Examining online international health professions education: a mixed methods review of barriers, facilitators, and early outcomes☠.

BACKGROUND: Access to quality healthcare education across the world is disproportionate. This study explores the potential for Cardiovascular Perfusion education to be delivered online to reach international students. METHODS: Exploratory mixed methods were used to identify the barriers, facilitators, and early outcomes of online international health professions education. RESULTS: Qualitative analysis yielded four primary and nine subthemes. Multiple interventions were implemented in the planning of a novel online international Extracorporeal Science (ECS) program based on these themes. Quantitative data from the first semester of the new ECS program was collected along with data from the traditional entry-level program and historic data from previous entry-level cohorts. No significant correlations or differences were found between students. Student satisfaction surveys were determined to be equivalent for each group. Mixed data analysis revealed exceptional student satisfaction in areas where qualitative feedback was incorporated into the program design. CONCLUSIONS: Online international education may be a viable option in the health professions. Barriers and facilitators to this mode of education were identified and utilized in designing one such program. Early outcomes from the novel ECS program reveal that student performance and satisfaction are equivalent to those of a traditional in-person training program.

Engaging Education About Risks of Opioid Use With Patients Before Elective Surgery of the Lower Extremity Did Not Reduce Postoperative Opioid Utilization: A Randomized Controlled Trial.

INTRODUCTION: After elective orthopaedic surgery, many individuals go on to become long-term opioid users. Mitigating this risk has become a priority for surgeons, other members of the medical care team, and healthcare systems. The purpose of this study was to compare opioid utilization after lower extremity orthopaedic surgery between patients who received an interactive video education session highlighting the risks of opioid use and those who did not. METHODS: Patients undergoing elective surgery of the lower extremity in the orthopaedic clinic at the Brooke Army Medical Center between July 2015 and February 2017 were recruited at their preoperative appointment and randomized in a 1:1 ratio to receive a one-time interactive opioid education session or usual care education. Unique days' supply of opioids and unique prescriptions were compared using a generalized linear model. Individuals were also grouped by whether they had become long-term opioid users after surgery, and frequencies within each intervention group were compared. RESULTS: There were 120 patients, 60 randomized to each group and followed for 1 year. There were no significant differences between opioid days' supply (mean diff = 8.33, 95% confidence interval -4.21 to 20.87) and unique prescriptions after surgery (mean diff = 0.45, 95% confidence interval -0.25 to 1.15). Most participants did not have any opioids past the initial 30 days after surgery, regardless of intervention (n = 77), and only three became long-term opioid users (one in usual care and two in interactive education). Sixteen in usual education and 18 in enhanced education filled at least one prescription in 6 months or later after the surgical procedure. CONCLUSION: Opioid use beyond 30 days of surgery was no different for participants who received enhanced education compared with usual education. Few became long-term opioid users after surgery (2.5%), although 28.3% were still filling opioid prescriptions 6 months after surgery.

Does Engaging Patients with Relevant Education About Long-Term Opioid Use Before Spine Surgery Affect Long-term Opioid Use? A Randomized Controlled Trial.

STUDY DESIGN: Parallel-arm randomized controlled trial. OBJECTIVE: To assess the effectiveness of an enhanced video education session highlighting risks of opioid utilization on longterm opioid utilization after spine surgery. SUMMARY OF BACKGROUND DATA: Long-term opioid use occurs in more than half of patients undergoing spine surgery and strategies to reduce this use are needed. METHODS: Patients undergoing spine surgery at Brooke Army Medical Center between July 2015 and February 2017 were recruited at their preoperative appointment, receiving the singlesession interactive video education or control at that same appointment. Opioid utilization was tracked for the full year after surgery from the Pharmacy Data Transaction Service of the Military Health System Data Repository. Self-reported pain also collected weekly for 1 and at 6months. RESULTS: A total of 120 participants (40 women, 33.3%) with a mean age of 45.9 ±â€Š10.6 years were randomized 1:1 to the enhanced education and usual care control (60 per group). In the year following surgery the cohort had a mean 5.1 (standard deviation [SD] 5.9) unique prescription fills, mean total days' supply was 88.3 (SD 134.9), and mean cumulative morphine milligrams equivalents per participant was 4193.0 (SD 12,187.9) within the year after surgery, with no significant differences in any opioid use measures between groups. Twelve individuals in the standard care group and 13 in the enhanced education group were classified with having long-term opioid utilization. CONCLUSION: The video education session did not influence opioid use after spine surgery compared to the usual care control. There was no significant difference in individuals classified as long-term opioid users after surgery based on the intervention group. Prior opioid use was a strong predictor of future opioid use in this cohort. Strategies to improve education engagement, understanding, and decision- making continue to be of high importance for mitigating risk of long-term opioid use after spine surgery.Level of Evidence: 1.

