Reliability of a Musculoskeletal Imaging Competency Examination for Physical Therapists.

INTRODUCTION: The Burley Readiness Examination (BRE) for Musculoskeletal (MSK) Imaging Competency assesses physical therapists' baseline MSK imaging competency. Establishing its reliability is essential to its value in determining MSK imaging competency. The purpose of this study was to test the reliability of the BRE for MSK Imaging Competency among physical therapists (PTs) with varying levels of training and education. REVIEW OF LITERATURE: Previous literature supports PTs' utility concerning diagnostic imaging; however, no studies directly measure their competency. With PTs expanding their practice scope and professional PT education programs, increasing their MSK imaging instruction, assessing competency becomes strategic in determining the future of MSK education and training. SUBJECTS: One hundred twenty-three United States licensed PTs completed the BRE. METHODS: Physical therapists completed the BRE through an online survey platform. Point biserial correlation (rpb) was calculated for each examination question. Final analyses were based on 140 examination questions. Examination scores were compared using independent sample t-test and one-way analysis of variance. Chi-square tests and odds ratios (ORs) assessed the relationship of a passing examination score (≥75%) and the type of training. Reliability of the BRE was assessed using Cronbach's alpha (α). RESULTS: Mean overall examination score was 75.89 ± 8.56%. Seventy PTs (56.9%) obtained a passing score. Physical therapists with additional MSK imaging training, board certification, and residency or fellowship training scored significantly higher (P < .001) compared with those with only entry-level PT program education. Physical therapists with additional MSK imaging training scored significantly higher (x̄ = 81.07% ± 8.93%) and were almost 5 times (OR = 4.74, 95% CI [1.95-11.50]) as likely to achieve a passing score than those without. The BRE demonstrated strong internal consistency (Cronbach's α = 0.874). DISCUSSION AND CONCLUSIONS: The BRE was reliable, consistently identifying higher examination scores among those with increased MSK imaging training. Training in MSK imaging influenced competency more than other factors. The BRE may be of analytical value to PT professional and postprofessional programs.

Physical therapist awareness of diagnostic imaging referral jurisdictional scope of practice: an observational study.

OBJECTIVES: To examine physical therapist awareness and utilization of imaging referral privileges in the United States (US) and how it relates to direct access frequency. METHODS: This study utilized survey data collected in 2020-2021 from US physical therapists. Subjects were asked about imaging referral jurisdictional authority in their state. Responses were analyzed for accuracy and compared to the level of jurisdictional authority and its impact on imaging referral. Analysis of imaging skills performance and imaging referral practices were compared to direct access frequency. RESULTS: Only 42.0% of physical therapists practicing in states that allow imaging referral were aware of this privilege. Those practicing where imaging referral was allowed via state legislation were significantly more likely (p < 0.01) to be aware of this privilege (71.4%) compared to those granted by the state board (25.2%). Those aware of their imaging referral scope were more likely (p < 0.01) to practice imaging referral (44.5%) compared to those who were unaware (3.2%). Direct access frequency was positively associated with imaging skill performance and imaging referral practice (p < 0.01). Doctors of Physical Therapy, residency/fellowship-trained physical therapists, and board-certified physical therapists all reported practicing greater frequency of direct access (p < 0.01). DISCUSSION/CONCLUSION: There is a striking lack of awareness of imaging privileges among physical therapists as influenced by the level of jurisdictional scope. These results suggest that the lack of awareness may have a dampening effect on diagnostic imaging referrals. The American Physical Therapy Association should consider engaging with state boards to raise imaging privilege awareness.

Physical Therapists Are Routinely Performing the Requisite Skills to Directly Refer for Musculoskeletal Imaging: An Observational Study.

