PHP.

Effectiveness of physical therapy treatment in addition to usual podiatry management of plantar heel pain: a randomized clinical trial.

BACKGROUND: Many patients will seek care from a podiatrist for plantar heel pain (PHP), while few of these patients will also be seen by a physical therapist. Physical therapists can provide treatment that is not a part of routine podiatric care for PHP and may provide additional improvement. Therefore, the purpose of this study was to examine the effects of interdisciplinary care for PHP that incorporated physical therapy treatment after initiating podiatric treatment. METHODS: Eligible individuals with PHP that presented to a podiatrist were randomized to receive usual podiatric care (uPOD) or usual podiatric care plus physical therapy treatment (uPOD+PT). The primary outcome was change in foot and ankle ability measure (FAAM) at 6-months. Secondary outcomes included change in numeric pain rating scale (NPRS), patient-reported success, and 6-week and 1-year endpoints. Patient-reported success was defined as the top two global rating of change scale rankings. Primary analysis was intention-to-treat (ITT) using analysis by covariance adjusted to baseline scores, and a secondary per-protocol (PP) analysis was performed analyzing only those who completed treatment. RESULTS: Ninety-five individuals participated and were included in the ITT analysis, and 79 were included in the PP analysis. For the primary outcome of FAAM change from baseline to 6-months, both groups improved significantly (uPOD+PT: 26.8 [95% CI 21.6, 31.9]; uPOD: (20 [15.6, 24.4]), but there was no between-group difference (4.3 [- 1, 9.6]). For secondary outcomes, the uPOD+PT group demonstrated greater improvement in NPRS at 6 weeks (0.9 [0.3, 1.4]) and 1 year (1.5 [0.6, 2.5]) in the ITT analysis. In the PP analysis, the uPOD+PT group demonstrated greater improvement in FAAM at 6 months (7.7 [2.1, 13.3]) and 1 year (5.5 [0.1, 10.8]), NPRS at 6 weeks (0.9 [0.2, 1.6]), 6 months (1.3 [0.6, 2.1]) and 1 year (1.3 [0.6, 2.1]), and in patient-reported success (relative risk [95% CI]) at 6 weeks (2.8 [1.1, 7.1]), 6 months (1.5 [1.1, 2.1]), and 1 year (1.5 [1.1, 1.9]). CONCLUSIONS: There was no significant benefit of uPOD+PT in the primary outcome of FAAM change at 6 months. Secondary outcomes and PP analysis indicated additional benefit of uPOD+PT, mostly observed in individuals who completed treatment. TRIAL REGISTRATION: Prospectively registered May 24, 2013 at www.clinicaltrials.gov (NCT01865734).

ILIAC CREST HEIGHT DIFFERENCE AND OTHER RUNNING-RELATED VARIABLES' RELATIONSHIP WITH RUNNING INJURY.

BACKGROUND: Leg-length inequality (LLI) is a common condition that may contribute to various spinal, pelvic, and lower extremity dysfunctions. Iliac crest height difference (ICHD) has been demonstrated to be a good estimate for LLI and may be a useful measure for identifying individuals who are at risk for injury. PURPOSE: To investigate the relationship between ICHD and other running-related variables with running injury. METHODS: An observational retrospective case-control design was used. Data were collected via questionnaire and physical examination from a purposive sample of 100 runners and were analyzed using chi-squared tests of independence. RESULTS: The prevalence of ICHD ≥ 5mm reported by subjects via questionnaire was ∼40%. There was no difference in report of injury between subjects with ICHD >5mm and those with ICHD <5mm (χ2 = 0.02, p = 0.88); however, lifetime history of injury (χ2 = 15.68, p = 0.00) and the number of running events participated (χ2 = 3.09, p = 0.04) were significant factors associated with injury; although not significant, there was a trend towards relationship with gender (χ2 = 3.2, = 0.07). CONCLUSION: Small ICHD is not associated with running injury among recreational runners. There appears to be an increased risk of running injury among runners who participate in more than one running event annually and those that have had a past history of running injury. Also, males may be at slightly greater risk of sustaining a running injury compared to females. LEVEL OF EVIDENCE: Therapy, level 3b.

PAIN AND PHYSICAL PERFORMANCE AMONG RECREATIONAL RUNNERS WHO RECEIVE A CORRECTION FOR AN ILIAC CREST HEIGHT DIFFERENCE: A CASE SERIES.