Are Exercise and Physical Therapy Common Forms of Conservative Management in the Year Before Lumbar Spine Surgery?

OBJECTIVE: To quantify and compare utilization of opioids, exercise therapy, and physical therapy in the year before spine surgery. DESIGN: A retrospective cohort of surgical and claims data. SETTING: Beneficiaries of the Military Health System seen at Brooke Army Medical Center PARTICIPANTS: Patients (N=411) undergoing surgery between January 1, 2014, and December 31, 2015, identified retrospectively through the Surgical Scheduling System (S3) based on procedure type (fusion, laminectomy, arthroplasty, vertebroplasty, and diskectomy). INTERVENTIONS: Elective lumbar spine surgery. MAIN OUTCOME MEASURES: Health care utilization variables present during the full 12 months before surgery, which included physical therapy services and visits for exercise therapy or manual therapy procedures and opioid prescriptions. RESULTS: The mean age of participants was 44.8±11.7 years and 32.4% were female. In the year before surgery, 143 (34.8%) patients had a physical therapy plan of care, 140 (34.1%) had at least 1 visit that included exercise therapy, and only 60 (14.6%) had a minimum of 6 exercise therapy visits. However, 347 (84.4%) patients received at least 1 opioid prescription fill (mean of 6.1 unique fills). CONCLUSIONS: Before elective lumbar spine surgery, opioid prescriptions were common but physical therapy services and exercise therapy utilization occurred infrequently.

Physical Therapy versus Glucocorticoid Injection for Osteoarthritis of the Knee.

BACKGROUND: Both physical therapy and intraarticular injections of glucocorticoids have been shown to confer clinical benefit with respect to osteoarthritis of the knee. Whether the short-term and long-term effectiveness for relieving pain and improving physical function differ between these two therapies is uncertain. METHODS: We conducted a randomized trial to compare physical therapy with glucocorticoid injection in the primary care setting in the U.S. Military Health System. Patients with osteoarthritis in one or both knees were randomly assigned in a 1:1 ratio to receive a glucocorticoid injection or to undergo physical therapy. The primary outcome was the total score on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at 1 year (scores range from 0 to 240, with higher scores indicating worse pain, function, and stiffness). The secondary outcomes were the time needed to complete the Alternate Step Test, the time needed to complete the Timed Up and Go test, and the score on the Global Rating of Change scale, all assessed at 1 year. RESULTS: We enrolled 156 patients with a mean age of 56 years; 78 patients were assigned to each group. Baseline characteristics, including severity of pain and level of disability, were similar in the two groups. The mean (±SD) baseline WOMAC scores were 108.8±47.1 in the glucocorticoid injection group and 107.1±42.4 in the physical therapy group. At 1 year, the mean scores were 55.8±53.8 and 37.0±30.7, respectively (mean between-group difference, 18.8 points; 95% confidence interval, 5.0 to 32.6), a finding favoring physical therapy. Changes in secondary outcomes were in the same direction as those of the primary outcome. One patient fainted while receiving a glucocorticoid injection. CONCLUSIONS: Patients with osteoarthritis of the knee who underwent physical therapy had less pain and functional disability at 1 year than patients who received an intraarticular glucocorticoid injection. (ClinicalTrials.gov number, NCT01427153.).

