Physical therapy musculoskeletal imaging authority: A survey of the World Confederation for Physical Therapy Nations

OBJECTIVES

Medical evidence largely supports PTs in expanded roles, however, healthcare policy within the United States (USA) typically restricts PTs from ordering musculoskeletal (MSK) imaging. It is unknown how MSK imaging policy in the USA compares to other World Confederation for Physical Therapy (WCPT) member nations. The primary objective of our study was to investigate the authority of PTs to order MSK imaging. A secondary objective was to identify factors associated with the authority for PTs to order MSK imaging.

METHODS

111 WCPT member nations were surveyed over a 2-month period on the authority of PTs ordering MSK imaging within their nation. A secondary analysis utilizing a step-wise binary regression compared member nation demographic statistics to MSK imaging authority.

RESULTS

81 member nations responded to the survey. 31 (38.3%) of member nations reported having some level of PT MSK imaging authority while 50 (61.7%) did not. Member nations with lower per capita healthcare costs were significantly more likely to allow PTs to order MSK imaging (p = 0.02). Those with direct access authority were 7.4 times more likely to authorize PTs to order MSK imaging (p < 0.01). Entry-level clinical degree and years of entry-level collegiate credit were not associated with imaging authority.

CONCLUSION

This is the first study to report MSK imaging policy within the WCPT member nations. While many nations within the WCPT allow PTs to order MSK imaging, the majority of nations still restrict PTs from such practice. Lower per capita healthcare costs and direct access authority were significant predictors of MSK imaging authority, however, causation cannot be established within the confines of this study. Future studies should consider issues such as restrictive policy origin (i.e. governmental vs. institutional), insurance reimbursement (i.e. private vs. public sector policy), and limitations on imaging modality.

Translational manipulation under anesthesia for patients with frozen shoulder: a case series study with five-year health care utilization and post-manipulative arthroscopic findings

Study Design

Case series study.

Objectives

Although there have been no reported complications from translational manipulation under anesthesia (tMUA) for individuals with adhesive capsulitis (AC) there are no cases reporting surgical findings post tMUA. Also, there are no studies evaluating health care utilization following tMUA. The purpose of this study was to: (1) report clinical outcomes following tMUA, (2) describe relevant health care costs and utilization following tMUA, and (3) summarize findings from two cases receiving joint arthroscopy following tMUA.

Methods

Fourteen Individuals with AC underwent tMUA. Range of motion (ROM) and Shoulder Pain and Disability Index (SPADI) values were collected at baseline and six weeks follow-up. Shoulder-related health care cost and utilization were analyzed for a five-year period following tMUA. Two additional patients with AC underwent tMUA followed by arthroscopic assessment for evidence of iatrogenic injury.

Results

Thirteen patients completed the six-week follow-up. Mean change scores for ROM and SPADI values were flexion; +38.5°, abduction; +71.1°, external rotation (shoulder abducted); +49.8°, internal rotation (shoulder abducted); +26.6°, SPADI scores; +44.4. 13 patient records were analyzed for health care utilization. Ten of the 13 patients utilized no additional shoulder-related health care. Surgical evaluation revealed no evidence of iatrogenic injury.

Discussion

Clinical outcomes were similar to previous studies. Utilization data indicated that for the majority of patients, little shoulder-related health care was utilized. Surgical evaluation provided further evidence that tMUA performed by a physical therapist is safe. Future research will be required to establish a causal relationship between tMUA and the results observed in this study.

Level of Evidence

Therapy, Level 4.

Association of Physical Inactivity, Weight, Smoking, and Prior Injury on Physical Performance in a Military Setting

CONTEXT

 Although inactivity, being overweight, smoking, and a history of injury are identified as risk factors for poor health and injury, few authors have examined their association on physical performance. Young adults may be more likely to adopt healthier lifestyles if they understand the effect of health behaviors on performance.

OBJECTIVE

 To determine the association of being overweight, smoking, inactivity, and a history of injury with physical performance.

DESIGN

 Cross-sectional study.

SETTING

 Military population.

PATIENTS OR OTHER PARTICIPANTS

 Active-duty service members (N = 1466; 1380 men, 86 women; age = 24.7 ± 5.0 years; body mass index = 26.7 ± 3.4 kg/m2).

MAIN OUTCOME MEASURE(S)

 Participants performed 8 measures (the triple-crossover hop for distance, the 6-m timed-hop test, the Functional Movement Screen, the Lower Quarter Y-Balance Test, the Upper Quarter Y-Balance Test, and the 3-event Army Physical Fitness Test) for evaluation of endurance, strength, muscular endurance, power, agility, balance, and motor control. Participants were categorized based on the number of health risk factors present. Using an analysis of covariance, we assessed the relationship between risk factors and physical performance with age and sex as covariates.