BACKGROUND: Leg-length inequality (LLI) is a musculoskeletal condition where one lower extremity is longer than the other. There is conflicting evidence on the relevance of LLI and conservative treatment options. Iliac crest height difference (ICHD) is a good estimate of LLI. OBJECTIVE: To observe changes in pain and performance among recreational runners with running-induced lower extremity pain who received ICHD correction. METHODS: A 12-week case series with multiple baseline and intervention (A-B-A-B) phases was used to observe the effects of ICHD correction on pain and performance among three symptomatic recreational runners. Primary outcome measures included the Lower Extremity Functional Scale (LEFS), the Visual Analog Scale -Worst Pain (VAS-W), symptom-free running distance, and average running speed. A standardized procedure for fabricating an in-shoe shim was utilized for ICHD correction. RESULTS: There were no clinically important differences in functional capacity for any subject between any phases. Also, two subjects demonstrated trends towards increased pain over the 12-week experimental period, whereas one subject demonstrated a decrease. One subject demonstrated a statistically significant increase in running distance during intervention phases, but the others demonstrated reductions. All subjects demonstrated trends towards increased running speed, but none were statistically significant. CONCLUSION: The correction of small ICHD < 9mm did not improve pain or performance among recreational runners. Individuals with small ICHD may be able to effectively compensate for lower extremity asymmetries; therefore, correction seems to be unnecessary and potentially harmful in short-term. LEVEL OF EVIDENCE: Therapy, level 4.

Does Health Care Utilization Before Hip Arthroscopy Predict Health Care Utilization After Surgery in the US Military Health System? An Investigation Into Health-Seeking Behavior.

BACKGROUND: The influence of prior patterns of health care utilization on future health care utilization has had minimal investigation in populations with musculoskeletal disorders. OBJECTIVES: The purpose of this study was to explore the relationship between presurgical health care utilization and postsurgical health care utilization in a population of patients undergoing hip surgery in the US Military Health System. METHODS: In this observational cohort study, person-level data were collected for patients undergoing hip arthroscopy in the Military Health System from 2003 to 2015, capturing all encounters 12 months before and 24 months after surgery for every individual. Cluster analysis was used to categorize individuals with high and low health care utilization, based on preoperative health care visits. Unadjusted and adjusted Poisson and generalized linear models were generated. Health care utilization outcomes were targeted, including costs, visits, and medication use. RESULTS: There were 1850 individuals in the final cohort (mean age, 32.18 years; 55.4% male). The high health care utilization group averaged 57.69 ± 25.87 visits, compared to 20.43 ± 8.36 visits in the low utilization group. There were significant differences between groups for total health care visits (58.17; 95% confidence interval [CI]: 57.39, 58.58), total health care costs ($11 539.71; 95% CI: $10 557.26, $12 595.04), hip-related visits (12.77; 95% CI: 12.59, 12.96), hip-related costs ($3325.07; 95% CI: $2886.43, $3804.51), days' supply of pain medications (752.67; 95% CI: 751.24, 754.11), opioid prescriptions (48.83; 95% CI: 48.47, 49.21), and cost of pain medications ($1074.80; 95% CI: $1011.91, $1137.68). CONCLUSION: Presurgical patterns of health care utilization were associated with postsurgical patterns of health care utilization, indicating that those patients who used more care before surgery also used more care after surgery. Clinicians should consider prior patterns of health care utilization, including utilization unrelated to the index condition, when determining care plans and prognosis. J Orthop Sports Phys Ther 2018;48(11):878-886. Epub22 Jul 2018. doi:10.2519/jospt.2018.8259.

Physical Therapists' Role in Solving the Opioid Epidemic.

An estimated 116 million Americans suffer from chronic pain, at a cost of over $600 billion per year, or roughly $2000 per person per year. In this Viewpoint, the authors highlight the challenges of the current opioid epidemic and outline strategies that the physical therapy profession may adopt to be part of the solution. These strategies include facilitating and providing patient education, early access to physical therapy services, and the promotion of health, wellness, and prevention. J Orthop Sports Phys Ther 2018;48(5):349-353. doi:10.2519/jospt.2018.0606.

Maintenance of Improved Attitudes Toward Stuttering.

Purpose: This study sought to determine the extent to which experimentally induced positive attitudes in high school students in a previous investigation were maintained 7 years later. Method: Authors and assistants recruited 36 adults in their early 20s (Follow-up group) who, in high school, had witnessed either a live oral talk by a person who stutters or a professionally made video on stuttering designed for teens followed by a short talk by the same speaker. The Public Opinion Survey of Human Attributes-Stuttering was administered before and after the interventions in high school and 7 years later such that pre-post group comparisons were made. Previously, the Follow-up group had demonstrated highly positive changes in their attitudes after the interventions. In addition, a control group of 56 former high school students from the same state, who did not participate in the interventions, were recruited and compared to the Follow-up group. Results: The Follow-up group, which was found to be representative of the original high school cohort, held more positive Public Opinion Survey of Human Attributes-Stuttering mean ratings than the Control group, although somewhat less positive than their previous postintervention ratings. Conclusions: The Follow-up group maintained many of the positive changes in their beliefs and self reactions regarding stuttering that were induced 7 years earlier after witnessing personal stories and facts about stuttering.

