Demonstration and Evaluation of Physical Examination Techniques Intended to Identify Proximal Femoral Bone Stress Injuries.

PURPOSE: Proximal femoral bone stress injuries (BSI), especially those involving the femoral neck (FNBSI), pose a risk to military medical readiness. There is currently no optimal physical examination technique or test item cluster that substantially influences the clinical diagnosis of FNBSI. Consequently, a lower threshold to order diagnostic imaging is employed by clinicians who manage military populations at risk for FNBSI. A viable physical examination technique or cluster of techniques is needed to better inform this clinical decision process and reduce the associated diagnostic imaging burden. This project assessed the perceived clinical utility of several novel physical examination techniques intended to identify proximal femoral bone stress injuries. METHODS: Thirteen FNBSI-specific physical examination techniques were evaluated using standardized grading criteria, evaluating safety, reliability, and credibility. Based on group consensus, two weight-bearing techniques- forward lunge and tap (FLT), rear lunge reach and tap (RLRT)-and three non-weight-bearing techniques- proximal femoral shear test, 45-degree compress and percuss, and the side-lying scissor test-were each determined to possess a parsimonious cluster of desirable examination properties. A one-hour, multimedia presentation accompanied by live demonstrations was presented to 13 clinicians. Each clinician rated the physical examination techniques based on the following five criteria: patient safety, likely to identify only bone pathology, accuracy regardless of symptom duration or acuity, performed in the mid-range of available motion, and reliability. These criteria were individually weighted from 1 (strongly disagree) to 5 (strongly agree), yielding a possible maximum score of 25. Each physical examination technique was also given a yes or no rating for overall credibility. The minimum acceptable value was set a priori at 80% yes votes. RESULTS: All clinicians in attendance were physical therapists with an average of 5.9 (SD: 4.4) years of experience managing patients with FNBSI. All attendees either agreed or strongly agreed all techniques would be safe to use with patients suspected of having a FNBSI. The highest overall scoring test based on the five criteria was the FLT with a score of 21. The only two tests to exceed the 80% benchmark for overall credibility were the FLT (92.3%) and the RLRT (83.3%). There were no overall statistically significant differences within each individual criterion except for the safety criterion. However, post hoc pairwise comparisons revealed no statistically significant differences. CONCLUSIONS: A minimum of two of the novel physical examination techniques (FLT, RLRT) appear to have sufficient credibility to warrant further evaluation based on voting results from an experienced group of clinicians. A concurrent criterion validity study to assess the diagnostic accuracy properties associated with these techniques is now indicated. CLINICAL RELEVANCE: This line of research may assist future clinicians to determine the need for diagnostic imaging procedures in patients with a suspected FNBSI.

Ultrasound shear wave elastography measurement of the deep posterior cervical muscles: Reliability and ability to differentiate between muscle contraction states.

The deep posterior cervical muscles (DPCM), specifically the semispinalis cervicis and cervical multifidus, are often impaired in patients with neck disorders and have been assessed by several imaging techniques. Prior ultrasound shear wave elastography (SWE) imaging and reliability assessments of the DPCM were performed utilizing similar positioning as assessments for the more superficial cervical extensors. Our objectives were to describe an SWE imaging technique for the DPCM, establish intra-rater reliability of DPCM SWE, and compare DPCM shear modulus during rest and submaximal contraction in both prone and seated positions in individuals without spinal pain. In sixteen participants, the DPCM was located using B-mode ultrasound, then muscle shear modulus was assessed via SWE at both rest and with contraction against a 2-kg resistance applied at the C2 spinous process. Within-day intra-rater reliability was moderate to good (ICC = 0.70-0.88). The DPCM were stiffer during contraction than at rest in the prone position (p = 0.002), and at rest in sitting versus at rest in prone (p = 0.003). Further research is needed to assess DPCM-specific SWE in symptomatic individuals and compare DPCM shear modulus to electromyography across contraction intensities.

SHORT-TERM EFFECTS OF TRIGGER POINT DRY NEEDLING ON PAIN AND DISABILITY IN SUBJECTS WITH PATELLOFEMORAL PAIN SYNDROME.

BACKGROUND: Patellofemoral pain syndrome (PFPS) is a prevalent knee disorder. A novel yet increasingly popular treatment for PFPS is trigger point dry needling (DN). PURPOSE: The purpose of this study was to determine if DN is more effective at reducing pain and disability than a sham treatment in individuals with PFPS. STUDY DESIGN: Randomized trial. MATERIALS/METHODS: Sixty military health care beneficiaries (36 males) with a clinical diagnosis of PFPS were recruited and completed the study. Subjects underwent a standardized clinical examination and were randomized into a DN or sham treatment group. DN treatment consisted of insertion of an acupuncture-like needle into six sites in the quadriceps femoris muscles of the symptomatic lower extremity based on a palpation examination. The sham grouped received a simulated treatment with a sharp object and needle guide tube without puncturing the skin. Self-reports of pain, disability, and overall status were collected before treatment, immediately after treatment and at 72 hours. Data were analyzed with separate 2x2 repeated measures analysis of variance, with independent variables being Group (DN vs. sham) and Time (pre-treatment vs. immediately post-treatment, and pre-treatment vs. 72 hours). The hypothesis of interest in each case was the Group*Time interaction. The alpha-level was set a priori to .05 using 2-tailed tests. RESULTS: Both groups exhibited a clinically meaningful reduction in pain based on numeric pain rating scale scores immediately post-treatment and at 72 hours, but there was no statistically significant difference between groups (p = 0.219, 0.310). There was no significant difference between groups for any other outcome measures. CONCLUSION: These data suggest that DN treatment is not more effective than a sham DN treatment at reducing short-term pain and disability in individuals with PFPS when used as an isolated treatment approach. LEVEL OF EVIDENCE: 2.