Effectiveness of translational manipulation under interscalene block for the treatment of adhesive capsulitis of the shoulder: A nonrandomized clinical trial.

Study Design: Nonrandomized controlled trial. Objective: To determine whether translational manipulation under anesthesia/local block (TMUA) adds to the benefit of mobilization and range of motion exercise for improving pain and functional status among patients with adhesive capsulitis of the shoulder (AC). Background: TMUA has been shown to improve pain and dysfunction in patients with AC. This intervention has not been directly compared to physical therapy treatment without TMUA in a prospective trial. Methods: Sixteen consecutive patients with a primary diagnosis of AC were divided into two groups. Patients in the first (TMUA) group received a session of translational manipulation under interscalene block, followed by six sessions of manipulation and exercise. Patients in the comparison group received seven sessions of manipulation and exercise. Outcome measures taken at baseline and 3, 6, 12 months and 4 years included Shoulder Pain and Disability Index (SPADI) scores. Four-year outcomes included percent of normal ratings, medication use, and activity limitations. Results: Both groups showed improved SPADI scores across all follow-up times compared to baseline. The TMUA group showed a greater improvement in SPADI scores than the comparison group at 3 weeks, with no significant differences in SPADI scores at other time points. However, at 4 years, significantly more subjects in the comparison group (5 of 8) had activity limitations versus subjects in the TMUA group (1 of 8). No subject experienced a complication from either intervention protocol. Conclusion: Physical therapy consisting of manual therapy and exercise provides benefit for patients with AC. Translational manipulation under local block may be a useful adjunct to manual therapy and exercise for patients with AC.

Effects of technique-focused training in conjunction with physical readiness training on Army physical fitness test performance.

The Army Physical Fitness Test (APFT) is a semiannual requirement. While conducting physical readiness training (PRT) is a requirement for all Soldiers, there is no requirement to train Soldiers on techniques that may help to optimize their performance on the APFT. A cohort of 34 officers that attended the Army Medical Department Basic Officer Leadership Course completed a technique-focused training program in conjunction with their required PRT program subsequent to failing one or more events on their initial APFT. The training consisted of a 30-minute video lesson and an individualized performance assessment completed by an Army physical therapist. Upon retest 10 days after the initial test, 27 (79.4%) participants passed the APFT with a mean improvement of 22.3 points on their overall APFT score. When evaluating change in performance by event based on failing the event initially, the observed improvement was an increase of over 9 push-ups, over 11 sit-ups, and nearly 2 minutes on the run event. The addition of a technique-focused training program to an existing PRT program can result in significant short-term improvement for those with substandard APFT performance.

Manual physical therapy combined with high-intensity functional rehabilitation for severe lower extremity musculoskeletal injuries: a case series.

OBJECTIVES: Severe lower extremity trauma accounts for large healthcare costs and often results in elective amputation and poor long-term outcomes. The purpose of this case series is to describe an orthopedic manual physical therapy (OMPT) approach combined with a return to run (RTR) clinical pathway consisting of high-intensity functional rehabilitation with a custom energy-storing orthosis. METHODS: Three consecutive male patients, aged 21-23 years, with severe lower extremity musculoskeletal injuries were treated with a combined intervention that included a mean (SD) of 12 (2·1) OMPT sessions and 24 (8·7) functional rehabilitation sessions over a mean of 6 weeks (1·0). Additional training with a custom energy-storing orthosis consisted of a mean of 15 (1·2) additional sessions over 4 weeks. Patient self-report outcome measures and a variety of physical performance tests captured change in function. RESULTS: Baseline lower extremity functional scale (LEFS) and foot and ankle ability measure activities of daily living subscale (FAAM-ADL) scores indicated severe disability. All patients exceeded the minimal clinically important difference (MCID) in at least one self-report outcome or physical performance test without a brace. Two of three patients exceeded the MCID for at least two physical performance tests after training with and utilizing a custom energy-storing orthosis. DISCUSSION: Clinically meaningful changes in self-reported function or physical performance were observed in all patients. A multi-modal approach, including manual therapy and functional exercise, may address the entire spectrum of impairments in patients with severe lower extremity trauma, resulting in improvements in both braced and un-braced function.

