Orthopaedic Section Research Presentations APTA Combined Sections Meeting

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Orthopaedic Section Research Presentations- 1996 APTA Combined Sections Meeting Copyright 1996. All rights reserved. Biomechanical Compensations for Leg Length Discrepancy in a Ballet Dancer Werner C; Westside Dance Physical Therapy, P.C., New York, NY The purpose of this presentation is to demonstrate, through a case study, the idiosyncrasies of a dancer's compensation to a leg length discrepancy and how treating those specific idiosyncrasies leads to improved compensation mechanics in dancers with leg length discrepancy. Professional classical and modern dancing precludes the use of a sole or heel lift, as such devices do not work in the soft canvas or leather footwear that is used. Instead, correcting and improving the compensations that an individual professional ballet dancer uses to move with a leg length discrepancy will be shown to produce restoration of function. The patient is a 27-year-old male professional dancer with a diagnosis of low back pain, (R) flexor hallucis longus tendinitis, and hallux triggering. Physical therapist's evaluation of the patient revealed the following problems: (apparent) structural leg length discrepancy, scoliosis, spinal segment movement dysfunctions, innominate movement dysfunctions, footrankle joint restrictions, muscle strength, flexibility and firing pattern imbalances, peripheral nerve/dural sleeve mobility restrictions, and faulty dance technique movement patterns. After treatment of these dysfunctions, the patient can dance without pain and demonstrates appropriate biomechanical compensations to a leg length discrepancy. Evaluation and treatment of en- tire kinetic chain compensations can restore function in dancers with leg length discrepancies who cannot use shoe insertslmodifications in their respective dance companies. The Role of Physical Therapists in Treating Injured Artists at the Juilliard School Zappile M, Gallagher S, Reiger C, Weiss D; The luilliard School, supervised by Performing Arts Physical Therapy, Philadelphia, PA The Juilliard School is one of the most prestigious arts schools in the country. Students at the college frequently utilize physical therapy services, which are rendered by Performing Arts Physical Therapy under the direction of Dr. David Weiss. The purpose of this research was to examine the types of injuries and the role of physical therapists in treating injured performing artists at The Juilliard School. The sample was composed of students from the music, dance, drama, and intern divisions of the college. Students reported 346 injuries between September of 1992 and May of 1995. Charts were reviewed and pertinent information was collected. Data were analyzed regarding the number of injuries represented from each division, the frequency of each injury, the types of treatments administered, and the number of physical therapy visits. Figures and tables were developed to represent this information. The results indicated that: 1) students from all divisions at The luilliard School utilized physical therapy services, 2) the most common injuries involved low back pain and cervical spine pain, 3) manual therapies were the most utilized treatments, and 4) 83% of students saw a therapist four times or less and did not require a physician's visit or further physical therapy treatment. These results are relevant for several reasons. First, the results support the need for therapists who specialize in the treatment of injured artists, utilizing rehabilitation and preventive training to ensure the health of performers. Second, findings indicate the importance of physical therapy intervention at the collegiate level. Finally, the results demonstrate evidence for the professionalization of physical therapists as independent caregivers, thus supporting Direct Access in the state of New York. Music Teachers' Beliefs and Opinions on Effective Treatment of Music-Related Injuries Quarrier NF; Department of Physical Therapy, lthaca College, Ithaca, NY Music teachers have contact with students with music-related injuries. A questionnaire examining the beliefs and opinions about effective treatments of musicrelated injuries was sent to 117 collegelevel music teachers. The effectiveness of 15 treatments was rated as to a high, moderate, and low degree of effectiveness. Some of the treatments examined were early ice and heat application, massage, rest, anti-inflammatories, total body fitness, and prophylactic bracing. Data were received and tabulated from 63 (54%) respondents. Results of the 15 treatment interventions were mixed with 30% of the respondents answering "no responset'/ "don't know," 17% low degree, 27% moderate degree, and 26% high degree. The top three treatments rating high or moderate were reducing practice time (83%), partial rest (7g0/0), and total body fitness (76%). The bottom three treatments receiving low ratings were vitamin supplements (47%), Ben Gay creams (48%), and hand/elbow braces (33%). The top three treatments receiving unknown effectiveness were biofeedback (48%), early heat application (46%), and early ice application (44%). Only 22% of the respondents offered other write-in treatments. This preliminary study suggests that music teachers are in need of continuing education on the treatment of music-related injuries. JOSPT Volume 23 Number 1 January 1996