Implications of early and guideline adherent physical therapy for low back pain on utilization and costs.

BACKGROUND: Initial management decisions following a new episode of low back pain (LBP) are thought to have profound implications for health care utilization and costs. The purpose of this study was to evaluate the impact of early and guideline adherent physical therapy for low back pain on utilization and costs within the Military Health System (MHS). METHODS: Patients presenting to a primary care setting with a new complaint of LBP from January 1, 2007 to December 31, 2009 were identified from the MHS Management Analysis and Reporting Tool. Descriptive statistics, utilization, and costs were examined on the basis of timing of referral to physical therapy and adherence to practice guidelines over a 2-year period. Utilization outcomes (advanced imaging, lumbar injections or surgery, and opioid use) were compared using adjusted odds ratios with 99% confidence intervals. Total LBP-related health care costs over the 2-year follow-up were compared using linear regression models. RESULTS: 753,450 eligible patients with a primary care visit for LBP between 18-60 years of age were considered. Physical therapy was utilized by 16.3% (n = 122,723) of patients, with 24.0% (n = 17,175) of those receiving early physical therapy that was adherent to recommendations for active treatment. Early referral to guideline adherent physical therapy was associated with significantly lower utilization for all outcomes and 60% lower total LBP-related costs. CONCLUSIONS: The potential for cost savings in the MHS from early guideline adherent physical therapy may be substantial. These results also extend the findings from similar studies in civilian settings by demonstrating an association between early guideline adherent care and utilization and costs in a single payer health system. Future research is necessary to examine which patients with LBP benefit early physical therapy and determine strategies for providing early guideline adherent care.

Predictors of response to physical therapy intervention for plantar heel pain.

BACKGROUND: Age, weight, and duration of symptoms have been associated with a poor response to treatment for plantar heel pain (PHP), but no studies were identified that examined predictors of response to physical therapy intervention. The purpose of this investigation was to examine the influence of age, body mass index (BMI), and symptom duration on treatment response to physical therapy intervention. METHODS: Sixty participants received 6 visits over 4 weeks of physical therapy intervention that included manual therapy and exercise or electrophysiological agents and exercise. Outcomes were assessed using the Foot and Ankle Ability Measure (FAAM), Numeric Pain Rating Scale (NPRS), and Global Rating of Change Scale (GRC). Logistic regression (P < .05) was used to analyze age, BMI, and symptom duration as potential predictors of a successful response based on the minimal clinically important difference of the outcome measures. Sensitivity analysis was used to assess the influence of success based on minimal clinically important changes in the FAAM, NPRS, and GRC or only the FAAM and NPRS. Receiver operating curves were used to determine the cut point for the significant predictor. RESULTS: At the 6-month follow-up to physical therapy intervention, NPRS was improved by 3 points (95% CI, 2.4-3.6) and FAAM improved by 22.5 points (95% CI, 16.8-28.2). Individuals with symptoms less than 7.2 months were 4.2 (95% CI, 1.3-13.8; P = .016) and 8.5 (95% CI, 2.5-28.9; P = .001) times more likely to respond to treatment based on the NPRS/FAAM/GRC and NPRS/FAAM success criteria, respectively. Age and BMI were not significant predictors (P ≥ .455 and P ≥ .450, respectively). CONCLUSION: Age and BMI were not associated with outcomes and obese individuals did achieve a successful outcome with the physical therapy intervention used in the clinical trial. Individuals with PHP symptoms longer than 7 months require additional consideration and further investigation of effective strategies to improve treatment response. LEVEL OF EVIDENCE: Prognosis, level 2b comparative study.

Diagnosis and expedited surgical intervention of a complete hamstring avulsion in a military combatives athlete: a case report.

