Pre-neuromusculoskeletal injury Risk factor Evaluation and Post-neuromusculoskeletal injury Assessment for Return-to-duty/activity Enhancement (PREPARE) in military service members: a prospective, observational study protocol.

BACKGROUND: Non-battle related musculoskeletal injuries (MSKI) are one of the primary medical issues diminishing Service member medical readiness. The MSKI problem is challenging because it is difficult to assess all of the factors that increase MSKI risk and influence post-MSKI outcomes. Currently, there are no high-throughput, clinically-feasible, and comprehensive assessments to generate patient-centric data for informing pre- and post-MSKI risk assessment and mitigation strategies. The objective of the "Pre-neuromusculoskeletal injury Risk factor Evaluation and Post-neuromusculoskeletal injury Assessment for Return-to-duty/activity Enhancement (PREPARE)" study is to develop a comprehensive suite of clinical assessments to identify the patient-specific factors contributing to MSKI risks and undesired post-MSKI outcomes. METHODS: This is a phased approach, multi-center prospective, observational study (ClinicalTrials.gov number: NCT05111925) to identify physical and psychosocial factors contributing to greater MSKI risk and undesired post-MSKI outcomes, and to identify and validate a minimal set of assessments to personalize risk mitigation and rehabilitation strategies. In Phase I, one cohort (n = 560) will identify the physical and psychosocial factors contributing to greater MSKI risks (single assessment), while a second cohort (n = 780) will identify the post-MSKI physical and psychosocial factors contributing to undesired post-MSKI outcomes (serial assessments at enrollment, 4 weeks post-enrollment, 12 weeks post-enrollment). All participants will complete comprehensive movement assessments captured via a semi-automated markerless motion capture system and instrumented walkway, joint range of motion assessments, psychosocial measures, and self-reported physical fitness performance and MSKI history. We will follow participants for 6 months. We will identify the minimum set of clinical assessments that provide requisite data to personalize MSKI risk mitigation and rehabilitation strategies, and in Phase II validate our optimized assessments in new cohorts. DISCUSSION: The results of this investigation will provide clinically relevant data to efficiently inform MSKI risk mitigation and rehabilitation programs, thereby helping to advance medical care and retain Service members on active duty status. TRIAL REGISTRATION: PREPARE was prospectively registered on ClinicalTrials.gov (NCT05111925) on 5 NOV 2021, prior to study commencement.

A spectral approach to determine location and orientation of azo dyes within surfactant aggregates.

The UV-vis absorption properties of azo dyes are known to exhibit a variation with the polarity and acidity of the dye environment. The spectral properties of a series of anionic azo dyes were characterized to further probe the interaction of these dyes with two types of surfactant aggregates: (1) the spherical micelles formed in aqueous solution by alkyltrimethylammonium bromide (C(n)TAB) surfactants with n=10-16 and (2) the unilamellar vesicles spontaneously formed in water from binary mixtures of the oppositely-charged double-tailed surfactants cationic didodecyldimethylammonium bromide (DDAB) and anionic sodium dioctylsulfosuccinate (Aerosol OT or AOT). The observed dye spectra reflect the solvatochromic behavior of the dyes and suggest the location and orientation of the dye within the surfactant aggregates. Deconvolution of the overall spectra into sums of Gaussian curves more readily displays any contributions of tautomeric forms of the azo dyes resulting from intramolecular hydrogen bonding. The rich variation in UV/vis absorption properties of these anionic azo dyes supports their use as sensitive tools to explore the nanostructures of surfactant aggregates.

The effectiveness of manual physical therapy and exercise for mechanical neck pain: a randomized clinical trial.

STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To assess the effectiveness of manual physical therapy and exercise (MTE) for mechanical neck pain with or without unilateral upper extremity (UE) symptoms, as compared to a minimal intervention (MIN) approach. SUMMARY OF BACKGROUND DATA: Mounting evidence supports the use of manual therapy and exercise for mechanical neck pain, but no studies have directly assessed its effectiveness for UE symptoms. METHODS: A total of 94 patients referred to 3 physical therapy clinics with a primary complaint of mechanical neck pain, with or without unilateral UE symptoms, were randomized to receive MTE or a MIN approach of advice, motion exercise, and subtherapeutic ultrasound. Primary outcomes were the neck disability index, cervical and UE pain visual analog scales (VAS), and patient-perceived global rating of change assessed at 3-, 6-, and 52-weeks. Secondary measures included treatment success rates and post-treatment healthcare utilization. RESULTS: The MTE group demonstrated significantly larger reductions in short- and long-term neck disability index scores (mean 1-year difference -5.1, 95% confidence intervals (CI) -8.1 to -2.1; P = 0.001) and short-term cervical VAS scores (mean 6-week difference -14.2, 95% CI -22.7 to -5.6; P = 0.001) as compared to the MIN group. The MTE group also demonstrated significant within group reductions in short- and long-term UE VAS scores at all time periods (mean 1-year difference -16.3, 95% CI -23.1 to -9.5; P = 0.000). At 1-year, patient perceived treatment success was reported by 62% (29 of 47) of the MTE group and 32% (15 of 47) of the MIN group (P = 0.004). CONCLUSION: An impairment-based MTE program resulted in clinically and statistically significant short- and long-term improvements in pain, disability, and patient-perceived recovery in patients with mechanical neck pain when compared to a program comprising advice, a mobility exercise, and subtherapeutic ultrasound.

Lumbopelvic manipulation for the treatment of patients with patellofemoral pain syndrome: development of a clinical prediction rule.

STUDY DESIGN: Prospective cohort/predictive validity study. OBJECTIVE: To determine the predictive validity of selected clinical exam items and to develop a clinical prediction rule (CPR) to determine which patients with patellofemoral pain syndrome (PFPS) have a positive immediate response to lumbopelvic manipulation. BACKGROUND: Quadriceps muscle function in patients with PFPS was recently shown to improve following treatment with lumbopelvic manipulation. No previous study has determined if individuals with PFPS experience symptomatic relief of activity-related pain immediately following this manipulation technique. METHODS AND MEASURES: Fifty subjects (26 male, 24 female; age range, 18-45 years) with PFPS underwent a standardized history and physical examination. After the evaluation, each subject performed 3 typically pain-producing functional activities (squatting, stepping up a 20-cm step, and stepping down a 20-cm step). The pain level perceived during each activity was rated on a numerical pain scale (0 representing no pain and 10 the worst possible pain). Following the assessment, all subjects were treated with a lumbopelvic manipulation, which was immediately followed by retesting the 3 functional activities to determine if there was any change in pain ratings. An immediate overall 50% or greater reduction in pain, or moderate or greater improvement on a global rating of change questionnaire, was considered a treatment success. Likelihood ratios (LRs) were calculated to determine which examination items were most predictive of treatment outcome. RESULTS: Data for 49 subjects were included in the data analysis, of which 22 (45%) had a successful outcome. Five predictor variables were identified. The most powerful predictor of treatment success was a side-to-side difference in hip internal rotation range of motion greater than 14 masculine (+LR, 4.9). If this variable was present, the chance of experiencing a successful outcome improved from 45% to 80%. CONCLUSION: A CPR was developed to predict an immediate successful response to lumbopelvic manipulation in patients with PFPS. However, in light of a limited sample size and omission of potentially meaningful predictor variables, future studies are necessary to validate the CPR.

Development of a clinical prediction rule for classifying patients with patellofemoral pain syndrome who respond to patellar taping.

STUDY DESIGN: Predictive validity/diagnostic test study. OBJECTIVE: To determine the predictive validity and interrater reliability of selected clinical exam items and to develop a clinical prediction rule (CPR) to determine which patients respond successfully to patellar taping. BACKGROUND: Patellar taping is often used to treat patients with PFPS. However, the characteristics of the patients who respond best to patellar taping intervention have not been identified. METHODS AND MEASURES: Fifty volunteers (27 males, 23 females) with PFPS underwent a standardized clinical examination. Diagnosis of PFPS was based on the complaint of retropatellar pain that was provoked by a partial squat or stair ascent/descent. Subjects performed 3 functional activities and rated their pain during each activity on a numerical rating scale (NPRS). All subjects received treatment with a medial glide patellar-taping technique and repeated the functional activities and pain ratings. An immediate 50% reduction in pain or moderate improvement on a global rating of change (GRC) questionnaire was considered a treatment success. Likelihood ratios (LRs) were calculated to determine which examination items were most predictive of treatment outcome. Logistic regression analysis identified items included in the CPR. RESULTS: Twenty-six subjects (52%) had an immediate successful response to the intervention. Two examination items (positive patellar tilt test or tibial varum greater than 5 degrees, +LR = 4.4) comprised the CPR. Application of the CPR improved the probability of a successful outcome from 52% to 83%. Fifty-eight percent of the lower extremity measures were associated with moderate to good reliability (reliability coefficient range, 0.52-0.84). The reliability coefficients for the items that comprised the CPR were 0.49 (patellar tilt) and 0.66 (tibial varum). CONCLUSION: A CPR was developed to predict an immediate successful response to a medial glide patellar taping technique. Validation of the CPR in an independent sample is necessary before widespread clinical use can be recommended.