Clinical and electrodiagnostic abnormalities of the median nerve in Army dental assistants before and after training as preventive dental specialists.

PURPOSE: Dentists and dental hygienists have been reported as having a high prevalence of upper-extremity musculoskeletal disorders, including carpal tunnel syndrome. Unfortunately, previous research has not involved the impact of preventive dental specialist training on dental assistants. Therefore, the purpose of this study was to determine the presence of median and ulnar neuropathies in US Army dental assistants before and after training as preventive dental specialists. METHODS: Thirty-five US Army dental assistants (24 female, 11 male; age range 18-41 years) volunteered for the study. Twenty-eight preventive dental specialist students completed both the pretraining and posttraining data collections. Subjects were evaluated during the first and last weeks of their 12-week course. Subjects completed a history form, were interviewed, and underwent a physical examination. Nerve conduction status of the median and ulnar nerves of both upper extremities were obtained by performing motor, sensory, comparison (unilateral median to ulnar distal motor and sensory latencies), and F-wave nerve conduction studies (NCS). Descriptive statistics for subject demographics and pre to post physical examination and nerve conduction variables were calculated. Chi square (χ²) analysis was also conducted to determine if a significant shift in the prevalence of neuropathies occurred following dental training. RESULTS: With the exception of comparison studies, pre-NCS and post-NCS electrophysiological variables were normal. Specifically, 9 subjects (26%) involving 14 hands (20%) were found to have meaningful (>1.0 millisecond) delayed median to ulnar distal motor latency comparisons in the pretraining assessment. Additionally, there was no statistically significant shift in the prevalence of electrodiagnostic abnormalities of the median nerve following the 12-week training program (χ²=0.280, P=.60). CONCLUSION: The prevalence of clinical and electrodiagnostic abnormalities of the median nerve in this sample of US Army dental assistants closely mirrors the prevalence reported for other dental professionals. This study also demonstrates that, for this sample, the 12-week training program did not appear to affect the electrophysiologic status of the median or ulnar nerves.

Clinical and electrodiagnostic abnormalities of the median nerve in dental assistants.

STUDY DESIGN: Descriptive. OBJECTIVES: To determine the presence of clinical and electrodiagnostic abnormalities of the median and ulnar nerves in both upper extremities of dental assistants. BACKGROUND: A high prevalence of median neuropathies at, or distal to, the wrist have been reported in dentists and dental hygienists. But there is a paucity of literature on the incidence of abnormalities of the median or ulnar nerves in dental assistants. METHODS: Thirty-five United States Army dental assistants (24 female, 11 male; age range, 18-41 years) volunteered for the study. Subjects completed a standardized history and physical examination. Nerve conduction status of the median and ulnar nerves of both upper extremities was obtained by performing motor, sensory, and F-wave (central) nerve conduction studies. RESULTS: All electrophysiological variables were normal for motor, sensory, and F-wave (central) values when compared to a chart of normal values. Based on comparison studies of median and ulnar motor latencies within the same hand, 9 subjects (26%) involving 14 hands (20%) were found to have electrodiagnostic abnormalities of the median nerve at, or distal to, the wrist. The other 26 dental assistants demonstrated normal comparison studies of the median and ulnar nerves in both upper extremities. CONCLUSIONS: In this descriptive study of 35 dental assistants, 9 subjects (26%) were found to have electrodiagnostic abnormalities of the median nerve at, or distal to, the wrist (when compared to the ulnar nerve of the same hand). Ulnar nerve electrophysiological function was within normal limits for all subjects examined.

Comparison of short-term response to two spinal manipulation techniques for patients with low back pain in a military beneficiary population.

OBJECTIVE: To determine whether military health care beneficiaries with low back pain (LBP) who are likely to respond successfully to spinal manipulation experience a difference in short-term clinical outcomes based on the manipulation technique that is used. METHODS: Sixty patients with LBP identified as likely responders to manipulation underwent a standardized clinical examination and were randomized to receive a lumbopelvic (LP) or lumbar neutral gap (NG) manipulation technique. Outcome measures were a numeric pain rating scale and the modified Oswestry Disability Questionnaire. RESULTS: Both the LP and NG groups experienced statistically significant reductions in pain and disability at 48 hours postmanipulation. The improvements seen in each group were small because of the short follow-up. There were no statistically significant or clinically meaningful differences in pain or disability between the two groups. CONCLUSION: The two manipulation techniques used in this study were equally effective at reducing pain and disability when compared at 48 hours posttreatment. Clinicians may employ either technique for the treatment of LBP and can expect similar outcomes in those who satisfy the clinical prediction rule (CPR). Further research is required to determine whether differences exist at longer-term follow-up periods, after multiple treatment sessions, or in different clinical populations.