BACKGROUND AND PURPOSE: Hamstring injuries are frequent injuries in athletes, with the most common being strains at the musculotendinous junction or within the muscle belly. Conversely, hamstring avulsions are rare and often misdiagnosed leading to delay in appropriate surgical interventions. The purpose of this case report is to describe the history and physical examination findings that led to appropriate diagnostic imaging and the subsequent diagnosis and expedited surgical intervention of a complete avulsion of the hamstring muscle group from the ischium in a military combatives athlete. CASE DESCRIPTION: The patient was a 25 year-old male who sustained a hyperflexion injury to his right hip with knee extension while participating in military combatives, presenting with acute posterior thigh and buttock pain. History and physical examination findings from a physical therapy evaluation prompted an urgent magnetic resonance imaging (MRI) study, which led to the diagnosis of a complete avulsion of the hamstring muscle group off the ischium. OUTCOME: Expedited surgical intervention occurred within 13 days of the injury potentially limiting comorbidities associated with delayed diagnosis. CONCLUSION: Recognition of the avulsion led to prompt surgical evaluation and intervention. Literature has shown that diagnosis of hamstring avulsions are frequently missed or delayed, which results in a myriad of complications. LEVEL OF EVIDENCE: Level 4.

Trigger point dry needling as an adjunct treatment for a patient with adhesive capsulitis of the shoulder.

STUDY DESIGN: Case report. BACKGROUND: Prognosis for adhesive capsulitis has been described as self-limiting and can persist for 1 to 3 years. Conservative treatment that includes physical therapy is commonly advised. CASE DESCRIPTION: The patient was a 54-year-old woman with primary symptoms of shoulder pain and loss of motion consistent with adhesive capsulitis. Manual physical therapy intervention initially consisted of joint mobilizations of the shoulder region and thrust manipulation of the cervicothoracic region. Although manual techniques seemed to result in some early functional improvement, continued progression was limited by pain. Subsequent examination identified trigger points in the upper trapezius, levator scapula, deltoid, and infraspinatus muscles, which were treated with dry needling to decrease pain and allow for higher grades of manual intervention. OUTCOMES: The patient was treated for a total of 13 visits over a 6-week period. After trigger point dry needling was introduced on the third visit, improvements in pain-free shoulder range of motion and functional outcome measures, assessed with the Shoulder Pain and Disability Index and the shortened form of the Disabilities of the Arm, Shoulder and Hand questionnaire, exceeded the minimal clinically important difference after 2 treatment sessions. At discharge, the patient had achieved significant improvements in shoulder range of motion in all planes, and outcome measures were significantly improved. DISCUSSION: This case report describes the clinical reasoning behind the use of trigger point dry needling in the treatment of a patient with adhesive capsulitis. The rapid improvement seen in this patient following the initiation of dry needling to the upper trapezius, levator scapula, deltoid, and infraspinatus muscles suggests that surrounding muscles may be a significant source of pain in this condition.

Comparison of usual podiatric care and early physical therapy intervention for plantar heel pain: study protocol for a parallel-group randomized clinical trial.

BACKGROUND: A significant number of individuals suffer from plantar heel pain (PHP) and many go on to have chronic symptoms and continued disability. Persistence of symptoms adds to the economic burden of PHP and cost-effective solutions are needed. Currently, there is a wide variation in treatment, cost, and outcomes of care for PHP with limited information on the cost-effectiveness and comparisons of common treatment approaches. Two practice guidelines and recent evidence of effective physical therapy intervention are available to direct treatment but the timing and influence of physical therapy intervention in the multidisciplinary management of PHP is unclear. The purpose of this investigation is to compare the outcomes and costs associated with early physical therapy intervention (ePT) following initial presentation to podiatry versus usual podiatric care (uPOD) in individuals with PHP. METHODS: A parallel-group, block-randomized clinical trial will compare ePT and uPOD. Both groups will be seen initially by a podiatrist before allocation to a group that will receive physical therapy intervention consisting primarily of manual therapy, exercise, and modalities, or podiatric care consisting primarily of a stretching handout, medication, injections, and orthotics. Treatment in each group will be directed by practice guidelines and a procedural manual, yet the specific intervention for each participant will be selected by the treating provider. Between-group differences in the Foot and Ankle Ability Measure 6 months following the initial visit will be the primary outcome collected by an independent investigator. In addition, differences in the European Quality of Life--Five Dimensions, Numeric Pain Rating Scale, Global Rating of Change (GROC), health-related costs, and cost-effectiveness at 6 weeks, 6 months, and 1 year will be compared between groups. The association between successful outcomes based on GROC score and participant expectations of recovery generally, and specific to physical therapy and podiatry treatment, will also be analyzed. DISCUSSION: This study will be the first pragmatic trial to investigate the clinical outcomes and cost-effectiveness of ePT and uPOD in individuals with PHP. The results will serve to inform clinical practice decisions and management guidelines of multiple disciplines. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01865734.