A comparison between two physical therapy treatment programs for patients with lumbar spinal stenosis: a randomized clinical trial.

STUDY DESIGN: Multicenter randomized, controlled trial. OBJECTIVE: To compare two physical therapy programs for patients with lumbar spinal stenosis. SUMMARY OF BACKGROUND DATA: Scant evidence exists regarding effectiveness of nonsurgical management programs for lumbar spinal stenosis. METHODS: Fifty-eight patients with lumbar spinal stenosis were randomized to one of two 6-week physical therapy programs. One program included manual physical therapy, body weight supported treadmill walking, and exercise (Manual Physical Therapy, Exercise, and Walking Group), while the other included lumbar flexion exercises, a treadmill walking program, and subtherapeutic ultrasound (Flexion Exercise and Walking Group). Perceived recovery was assessed with a global rating of change scale. Secondary outcomes included: Oswestry, a numerical pain rating scale, a measure of satisfaction, and a treadmill test. Testing occurred at baseline, 6 weeks, and 1 year. Perceived recovery, pain, and other healthcare resources used were collected with a long-term follow-up questionnaire. RESULTS: A greater proportion of patients in the manual physical therapy, exercise, and walking group reported recovery at 6 weeks compared with the flexion exercise and walking group (P = 0.0015), with a number needed to treat for perceived recovery of 2.6 (confidence interval, 1.8-7.8). At 1 year, 62% and 41% of the manual therapy, exercise, and walking group and the flexion exercise and walking group, respectively, still met the threshold for recovery. Improvements in disability, satisfaction, and treadmill walking tests favored the manual physical therapy, exercise, and walking group at all follow-up points. CONCLUSIONS: Patients with lumbar spinal stenosis can benefit from physical therapy. Additional gains may be realized with the inclusion of manual physical therapy interventions, exercise, and a progressive body-weight supported treadmill walking program.

Diagnostic imaging and differential diagnosis in 2 case reports.

STUDY DESIGN: Retrospective resident's case reports. BACKGROUND: In today's healthcare setting, it is important for physical therapists to recognize when diagnostic imaging is necessary--as well as know how to interpret the results of these tests--to assist in the clinical decision-making process. Two cases are presented that illustrate how a physical therapist, credentialed to request and review diagnostic imaging, effectively and efficiently utilized multiple forms of diagnostic imaging to assist in his differential diagnosis and clinical decision making. DIAGNOSIS: The first case report describes the differential diagnostic process for a 33-year-old active duty military paratrooper who had sustained trauma to his neck. His history was consistent with a C6 radiculopathy, which was confirmed by a neurological screening examination. Radiographs requested by the physical therapist revealed an anterolithesis of C5 on C6, with a possible fracture. An orthopedic surgeon was consulted and further diagnostic testing via magnetic resonance imaging revealed a large disc herniation at C5-6, with spinal cord compression, as well as a C5 vertebral body fracture with nearly perched facets at C5 on C6. The patient was subsequently referred to a neurosurgeon and underwent an emergency C5-6 fusion that afternoon. The second case report describes the differential diagnosis of a 20-year-old active-duty soldier referred for rehabilitation with a diagnosis of a distal fibula stress fracture. Previous treatment by the referring provider included 3 months of rest and anti-inflammatory medications. Physical examination of the patient revealed a marked decrease in ankle inversion with a firm end feel. This was not consistent with the diagnosis established by the referring provider. Subsequent radiographs requested by the physical therapist and a computed tomography scan requested by a podiatrist revealed synostosis of the middle facet of the talocalcaneal joint with an apparent fracture line. The patient subsequently underwent a subtalar arthrodesis. DISCUSSION: In these cases the physical therapist requested imaging needed for appropriate management, despite the patient having previously seen a primary care provider. In both examples, the physical therapist successfully identified abnormalities prior to a radiologist or other physician reviewing the results. This avoided delay in definitive management of the patients' problems. It is imperative that physical therapists understand when diagnostic imaging is necessary to assist in the differential diagnosis of patients. Likewise, it is important for physical therapists to be competent in interpreting the results of these tests. When not in a direct access physical therapy environment, a physical therapist should understand when diagnostic imaging tests are indicated. This facilitates working with the entire health care team to acquire necessary tests in an appropriate timeframe.