OBJECTIVES: To explore if physical therapists are practicing skills necessary to refer patients for musculoskeletal imaging. METHODS: An expert panel established a list of nine requisite skills to refer for musculoskeletal imaging. A blinded expert panel validated the list using a 5-point Likert scale. The skills list was examined via an electronic survey distributed to United States physical therapists. RESULTS: 4,796 respondents were included. Each of the nine skills were routinely performed by a majority of the respondents (range: 54.52-94.72%). Respondents routinely performed 6.95 (± 0.06) skills, with 67.41% routinely performing seven or more skills. Doctors of physical therapy routinely performed more imaging skills (7.15 ± 0.06) compared to their masters- (6.44 ± 0.19) and bachelors-trained (5.95 ± 0.21) counterparts (p < 0.001). Residency/fellowship-trained physical therapists were more likely to routinely perform more imaging skills (7.60 ± 0.11 vs. 6.79 ± 0.07, p < 0.001). Imaging skill performance was greater among board-certified physical therapists (7.39 ± 0.09 vs. 6.71 ± 0.08, p < 0.001) and APTA members (7.06 ± 0.07 vs. 6.65 ± 0.12, p < 0.001). CONCLUSION: Physical therapists are routinely practicing the requisite imaging skills to directly refer to a radiologist for musculoskeletal imaging.

Isolated Medial Cuneiform Fractures: A Systematic Search and Qualitative Analysis of Case Studies.

BACKGROUND: Isolated medial cuneiform fracture is a rare but diagnostically challenging condition. Diagnostic delay in these cases may lead to delays in ideal treatment approaches and prolonged symptoms. An understanding of clinical presentation is needed to expedite diagnosis, facilitate decision making, and guide treatment approach. METHODS: Case studies/series were searched in four databases until September 2019. Included studies had participants with a history of traumatic closed medial cuneiform fracture. Studies were excluded if the medial cuneiform fractures were open fractures, associated with multitrauma, or associated with dislocation/Lisfranc injury. Three blinded reviewers assessed the methodological quality of the studies, and a qualitative synthesis was performed. RESULTS: Ten studies comprising 15 patients were identified. Mean ± SD patient age was 38.0 ± 12.8 years, with 86.7% of reported participants being men. The overall methodological quality was moderate to high, and reporting of the patient selection criteria was poor overall. The most commonly reported clinical symptoms were localized tenderness (60.0%) and edema (53.3%). Direct blow was the most common inciting trauma (46.2%), followed by axial load (30.8%) and avulsion injuries (23.1%). Baseline radiographs were occult in 72.7% of patients; magnetic resonance imaging and computed tomography were the most common diagnostic modalities. Mean ± SD diagnostic delay was 64.7 ± 89.6 days. Conservative management was pursued in 54.5% of patients, with reported resolution of symptoms in 3 to 6 months. Surgical intervention occurred in 45.5% of patients and resulted in functional restoration in 3 to 6 months in all but one patient. CONCLUSIONS: Initial radiographs for isolated medial cuneiform fractures are frequently occult. Due to expedience and relatively low cost, radiographs are still a viable first-line imaging modality. If clinical concern remains, magnetic resonance imaging may be pursued to minimize diagnostic delay. Conservative management is a viable treatment method, with expected return to full function in 3 to 6 months.

Development of a Musculoskeletal Imaging Competency Examination for Physical Therapists.

OBJECTIVE: The number of physical therapists with imaging ordering privileges is increasing; however, a known level of competency and knowledge is generally lacking within the profession, as is a method to determine practitioner competency. The purpose of this study was to develop a valid musculoskeletal (MSK) imaging competency examination for physical therapists. METHODS: This 3-round Delphi method study utilized experts to reach consensus on examination content and development. Round 1 was completed by 37 experts. The last 2 rounds were completed by 35 experts. Experts rated questions on a 5-point Likert rating scale of importance (1 = not at all important, 5 = very important). Consensus was achieved with an a priori decision of (1) >75% agreement of the expert panel rating and ≥4 on the Likert scale, and (2) ≥.90 on Cronbach alpha and intraclass correlation coefficients. Experts recommended a passing score of 75%. The examination was subsequently reviewed by a panel of 5 radiologists. RESULTS: The Delphi method and radiologist panel review resulted in the 151-question Burley Readiness Examination (BRE) for MSK Imaging Competency. Interrater agreement and internal consistency of the Delphi panel were excellent, with an average intraclass correlation coefficient and Cronbach alpha of .928 and .950, respectively. CONCLUSIONS: The BRE is a tool that has the potential to demonstrate practitioners' level of baseline competency with MSK imaging. Additional testing among physical therapists will provide further validation and reliability of the examination. IMPACT: The use and application of diagnostic imaging is becoming more widespread in physical therapist practice throughout the United States. The BRE could potentially have broader implications for health care utilization and cost in the area of MSK imaging.