A multicenter randomised, 1-year comparative effectiveness, parallel-group trial protocol of a physical therapy approach compared to corticosteroid injection on pain and function related to knee osteoarthritis (PTA Trial)

INTRODUCTION: Corticosteroid injections (CSIs) are commonly used as an initial or a primary intervention for knee osteoarthritis (OA). Consistent evidence indicates CSIs offer symptom relief with conflicting reports regarding long-term efficacy. Physical therapy (PT) offers a non-invasive alternative. There is moderate evidence suggesting short-term and long-term symptom relief and functional improvement with PT interventions. Patients with knee OA are more commonly prescribed CSI than PT prior to total joint replacement. UnitedHealthcare and Military Health System data show substantially more total knee replacement patients receive preoperative CSI than PT. There are no studies comparing CSI to a PT approach in individuals with knee OA. The primary objective of this study is to compare the effectiveness of CSI to PT in individuals with knee OA at 1, 2 and 12 months. METHODS AND ANALYSIS: We plan to recruit 156 participants meeting established knee OA criteria. Following informed consent, participants will be randomised to receive either CSI or PT. All participants will receive instruction on recommended exercise and weight control strategies plus usual medical care. The CSI intervention consisting of 3 injections and the PT intervention consisting of 8-12 sessions will be spaced over 12 months. Measures of the dependent variables (DVs) will occur at baseline, 4 weeks, 8 weeks, 6 months and 12 months post enrolment. This pragmatic, randomised clinical trial will be a mixed-model 2×5 factorial design. The independent variables are treatment (CSI and PT) and time with five levels from baseline to 1 year. The primary DV is the Western Ontario & McMaster Universities Arthritis Index (WOMAC). We will also compare healthcare utilisation between the 2 groups. ETHICS AND DISSEMINATION: The protocol was approved by the Madigan Army Medical Center Institutional Review Board. The authors intend to publish the results in a peer-reviewed source. TRIAL REGISTRATION NUMBER: NCT01427153.

Knee extension and stiffness in osteoarthritic and normal knees: a videofluoroscopic analysis of the effect of a single session of manual therapy.

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

Clinical reasoning and advanced practice privileges enable physical therapist point-of-care decisions in the military health care system: 3 clinical cases.

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

Joint mobilization forces and therapist reliability in subjects with knee osteoarthritis.

OBJECTIVES: This study determined biomechanical force parameters and reliability among clinicians performing knee joint mobilizations. METHODS: Sixteen subjects with knee osteoarthritis and six therapists participated in the study. Forces were recorded using a capacitive-based pressure mat for three techniques at two grades of mobilization, each with two trials of 15 seconds. Dosage (force-time integral), amplitude, and frequency were also calculated. Analysis of variance was used to analyze grade differences, intraclass correlation coefficients determined reliability, and correlations assessed force associations with subject and rater variables. RESULTS: Grade IV mobilizations produced higher mean forces (P<0.001) and higher dosage (P<0.001), while grade III produced higher maximum forces (P = 0.001). Grade III forces (Newtons) by technique (mean, maximum) were: extension 48, 81; flexion 41, 68; and medial glide 21, 34. Grade IV forces (Newtons) by technique (mean, maximum) were: extension 58, 78; flexion 44, 60; and medial glide 22, 30. Frequency (Hertz) ranged between 0.9-1.1 (grade III) and 1.4-1.6 (grade IV). Intra-clinician reliability was excellent (>0.90). Inter-clinician reliability was moderate for force and dosage, and poor for amplitude and frequency. DISCUSSION: Force measurements were consistent with previously reported ranges and clinical constructs. Grade III and grade IV mobilizations can be distinguished from each other with differences for force and frequency being small, and dosage and amplitude being large. Intra-clinician reliability was excellent for all biomechanical parameters and inter-clinician reliability for dosage, the main variable of clinical interest, was moderate. This study quantified the applied forces among multiple clinicians, which may help determine optimal dosage and standardize care.