RESULTS

 Compared with those who had no risk factors (27.9% of men, 34.9% of women), physical performance was worse in those who had 1, 2, or 3 to 4 risk factors present by 4.3%, 6.7%, and 10.3%, respectively. Decrements in performance for those with 3 to 4 risk factors ranged from 3.3% to 14.4%.

CONCLUSIONS

 An unhealthy lifestyle habit or a history of injury was negatively associated with physical performance. Physical performance decrements were associated with the number of risk factors present. Understanding how risk factors contribute to decreased physical performance may enable clinicians to improve compliance with injury-prevention programs in occupational settings in which a young and relatively healthy workforce may be more concerned about performance than health.

A manual physical therapy approach versus subacromial corticosteroid injection for treatment of shoulder impingement syndrome: a protocol for a randomised clinical trial

INTRODUCTION

Corticosteroid injections (CSI) are a recommended and often-used first-line intervention for shoulder impingement syndrome (SIS) in primary care and orthopaedic settings. Manual physical therapy (MPT) offers a non-invasive approach with negligible risk for managing SIS. There is limited evidence to suggest significant long-term improvements in pain, strength and disability with the use of MPT, and there are conflicting reports from systematic reviews that question the long-term efficacy of CSI. Specifically, the primary objective is to compare the effect of CSI and MPT on pain and disability in subjects with SIS at 12 months.

DESIGN

This pragmatic randomised clinical trial will be a mixed-model 2×5 factorial design. The independent variables are treatment (MPT and CSI) and time with five levels from baseline to 1 year. The primary dependent variable is the Shoulder Pain and Disability Index, and the secondary outcome measures are the Global Rating of Change and the Numeric Pain Rating Scale. For each ANOVA, the hypothesis of interest will be the two-way group-by-time interaction.

METHODS AND ANALYSIS

The authors plan to recruit 104 participants meeting established impingement criteria. Following examination and enrollment, eligible participants will be randomly allocated to receive a pragmatic approach of either CSI or MPT. The MPT intervention will consist of six sessions, and the CSI intervention will consist of one to three sessions. All subjects will continue to receive usual care. Subjects will be followed for 12 months.

DISSEMINATION AND ETHICS

The protocol was approved by the Madigan Army Medical Center Institutional Review Board. The results may have an impact on clinical practice guidelines. This study was funded in part by the Orthopaedic Physical Therapy Products Grant through the American Academy of Orthopaedic Manual Physical Therapists. Trial Registration http://clinicaltrials.gov/ NCT01190891.

The immediate effects of thoracic spine and rib manipulation on subjects with primary complaints of shoulder pain

Shoulder pain is a common orthopedic condition seen by physical therapists, with many potential contributing factors and proposed treatments. Although manual physical therapy interventions for the cervicothoracic spine and ribs have been investigated for this patient population, the specific effects of these treatments have not been reported. The purpose of this investigational study is to report the immediate effects of thoracic spine and rib manipulation in patients with primary complaints of shoulder pain. Using a test-retest design, 21 subjects with shoulder pain were treated during a single treatment session with high-velocity thrust manipulation to the thoracic spine or upper ribs. Post-treatment effects demonstrated a 51% (32mm) reduction in shoulder pain, a corresponding increase in shoulder range of motion (30 degrees -38 degrees ), and a mean patient-perceived global rating of change of 4.2 (median 5). These immediate post-treatment results suggest that thoracic and rib manipulative therapy is associated with improved shoulder pain and motion in patients with shoulder pain, and further these interventions support the concept of a regional interdependence between the thoracic spine, upper ribs, and shoulder.

Responsiveness of the Neck Disability Index in patients with mechanical neck disorders

PURPOSE

Report the test-retest reliability, construct validity, minimum clinically important difference (MCID), and minimal detectable change (MDC) for the Neck Disability Index (NDI).

STUDY DESIGN/SETTING

Cohort study of patients presenting to outpatient physical therapy clinics.

PATIENT SAMPLE

Ninety-one subjects with a primary complaint of neck pain, with or without concomitant upper extremity (UE) symptoms, who were participants in a randomized clinical trial.

OUTCOME MEASURES

NDI and the 15-point Global Rating of Change (GRC) self-report measures.

METHODS

All subjects completed the NDI at baseline and at a 3-week follow-up. Additionally, subjects completed the GRC scale, which was used to dichotomize patients into improved or stable groups. Changes in the NDI were used to assess test-retest reliability, construct validity, MCID, and MDC.

RESULTS

Test-retest reliability was moderate for the NDI (intraclass correlation coefficient, 0.64; 95% confidence interval, 0.19-0.84). For the NDI, the MCID was 7.5 points and the MDC was 10.2 points.