Copyright 1996. All rights reserved. Profile of Dance Injuries in a Broadway Show: A Discussion of Issues in Dance Medicine Epidemiology Bronner S, Brownstein B; Sports Orthopedic and Athletic Rehabilitation, New York, NY As interest and research in dance medicine increases, standardization of reporting methods and definitions becomes critical in discussions of epidemiology and etiology. A description of dance injuries in a Broadway show using ballet techniques is reported for the first time. Borrowing from sports medicine classifications of injuries, "time lost from play," we suggest injury be defined as "time lost from performing." A major injury is defined as complete absence from performance and a minor injury as dancing a partial show. The incidence of dance injuries in 30 dancers during a 7-week run is profiled. Although the common assumption has been that dancing the same repertoire would lead to increased incidence of injury, absences due to injury per performance were low compared with those of ballet companies. Only 4.9% of the dancers were absent from any one performance. The overall injury rate was 40%, with 30% major and 10% minor injuries. Injury patterns were similar to those of ballet companies: the majority involved the ankle and foot. Put within the context of our definition, ankle-foot injuries accounted for 78% of the missed performances and 78% of the partial performances. There was an average of 1.0 injuries for each of the 12 injured dancers compared with 2.97 and 1.7 in other ballet companies. Further comparisons are made to epidemiologic reports of national level ballet companies. Long term injury profiles and comparisons of differing styles of "show dancing" are needed in subsequent reports. Variables that cannot be controlled are differing repertory and changing dancers. The inclusion of definition of injury, who determines injury, time frame of report, work load per dancer, size and level of company, and style of dance are suggested in future profiles of dance injuries. This study may contribute to injury prevention in future "show dancing" and allow enhanced comparison and discussion of injury epidemiology throughout the field of dance medicine. Correlation Between Upper Extremity Injuries and Adverse Neural Tension Signs in Elite Musicians Anderson BD, Weaver L; Salzburg, Austria, Sacramento, CA The null hypothesis of this study is to establish that there is no significant correlation between musicians with upper extremity dysfunction and positive neural tension signs. Positive neural tension signs are defined in this study by a positive reproduction of symptoms by stressing proximal neural structures using the brachial plexus tension tests. Thirtv musicians from the Mozarteum in ~aizbur~, Austria were screened in October of 1994. The musicians were divided into five groups: 1) those who presented with a upper extremity injury and positive neural tension with reproduction of symptoms; 2) those who presented with upper extremity injury and positive neural tension without reproduction of symptoms; 3) those who presented with upper extremity injury and negative brachial plexus tension test; 4) those who presented without upper extremity injury and a positive brachial plexus tension test; and 5) those who presented without upper extremity injury and negative brachial plexus tension test. Data were gathered from a screening that was designed for multiple studies. Methodology of testing the Brachial Plexus Tension Test (BPlT) was a median nerve biased test in standing using a fixed string, wall, and measuring tape for reproducibility. The software correlated the subjective complaints with the objective data acquired from the BPlT test. The results, though only a pilot study, were as follows: Groups (1) incidence of 29%, (2) incidence of 08%, (3) incidence of 17%, (4) incidence of 25% and (5) incidence of 21 %. Though it appears that a strong correlation exists where over 50% of those reporting upper extremity injuries were reproducible with the BPlT, it was also found that over 50% of those who did not report upper extremity injuries manifested positive BPTT signs. Though no direct correlation can be drawn between group 1 and group 4, follow-up studies will be looking at musicians over a 4-year period at the conservatorium. Application of these findings will determine the course of treatment for musicians who suffer from overuse injuries with an emphasis on prevention and self management through a series of self-mobilization techniques incorporated early in music training. Hip Pain Associated With Superior Gluteal Nerve Impingement Turner RR; Westside Dance Physical Therapy, New York, NY The purpose of this presentation is to investigate the correlation in professional dancers between impingement of the superior gluteal nerve and two variables: 1) a lack of hip internal rotation and 2) anterior innominate rotation on the affected side. By presenting a literature review of the neuromuscular influences on the hip and pelvis, combined with preliminary clinical research, evidence will be presented to demonstrate the effects of impingement of the superior gluteal nerve as it passes between the greater sciatic notch and piriformis, then courses cephalad to innervate the gluteus medius, minimus, tensor fascia lata, and the posterior and superior portions of the hip capsule. An impingement in this area can be easily reduced and the adverse biomechanical effects substantially reversed with simple treatment, assuming that degenerative changes of the hip joint have not occurred. The presentation will include a quick screening exam to identify possible impingement candidates and discuss treatment methods and outcomes. This information is relevant to the Orthopaedic Section in that it provides an effective and efficient assessment and treatment model. Further research is needed to determine if detection of an impingement of the superior gluteal nerve can be implicated in later degenerative osteoarthritis of the hip, both in older dancers and the general population.... -.