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

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

Lateral abdominal muscle symmetry in collegiate single-sided rowers.

PURPOSE/BACKGROUND: Although side to side symmetry of lateral abdominal muscle thickness has been established in healthy individuals, it is unknown whether abdominal muscle symmetry exists in athletes with asymmetrical physiological demands, such as those of single-sided rowers. The purpose of this study was to examine the oarside versus the non-oarside lateral abdominal musculature thickness in collegiate single-sided rowers, as measured by ultrasound imaging (USI). METHODS: The study was a prospective, cross-sectional, observational design. Thirty collegiate crew team members (17 males, 13 females, age 19.8±1.2 years) characterized as single-sided rowers participated. Resting muscle thickness measurements of the transversus abdominis (TrA), internal oblique (IO), and external oblique (EO) muscles were obtained via USI. Comparisons of absolute and relative muscle thickness between oarside and non-oarside were performed using paired t-tests. Potential differences based on gender, rowing experience, and history of low back pain were investigated using mixed model analysis of variance. RESULTS: There were no clinically significant differences in absolute or relative thickness of the TrA, IO or EO on the oarside versus the non-oarside. There were no significant side to side differences in the relative muscle thickness of the TrA, IO or EO based on gender, rowing experience, or history of low back pain. CONCLUSIONS: In this sample of single-sided rowing athletes, no clinically significant side to side differences in lateral abdominal muscle thickness were observed. Despite the asymmetrical functional demands of single-sided rowers in this study, thickness of the lateral abdominal muscles was symmetric. LEVEL OF EVIDENCE: 4.

Knee OA: which patients are unlikely to benefit from manual PT and exercise?

BACKGROUND: The combination of manual physical therapy and exercise provides important benefit for more than 80% of patients with knee osteoarthritis (OA). Our objective was to determine predictor variables for patients unlikely to respond to these interventions. METHODS: We used a retrospective combined cohort study design to develop a preliminary clinical prediction rule (CPR). To determine useful predictors of nonsuccess, we used an extensive set of 167 baseline variables. These variables were extracted from standardized examination forms used with 101 patients(64 women and 37 men with a mean age of 60.5}11.8 and 63.6}9.3 years, respectively) in 2 previously published clinical trials. We classified patients based on whether they achieved a clinically meaningful benefit of at least 12%improvement in Western Ontario MacMaster(WOMAC) scores after 4 weeks of treatment using the smallest and most efficient subset of predictors. RESULTS: The variables of patellofemoral pain, anterior cruciate ligament laxity, and height >1.71 m (5'7'') comprise the CPR. Patients with at least 2 positive tests yield eda posttest probability of 88% for nonsuccess with this treatment (positive likelihood ratio=36.7). The overall prognostic accuracy of the CPR was 96%. CONCLUSION: Most patients with knee OA will benefit from a low-risk, cost-effective program of manual physical therapy and supporting exercise.1,2 The few patients who may not benefit from such a program are identifiable by a simple (preliminary) CPR. After validation,this rule could improve primary patient management,allowing more appropriate referrals and choices in intervention.