Exploration of Medical Screening and Differential Diagnosis Instructional Methods and Faculty Perceptions in Physical Therapist Educational Programs.

BACKGROUND: Little is known about medical screening and differential diagnosis (MSDD) preparation of physical therapist students. METHODS: Professional degree physical therapist programs in the U.S. were surveyed regarding MSDD content and faculty perception of graduate competence. RESULTS: Fifty-five of 226 programs responded for a 24.3% response rate. Sixty-six percent strongly agreed that students were adequately prepared to perform MSDD with patients who are referred, whereas 47.3% strongly agreed for patients who are direct access. Faculty board specialty certification status affected perception of student competence (p=0.04). Increased emphasis during clinical affiliations was the most beneficial way to increase student knowledge of MSDD skills. Non-response bias assessment was non-significant. CONCLUSION: Increasing clinical exposure was the top recommendation for expanding both faculty and student knowledge and skills. Factors potentially impacting student preparation in MSDD content have been identified and require further study.

The effects of cryotherapy on quadriceps electromyographic activity and isometric strength in patient in the early phases following knee surgery.

PURPOSE: To determine the effects of cryotherapy on quadriceps electromyographic (EMG) activity and isometric strength in early postoperative knee surgery patients. METHODS: Twenty-two volunteers with recent knee surgeries were included. EMG readings of the vastus medialis (VM), rectus femoris (RF), and vastus lateralis (VL) from the surgical leg were collected during a maximal voluntary quadriceps setting (QS) activity. Maximum isometric knee extension force measurements were also recorded. Subjects were randomly assigned to receive an ice bag or a sham room-temperature bag to the front of their postsurgical knee for 20 min. After treatment, the subjects repeated the above mentioned maximum QS and isometric knee extension force measurements. The subjects returned 24 h later to conduct the same test protocol but received the treatment (ice or sham) not applied during their first test session. RESULTS: A 38% increase in VM EMG activity during QS and a 30% increase in maximum isometric knee extension strength were found after cryotherapy treatment. No significant differences were found in RF or VL EMG activity during QS after cryotherapy. No significant differences were found in any measurements after the sham treatment. CONCLUSION: Clinicians should consider applying ice to knee joints prior to exercise for patients following knee surgery with inhibited quadriceps.

A community-based aquatic exercise program to improve endurance and mobility in adults with mild to moderate intellectual disability.

The purpose of this study was to investigate the impact of a community-based aquatic exercise program on physical performance among adults with mild to moderate intellectual disability (ID). Twenty-two community-dwelling adults with mild to moderate ID volunteered to participate in this study. Participants completed an 8-week aquatic exercise program (2 days/wk, 1 hr/session). Measures of physical performance, which were assessed prior to and following the completion of the aquatic exercise program, included the timed-up-and-go test, 6-min walk test, 30-sec chair stand test, 10-m timed walk test, hand grip strength, and the static plank test. When comparing participants' measures of physical performance prior to and following the 8-week aquatic exercise program, improvements were seen in all measures, but the change in scores for the 6-min walk test, 30-sec chair stand test, and the static plank test achieved statistical significance (P<0.05). An 8-week group aquatic exercise program for adults with ID may promote improvements in endurance and balance/mobility.

Rehabilitation robotics for the upper extremity: review with new directions for orthopaedic disorders.