Physical therapy treatment effectiveness for osteoarthritis of the knee: a randomized comparison of supervised clinical exercise and manual therapy procedures versus a home exercise program.

BACKGROUND AND PURPOSE: Manual therapy and exercise have not previously been compared with a home exercise program for patients with osteoarthritis (OA) of the knee. The purpose of this study was to compare outcomes between a home-based physical therapy program and a clinically based physical therapy program. SUBJECTS: One hundred thirty-four subjects with OA of the knee were randomly assigned to a clinic treatment group (n=66; 61% female, 39% male; mean age [+/-SD]=64+/-10 years) or a home exercise group (n=68, 71% female, 29% male; mean age [+/-SD]=62+/-9 years). METHODS: Subjects in the clinic treatment group received supervised exercise, individualized manual therapy, and a home exercise program over a 4-week period. Subjects in the home exercise group received the same home exercise program initially, reinforced at a clinic visit 2 weeks later. Measured outcomes were the distance walked in 6 minutes and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). RESULTS: Both groups showed clinically and statistically significant improvements in 6-minute walk distances and WOMAC scores at 4 weeks; improvements were still evident in both groups at 8 weeks. By 4 weeks, WOMAC scores had improved by 52% in the clinic treatment group and by 26% in the home exercise group. Average 6-minute walk distances had improved about 10% in both groups. At 1 year, both groups were substantially and about equally improved over baseline measurements. Subjects in the clinic treatment group were less likely to be taking medications for their arthritis and were more satisfied with the overall outcome of their rehabilitative treatment compared with subjects in the home exercise group. DISCUSSION AND CONCLUSION: Although both groups improved by 1 month, subjects in the clinic treatment group achieved about twice as much improvement in WOMAC scores than subjects who performed similar unsupervised exercises at home. Equivalent maintenance of improvements at 1 year was presumably due to both groups continuing the identical home exercise program. The results indicate that a home exercise program for patients with OA of the knee provides important benefit. Adding a small number of additional clinical visits for the application of manual therapy and supervised exercise adds greater symptomatic relief.

Passive versus active stretching of hip flexor muscles in subjects with limited hip extension: a randomized clinical trial.

BACKGROUND AND PURPOSE: Active stretching is purported to stretch the shortened muscle and simultaneously strengthen the antagonist muscle. The purpose of this study was to determine whether active and passive stretching results in a difference between groups at improving hip extension range of motion in patients with hip flexor muscle tightness. SUBJECTS AND METHODS: Thirty-three patients with low back pain and lower-extremity injuries who showed decreased range of motion, presumably due to hip flexor muscle tightness, completed the study. The subjects, who had a mean age of 23.6 years (SD = 5.3, range = 18-25), were randomly assigned to either an active home stretching group or a passive home stretching group. Hip extension range of motion was measured with the subjects in the modified Thomas test position at baseline and 3 and 6 weeks after the start of the study. RESULTS: Range of motion in both groups improved over time, but there were no differences between groups. DISCUSSION AND CONCLUSION: The results indicate that passive and active stretching are equally effective for increasing range of motion, presumably due to increased flexibility of tight hip flexor muscles. Whether the 2 methods equally improve flexibility of other muscle groups or whether active stretching improves the function of the antagonist muscles is not known. Active and passive stretching both appeared to increase the flexibility of tight hip flexor muscles in patients with musculoskeletal impairments.