Development of a clinical prediction rule for diagnosing hip osteoarthritis in individuals with unilateral hip pain.

STUDY DESIGN: Prospective cohort/predictive validity study. OBJECTIVE: To determine the diagnostic accuracy of common clinical examination items and to construct a preliminary clinical prediction rule for diagnosing hip osteoarthritis (OA) in individuals with unilateral hip pain. BACKGROUND: The current gold standard for the diagnosis of hip OA is a standing anteroposterior (AP) radiograph of the pelvis. Other than for Altman's criteria, little research has been done to determine the accuracy of clinical examination findings for diagnosing hip OA. METHODS AND MEASURES: Seventy-two subjects completed the study. Each subject received a standardized history, physical examination, and standing AP radiograph of the pelvis. Subjects with a Kellgren and Lawrence score of 2 or higher based on the radiographs were considered to have definitive hip OA. Likelihood ratios (LRs) were computed to determine which clinical examination findings were most diagnostic of hip OA. Potential predictor variables were entered into a logistic regression model to determine the most accurate set of clinical examination items for diagnosing hip OA. RESULTS: Twenty-one (29%) of the 72 subjects had radiographic evidence of hip OA. A clinical prediction rule consisting of 5 examination variables was identified. If at least 4 of 5 variables were present, the positive LR was equal to 24.3 (95% confidence interval: 4.4-142.1), increasing the probability of hip OA to 91%. CONCLUSION: The preliminary clinical prediction rule provides the ability to a priori identify patients with hip pain who are likely to have hip OA. A validation study should be done before the rule can be implemented in routine clinical practice.

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.

Identification of individuals with patellofemoral pain whose symptoms improved after a combined program of foot orthosis use and modified activity: a preliminary investigation.

BACKGROUND AND PURPOSE: In patients with patellofemoral pain syndrome (PFPS), the authors determined which aspects of the examination could be used to identify those patients most likely to respond to off-the-shelf foot orthoses and instruction in activity modification. PARTICIPANTS AND METHODS: Fifty participants were enrolled in the study, and data for 5 individuals were excluded from analysis. Thirty-four men and 11 women completed the study. Participants were given foot orthoses and instructed in activity modification for 3 weeks. A 50% reduction in pain was considered a success. Likelihood ratios (LRs) were computed to determine which examination findings were most predictive of success. RESULTS: The best predictors of improvement were forefoot valgus alignment of 2 degrees (+LR=4.0, 95% confidence interval [CI]=0.7-21.9), great toe extension of 78 degrees (+LR=4.0, 95% CI=0.7-21.9), and navicular drop of 3 mm (+LR=2.4, 95% CI=1.3-4.3). DISCUSSION AND CONCLUSION: The results suggest that patients with PFPS who have forefoot valgus alignment of 2 degrees, passive great toe extension of 78 degrees, or navicular drop of 3 mm are most likely to respond favorably to initial intervention with an off-the-shelf foot orthosis and instruction in activity modification.

The accuracy of the Palpation Meter (PALM) for measuring pelvic crest height difference and leg length discrepancy.

STUDY DESIGN: Test-retest reliability and validity. OBJECTIVE: To determine the validity and reliability of the Palpation Meter (PALM). BACKGROUND: Leg length discrepancy (LLD) has been associated with a variety of musculoskeletal disorders. Therefore, the clinical measurement of LLD has become a routine and important part of the physical examination. The PALM is an instrument that was recently developed to indirectly measure LLD, but little is known about its measurement properties. METHODS AND MEASURES: Fifteen healthy and 15 symptomatic subjects with suspected LLD participated in this study. Measurements of pelvic crest height difference (PD) were obtained by 2 examiners using the PALM. A standing antero-posterior (AP) radiograph of each subject's pelvis was taken, and PD and LLD (femoral head height difference) were determined from the radiograph for comparison with the PALM values. Intraclass correlation coefficients (ICCs) were calculated to determine the validity and reliability estimates of the PALM. RESULTS: For all subjects, the validity estimates (ICC2,3) of the PALM for PD were excellent (0.90 for rater 1 and 0.92 for rater 2) when compared with the standing AP radiograph of the pelvis. The PALM was less accurate (ICC2,3 of 0.76 and 0.78 for rater 1 and 2, respectively) as an indirect estimate of LLD. Intrarater reliability for each rater was excellent (ICC3,3 = 0.97 and 0.98) and interrater reliability was very good (ICC2,3 = 0.88). CONCLUSION: The PALM is a reliable and valid instrument for measuring PD. Clinicians should consider this convenient, cost-effective clinical tool as an alternative to radiographic measurement of pelvic crest height difference.