The focus of research using technological innovations such as robotic devices has been on interventions to improve upper extremity function in neurologic populations, particularly patients with stroke. There is a growing body of evidence describing rehabilitation programs using various types of supportive/assistive and/or resistive robotic and virtual reality-enhanced devices to improve outcomes for patients with neurologic disorders. The most promising approaches are task-oriented, based on current concepts of motor control/learning and practice-induced neuroplasticity. Based on this evidence, we describe application and feasibility of virtual reality-enhanced robotics integrated with current concepts in orthopaedic rehabilitation shifting from an impairment-based focus to inclusion of more intense, task-specific training for patients with upper extremity disorders, specifically emphasizing the wrist and hand. The purpose of this paper is to describe virtual reality-enhanced rehabilitation robotic devices, review evidence of application in patients with upper extremity deficits related to neurologic disorders, and suggest how this technology and task-oriented rehabilitation approach can also benefit patients with orthopaedic disorders of the wrist and hand. We will also discuss areas for further research and development using a task-oriented approach and a commercially available haptic robotic device to focus on training of grasp and manipulation tasks. Implications for Rehabilitation There is a growing body of evidence describing rehabilitation programs using various types of supportive/assistive and/or resistive robotic and virtual reality-enhanced devices to improve outcomes for patients with neurologic disorders. The most promising approaches using rehabilitation robotics are task-oriented, based on current concepts of motor control/learning and practice-induced neuroplasticity. Based on the evidence in neurologic populations, virtual reality-enhanced robotics may be integrated with current concepts in orthopaedic rehabilitation shifting from an impairment-based focus to inclusion of more intense, task-specific training for patients with UE disorders, specifically emphasizing the wrist and hand. Clinical application of a task-oriented approach may be accomplished using commercially available haptic robotic device to focus on training of grasp and manipulation tasks.

Changes in lumbar multifidus muscle function and nociceptive sensitivity in low back pain patient responders versus non-responders after dry needling treatment.

BACKGROUND: Little is known about the physiologic mechanism of dry needling. While some evidence suggests that dry needling may decrease nocioceptive sensitivity and facilitate muscle function, no studies to date have examined these physiologic changes compared to clinical outcomes. OBJECTIVE: To examine changes in lumbar multifidus (LM) muscle function and nociceptive sensitivity after dry needling in patients with LBP and to determine if such changes differ in patients that exhibit improved disability (responders) and those that do not (non-responders). DESIGN: Quasi-experimental study. METHODS: Sixty-six volunteers with mechanical LBP (38 men, age = 41.3 ± 9.2 years) completed the study. Ultrasound measurements and pain algometry of the LM were taken at baseline and repeated immediately following dry needling treatment to the LM muscles and after one week. The percent change in muscle thickness from rest to contraction was calculated for each time point to represent muscle function. Pressure pain threshold (PPT) was used to measure nociceptive sensitivity. Participants were dichotomized as responders and non-responders based on whether or not they experienced clinical improvement using the modified Oswestry Disability Index after one week. 2 × 3 mixed-model ANOVA were conducted for group (responders vs. non-responders) by time. RESULTS: Patient responders exhibited larger improvements in LM muscle contraction and nociceptive sensitivity 1 week, but not immediately, after dry needling than non-responders. CONCLUSIONS: Our results suggest that there may be lasting and clinically relevant sensorimotor changes that occur in LBP patients that improve with dry needling treatment that partially explain the physiologic mechanism of action.

Localization of APOL1 protein and mRNA in the human kidney: nondiseased tissue, primary cells, and immortalized cell lines.