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

OBJECTIVES: Describe short- and long-term outcomes observed in individuals with hip osteoarthritis (OA) treated with a pre-selected, standardized set of best-evidence manual therapy and therapeutic exercise interventions. METHODS: Fifteen consecutive subjects (9 males, 6 females; mean age: 52±7.5 years) with unilateral hip OA received an identical protocol of manual therapy and therapeutic exercise interventions. Subjects attended 10 treatment sessions over an 8-week period for manual therapy interventions and performed the therapeutic exercise as a home program. RESULTS: Baseline to 8-week follow-up outcomes were as follows: Harris Hip Scale (HHS) scores improved from 60.3(±10.4) to 80.7(±10.5), Numerical Pain Rating Scale (NPRS) scores improved from 4.3(±1.9) to 2.0(±1.9), hip flexion range of motion (ROM) improved from 99 degrees (±10.6) to 127 degrees (±6.3) and hip internal rotation ROM improved from 19 degrees (±9.1) to 31 degrees (±11.5). Improvements in HHS, NPRS, and hip ROM measures reached statistical significance (P<0.05) at 8-weeks and remained significant at the 29-week follow-up. Mean changes in NPRS and HHS scores exceeded the minimal clinically important difference (MCID) at 8-weeks and for the HHS scores alone at 29 weeks. The 8 and 29 week mean Global Rating of Change scores were 5.1(±1.4) and 2.1(±4.2), respectively. Improved outcomes observed following a pre-selected, standardized treatment protocol were similar to those observed in previous studies involving impairment-based manual therapy and therapeutic exercise for hip OA. Future studies might directly compare the two approaches.

Well-tolerated strategies for managing knee osteoarthritis: a manual physical therapist approach to activity, exercise, and advice.

The orthopedic manual physical therapist approach to knee osteoarthritis (OA) is an effective, well-tolerated, and comprehensive strategy that provides a spectrum of intervention measures, which include guidance on activity selection, as well as selection of manual treatment and exercises to systematically address impairments and increase strength and movement in the knee and other related body regions. This approach integrates manually applied treatment while reinforcing exercise and functional activities that are tailored in scope and dose to each patient. Concepts used in the careful design of this exercise program include emphasizing minimal dosing, avoiding exacerbation, using exercises with multiple effects, effective functional positioning, emphasizing the importance of mid-range movements and end-range challenges, and strategic timing of exercises. Focusing on motion and strength gains through range of motion, along with functional or reinforcing activities, such as walking or biking to maintain motion and strength gains, are keys to long-term success. The overarching theme is that well-tolerated strategies using manual treatment, exercise, and activity require deliberate design and targeting of the most common impairments and functional limitations seen in the knee OA population and, more importantly, tailoring to the individual patient.

Manual physical therapy for injection-confirmed nonacute acromioclavicular joint pain.

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

Investigation of abdominal muscle thickness changes after spinal manipulation in patients who meet a clinical prediction rule for lumbar stabilization.

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

Association between changes in abdominal and lumbar multifidus muscle thickness and clinical improvement after spinal manipulation.

STUDY DESIGN: Prospective case series. OBJECTIVE: To examine the relation between improved disability and changes in abdominal and lumbar multifidus (LM) thickness using ultrasound imaging following spinal manipulative therapy (SMT) in patients with low back pain (LBP). BACKGROUND: Although there is a growing body of literature demonstrating physiologic effects following the application of SMT, few studies have attempted to correlate these changes with clinically relevant outcomes. METHODS: Eighty-one participants with LBP underwent 2 thrust SMT treatments and 3 assessment sessions within 1 week. Transversus abdominis (TrA), internal oblique (IO), and LM muscle thickness was assessed during each session, using ultrasound imaging of the muscles at rest and during submaximal contractions. The Modified Oswestry Disability Index was used to quantify participants' improvement in LBP-related disability. Stepwise hierarchical multiple linear regression and repeated-measures analysis of variance were performed to examine the multivariate relationship between change in muscle thickness and clinical improvement over time. RESULTS: After controlling for the effects of age, sex, and body mass index, change in contracted LM muscle thickness was predictive of improved disability at 1 week (P = .02). As expected, larger increases in contracted LM muscle thickness at 1 week were associated with larger improvements in LBP-related disability. Contrary to our hypothesis, significant decreases in both contracted TrA and IO muscle thickness were observed immediately following SMT; but these changes were transient and unrelated to whether participants experienced clinical improvements. CONCLUSION: These findings provide evidence that clinical improvement following SMT is associated with increased thickening of the LM muscle during a submaximal task. LEVEL OF EVIDENCE: Prognosis, level 4.