-.. -....-.-,, Volume 23 Number 1 January I996 JOSPT

Copyright 1996. All rights reserved. An Accelerometer-Based System for Assessing Functional Dynamic Postural Stability in the Elderly Schieb DA, Chen FC, Protas 1, Hasson SM; School of Physical Therapy, Texas Woman's University, Houston, TX. Partial support provided by a NIH postdoctoral training grant. Injuries from falling are the main cause of trauma morbidity that leads to mortality among the elderly. About one in three older persons will fall each year in the U.S. Several clinical and biomechanical methods are used to establish fall risk parameters; however, limitations exist. The purpose of this study was to develop and validate a portable tri-axial accelerometer system for quantifying dynamic postural stability in elderly populations. Elderly nursing home residents and community ambulators served as subjects. Three miniature lightweight accelerometers were mounted to a recessed cube in an orthogonal orientation. Two inclinometers, positioned in the pitch and roll axes and housed within the tri-axial accelerometer cube, were used to correct accelerations to a point of reference. The tri-axial unit was secured to the spinous process of C7 or positioned against the L4A5 area. Leads from the tri-axial unit were connected to miniature signal conditioners housed in a waist-pack worn by the subject. Power to the accelerometers and inclinometers was supplied from a d-c source. Data could be sampled and stored through either a portable 16-channel, 12-bit data logger or directly into a computer. For each subject, accelerometer data were collected during consecutive gait cycles and also during clinical tests, including functional reach, Tinetti balance and gait, get-up-and-go, sit-tostand, and during a force plate assessment of postural balance. Collected data were read from the data logger into a personal computer as text files via a RS-232 serial interface. Accelerometer data were reduced to provide the following parameters: harmonic ratios in the medio-lateral and anterior-posterior planes, loading, and temporal information. Angle deviations (5) in the pitch and roll directions were used to correct acceleration data through an algorithm as the subject ambulated and/or moved about during functional activities. Descriptive data were used to assess dynamic balance and compare the accelerometer pa- rameters with the clinical functional scores and the force plate balance results. Preliminary data indicated that the medio-lateral and anterior-posterior harmonic ratios are sensitive indicators of dynamic stability in elders. The periodic accelerometer data were found to be highly repeatable from stride to stride. Comparisons among the biomechanical and clinical measures of balance suggest similarities with respect to degree of instability among elder subjects. The portable tri-axial accelerometer system appears to represent a valid, reliable, relatively low-cost, and noncumbersome approach for assessing functional dynamic stability in elderly subjects. Platform presentation, 1996 A PTA Combined The Effects of a Preoperative Educational and Exercise Program on Postoperative Mobility in Total Hip Art hroplasty Patients Gatti LA, Bourbon B, Scott CM; Philadelphia College of Pharmacy and Science, Pennsylvania Hospital, Haddonfield, N) Purpose: To determine if a preoperative exercise and/or educational program would improve early postoperative mobility in patients receiving total hip arthroplasty. Subjects: Forty-five female subjects age 55 or over with diagnosis of degenerative joint disease undergoing unilateral uncemented total hip arthroplasty. Method: A doubleblind posttest-only study with control group design. Two groups of 15 subjects each were established by random assignment and recruited approximately 1 month preoperatively. The Education group was given an overview of the total hip arthroplasty physical therapy protocol at our facility and instructed in the use of a walker and crutches for partial weight-bearing ambulation. The Education and Exercise group received the same information and additionally was instructed in five exercises to be performed daily as a home program. Fifteen patients who received no preoperative intervention were randomly selected postoperatively and comprised a third Baseline group. All three groups were assessed on the third postoperative day for bed mobility, transfers, and ambulation using the functional independence measure. Analysis: A two-way analysis of variance with one repeated factor was performed. Tukey's HSD statistic was used for post hoc analysis. Summary Data: Transfers