Although APOL1 gene variants are associated with nephropathy in African Americans, little is known about APOL1 protein synthesis, uptake, and localization in kidney cells. To address these questions, we examined APOL1 protein and mRNA localization in human kidney and human kidney-derived cell lines. Indirect immunofluorescence microscopy performed on nondiseased nephrectomy cryosections from persons with normal kidney function revealed that APOL1 protein was markedly enriched in podocytes (colocalized with synaptopodin and Wilms' tumor suppressor) and present in lower abundance in renal tubule cells. Fluorescence in situ hybridization detected APOL1 mRNA in glomeruli (podocytes and endothelial cells) and tubules, consistent with endogenous synthesis in these cell types. When these analyses were extended to renal-derived cell lines, quantitative RT-PCR did not detect APOL1 mRNA in human mesangial cells; however, abundant levels of APOL1 mRNA were observed in proximal tubule cells and glomerular endothelial cells, with lower expression in podocytes. Western blot analysis revealed corresponding levels of APOL1 protein in these cell lines. To explain the apparent discrepancy between the marked abundance of APOL1 protein in kidney podocytes observed in cryosections versus the lesser abundance in podocyte cell lines, we explored APOL1 cellular uptake. APOL1 protein was taken up readily by human podocytes in vitro but was not taken up efficiently by mesangial cells, glomerular endothelial cells, or proximal tubule cells. We hypothesize that the higher levels of APOL1 protein in human cryosectioned podocytes may reflect both endogenous protein synthesis and APOL1 uptake from the circulation or glomerular filtrate.

Metastatic cancer mimicking mechanical low back pain: a case report.

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.

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.

Cervical myelopathy: diagnosing another great impostor.

CONTEXT: Cervical myelopathy, especially during the early stages of the disorder, is very difficult to diagnose. It has the ability to mimic a number of other neurologic and musculoskeletal conditions, resulting in prolonged diagnostic delay in some cases. Excessive delay can result in permanent paralysis, gait, and genitourinary dysfunction. While most common in aging populations, it can present to military clinicians at any time. Consequently, there needs to be an increased index of clinical suspicion when evaluating Soldiers. OBJECTIVE: The purpose of this clinical review is to provide an evidence-based update regarding the diagnostic utility of both common and novel clinical tools. DATA SOURCES: English language articles published in peer reviewed journals were identified by searching the PubMed, CINAHL, and SPORTDiscus databases. RESULTS: Historically, clinicians have performed tests such as the Hoffmann or Babinski signs in order to rule out the presence of cervical myelopathy or other upper motor neuron disease. While there is some evidence to suggest their clinical usefulness, several other clinical tools should be considered as well. Specifically, the Trömner and the Wazir hand myelopathy signs are very sensitive for detecting myelopathy at or above the C5-6 level. There is sufficient evidence to suggest that any neurologic screen with the purpose of excluding cervical myelopathy needs to include the lower extremity tests such as the patellar tendon and Rossolimo reflexes. Analysis of the lateral cervical radiograph is an efficient and inexpensive method of evaluating for the presence of congenital cervical spine stenosis, a known risk factor for cervical myelopathy. Magnetic resonance imaging findings on T2, and especially the T1 weighted images, appear correlated with surgical outcomes. CONCLUSION: Military clinicians should use the most valid clinical tools when evaluating for the presence of cervical myelopathy.

Abdominal aortic aneurysm in a patient with low back pain.

STUDY DESIGN: Resident's 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 patient's 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 clinician's 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.

Physical therapist vs. family practitioner knowledge of simple low back pain management in the U.S. Air Force.

The purpose of this study was to compare knowledge in managing low back pain (LBP) between physical therapists and family practice physicians. Fifty-four physical therapists and 130 family practice physicians currently serving in the U.S. Air Force completed standardized examinations assessing knowledge, attitudes, the usefulness of clinical practice guidelines, and management strategies for patients with LBP. Beliefs of physical therapists and family practice physicians about LBP were compared using relative risks and independent t tests. Scores related to knowledge, attitudes, and the usefulness of clinical practice guidelines were generally similar between the groups. However, physical therapists were more likely to recommend the correct drug treatments for patients with acute LBP compared to family practice physicians (85.2% vs. 68.5%; relative risk: 1.24 [95% confidence interval: 1.06-1.46]) and believe that patient encouragement and explanation is important (75.9% vs. 56.2%; relative risk: 1.35 [95% confidence interval: 1.09-1.67]). In addition, physical therapists showed significantly greater knowledge regarding optimal management strategies for patients with LBP compared to family practice physicians. The results of this study may have implications for health policy decisions regarding the utilization of physical therapists to provide care for patients with LBP without a referral.

Plasma apolipoprotein L1 levels do not correlate with CKD.