CONCLUSIONS

The NDI appears to demonstrate adequate responsiveness based on statistical reference criteria when used in a sample that approximates the high percentage of patients with neck pain and concomitant UE referred symptoms. Because the MCID is within the bounds of measurement error, a 10-point change (the MDC) should be used as the MCID.

The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome

The study was an exploratory, one group pretest/post-test study, with the objective of investigating the short-term effects of thoracic spine thrust manipulations (TSTMs) on patients with shoulder impingement syndrome (SIS). There is evidence that manual physical therapy that includes TSTM and non-thrust manipulation and exercise is effective for the treatment of patients with SIS. However, the relative contributions of specific manual therapy interventions are not known. To date, no published studies address the short-term effects of TSTM in the treatment of SIS. Fifty-six patients (40 males, 16 females; mean age 31.2+/-8.9) with SIS underwent a standardized shoulder examination, immediately followed by TSTM techniques. Outcomes measured were the Numeric Pain and Rating Scale (NPRS) and the Shoulder Pain and Disability Index (SPADI), all collected at baseline and at a 48-h follow-up period. Additionally, the Global Rating of Change Scale (GRCS) was collected at 48-h follow-up to measure patient perceived change. At 48-h follow-up, the NPRS change scores for Neer impingement sign, Hawkins impingement sign, resisted empty can, resisted external rotation, resisted internal rotation, and active abduction were all statistically significant (p<0.01). The reduction in the SPADI score was also statistically significant (p<0.001) and the mean GRCS score=1.4+/-2.5. In conclusion, TSTM provided a statistically significant decrease in self reported pain measures and disability in patients with SIS at 48-h follow-up.

Development of a clinical prediction rule to identify patients with knee pain and clinical evidence of knee osteoarthritis who demonstrate a favorable short-term response to hip mobilization

BACKGROUND AND PURPOSE

The primary purpose of this study was to develop a clinical prediction rule (CPR) for identifying patients with knee pain and clinical evidence of knee osteoarthritis (OA) with favorable short-term response to hip mobilizations. The secondary purpose was to determine the predictive validity of individual clinical tests for identifying these same patients.

SUBJECTS AND METHODS

Sixty subjects with knee OA, aged 51 to 79 years, completed self-report questionnaires, a clinical examination of the hip and knee, and functional tests and were treated with 4 hip mobilizations. Follow-up testing was completed 2 days later. The reference criterion for determining a favorable response was either (1) a decrease of at least 30% on composite Numerical Pain Rating Scale score obtained during functional tests or (2) a Global Rating of Change Scale score of at least 3.

RESULTS

The CPR developed in this study comprised 5 variables: (1) hip or groin pain or paresthesia, (2) anterior thigh pain, (3) passive knee flexion less than 122 degrees, (4) passive hip medial (internal) rotation less than 17 degrees, and (5) pain with hip distraction. Based on the pretest probability of success (68%), the presence of one variable had a positive likelihood ratio of 5.1 and increased the probability of a successful response to 92% at 48-hour follow-up. If 2 variables were present, the positive likelihood ratio was 12.9 and the probability of success increased to 97%.

DISCUSSION AND CONCLUSION

The results suggest that the CPR developed in this study could improve clinicians' decision making and efficiency in examining and treating patients with knee OA.

The use of ultrasound imaging of the abdominal drawing-in maneuver in subjects with low back pain

STUDY DESIGN

Randomized controlled trial among patients with low back pain (LBP).

OBJECTIVES

(1) Determine the reliability of real-time ultrasound imaging for assessing activation of the lateral abdominal muscles; (2) characterize the extent to which the abdominal drawing-in maneuver (ADIM) results in preferential activation of the transverse abdominis (TrA); and (3) determine if ultrasound biofeedback improves short-term performance of the ADIM in patients with LBP.

BACKGROUND

Ultrasound imaging is reportedly useful for measuring and training patients to preferentially activate the TrA muscle. However, research to support these claims is limited.

METHODS AND MEASURES

Thirty patients with LBP referred for lumbar stabilization training were randomized to receive either traditional training (n = 15) or traditional training with biofeedback (n = 15). Ultrasound imaging was used to measure changes in thickness of the lateral abdominal muscles. Differences in preferential changes in muscle thickness of the TrA between groups and across time were assessed using analysis of variance.

RESULTS

Intrarater reliability measuring lateral abdominal muscle thickness exceeded 0.93. On average, patients in both groups demonstrated a 2-fold increase in the thickness of the TrA during the ADIM. Performance of the ADIM did not differ between the groups.

CONCLUSION

These data provide construct validity for the notion that the ADIM results in preferential activation of the TrA in patients with LBP. Although, the addition of biofeedback did not enhance the ability to perform the ADIM at a short-term follow-up, our data suggest a possible ceiling effect or an insufficient training stimulus. Further research is necessary to determine if there is a subgroup of patients with LBP who may benefit from biofeedback.