Polymorphisms in APOL1 are associated with CKD, including HIV-related CKD, in individuals of African ancestry. The apolipoprotein L1 (APOL1) protein circulates and is localized in kidney cells, but the contribution of APOL1 location to CKD pathogenesis is unclear. We examined associations of plasma APOL1 levels with plasma cytokine levels, dyslipidemia, and APOL1 genotype in a nested case-control study (n=270) of HIV-infected African Americans enrolled in a multicenter prospective observational study. Patients were designated as having CKD when estimated GFR (eGFR) decreased to <60 ml/min per 1.73 m(2) (eGFR<60 cohort) or protein-to-creatinine ratios became >3.5 g/g (nephrotic proteinuria cohort). Circulating APOL1 levels did not associate with APOL1 genotype, CKD status, or levels of proinflammatory cytokines, but did correlate with fasting cholesterol, LDL cholesterol, and triglyceride levels. At ascertainment, CKD-associated polymorphisms (risk variants) in APOL1 associated with the eGFR<60 cohort, but not the nephrotic-range proteinuria cohort. Of note, in both the eGFR<60 and nephrotic proteinuria cohorts, CKD cases with two APOL1 risk variants had significant declines in eGFR over a median of 4 years compared with individuals with one or no risk variants. APOL1 risk genotype was not associated with changes in proteinuria. Higher circulating proinflammatory cytokine levels were independently associated with CKD but not APOL1 genotype. In conclusion, the function of variant APOL1 proteins derived from circulation or synthesized in the kidney, but not the level of circulating APOL1, probably mediates APOL1-associated kidney disease in HIV-infected African Americans.

Impaction fracture of the medial femoral condyle.

The patient was a 20-year-old man who sustained a noncontact left knee hyperextension injury while playing soccer. In reviewing left knee radiographs that had previously been interpreted as normal, the physical therapist noted an abnormally deep depression of the medial condylopatellar sulcus, which was concerning for a possible impacted osteochondral fracture. After discussing the radiographic findings with a radiologist, the physical therapist ordered magnetic resonance imaging, which revealed a focal indentation of the anterior portion of the medial femoral condyle with adjacent bone marrow edema that was consistent with an impaction fracture of the medial femoral condyle.

Abdominal pain in physical therapy practice: 3 patient cases.

STUDY DESIGN: Resident's case problem. BACKGROUND: Abdominal pain is a common symptom, but not a common diagnosis, of patients referred to physical therapists for examination and intervention. For patients with primary symptoms of abdominal pain, a thorough evaluation must be performed to determine if symptoms are musculoskeletal in nature or of a nonmusculoskeletal origin that would warrant a referral to a different healthcare provider. This report describes the management of 3 adults with primary complaints of abdominal pain who were referred for physical therapy evaluation and treatment. DIAGNOSIS: Two of the patients had secondary symptoms of hip and/or low back pain and had previously undergone extensive medical testing for their chronic abdominal pain, without a definitive diagnosis having been determined. A physical therapy evaluation was conducted, and treatment, including manual physical therapy and exercise, was administered to address all relative impairments, once the physical therapist had determined that the patients' symptoms were of musculoskeletal origin. The third patient included in this series was referred to a physical therapist with a diagnosis of greater trochanteric versus iliopsoas bursitis. However, the patient had abdominal pain that was more acute in nature and a history and physical examination findings that were concerning for abdominal pain of nonmusculoskeletal origin. Both patients with abdominal pain of musculoskeletal origin showed marked improvement in pain and disability after 7 treatment sessions. The third patient was referred to her primary care physician, and ultrasound examination of the abdomen revealed several intrauterine masses that were consistent with uterine fibroids. Following uterine fibroid embolization, the patient was symptom free. DISCUSSION: Although not routinely managed by physical therapists, abdominal pain is a relatively common patient symptom that can have several causes, both musculoskeletal and nonmusculoskeletal. This paper emphasizes the importance of physical therapists having the necessary differential diagnostic skills to determine if patients with primary symptoms of abdominal pain require physician referral or physical therapist intervention.