showed significant improvement among patients who received both education and exercise (p =.05L Ambulation and bed mobility data showed high error variance and were not significant. Conclusion: Preoperative exercise and education improved selected postoperative mobility in total hip arthroplasty patients. Relevance: Patients undergoing elective surgery would benefit from preoperative education and exercise to improve early functional mobility. Classes, videos, or outpatient sessions may be considered for this purpose. Effect of Vertical Ground Reaction Forces on Peak Plantar Pressures in Diabetic Individuals With Limited Joint Mobility and Peripheral Neuropathy Gamboa IM, Sims DS Ir, Brownell SD, Lazo AF, Shah NP, Williams )C; Shenandoah University- Winchester Medical Center Program in Physical Therapy, Winchester, VA Although increased plantar pressure is a significant risk factor for developing neuropathic ulcers, pressure data alone are often not sufficient to accurately predict the likelihood or location of ulceration. Inaccurate predictions may be related to an incomplete understanding of the relative contribution of force vs. contact area in the development of high plantar pressures. The purposes of this study were to determine: I) if vertical ground reaction forces (GRF) during barefoot walking were different between diabetic subjects with limited joint mobility (LJM) and neuropathy and nondiabetic controls; and 2) if a relationship existed between altered GRF and forefoot peak plantar pressures (P,). Fifty-five volunteers from 30 to 80 years of age were assigned to one of three age-matched groups: DMS- (diabetic subjects with LJM and decreased sensation); DMS+ (diabetic subjects with LJM and normal sensation); or NDC (nondiabetic controls). Following a comprehensive lower quarter examination, we collected simultaneous GRF and,, P, JOSPT Volume 23 Number 1 January 1996

Copyright 1996. All rights reserved. data during walking at a prescribed velocity. We analyzed between-group mean differences for vertical GRF parameters,,,, P, and ankle isokinetic strength using singlefactor analysis of variance models followed by Bonferroni's t tests. The relationship between vertical GRF parameters and forefoot,, P, was examined using a modified discriminant analysis. We found the DMSand DMS+ groups had significantly steeper average slopes to and from the first vertical GRF peak (30% and 33%, respectively) and a significantly steeper average slope from the second vertical GRF peak (23%) as compared with the NDC group. We also found the DMS- group had significantly higher,, P, (41%)than the NDC group, and the diabetic groups had significantly less (-21%) plantar flexor strength. An earlier time of occurrence and a decreased magnitude of the first vertical GRF peak were associated significantly with diabetic individuals with a high,, P, (r 1000 KPa). We concluded that limited joint mobility and decreased ankle strength alter the rate of vertical GRF loading in diabetic subjects as compared with nondiabetic controls. To a lesser extent, the sequence of loading may also be altered. The clinical importance of this study is that temporal changes may lead to increased,, P, by altering the functional distribution of forces across the plantar surface regardless of available structural contact area. The Rationale and Reliability of Three Functional performance Tests in the Assessment of Lower Extremity Function Greenberger HB, Sperling L, Frankford G; Department of Physical Therapy, lthaca College, Ithaca, NY The purpose of this study was two-fold: 1) to develop the testing protocol for three functional tests: hip adduction excursion test (HAE), anterior lunge test (AL), and balance leg reach test (BLR), and 2) to determine the rationale and reliability for these tests when used to assess lower extremity function. Thirty-three subjects (12 males and 21 females; % = 19.6 years) with no history in the past year of lower extremity injury participated in this study. Subjects committed to 2 days of testing separated by a maximum of 24 hours. Both testing days consisted of a 5-minute warm-up on a stationary bicycle, followed by four lower extremity stretches. Subjects then performed the three functional tests. All tests started in a unilateral position. For the HAE and AL tests, the test side was considered to be the moving foot. For the BLR test, the test side was considered to be the stationary foot. The HAE test determined the maximum distance subjects could actively move at the hip in the frontal plane. The subjects performed this test until it was determined that maximum excursion had been reached. The AL test was designed to determine the maximum distance excursed through the sagittal plane at the hip, knee, and ankle. The BLR test examined the maximum distance excursed in the frontal plane of the nontest leg while balancing on the test leg. For the latter two tests, subjects were given four practice trials, followed by three measured efforts. The means of the three efforts were used for data collection. All measurements were recorded with a standard measuring tape. On both testing days, the leg tested first and the test order were randomized for each subject. Paired t tests revealed no significant difference between the dominant and nondominant legs for all tests except the HAE test. lntraclass correlation coefficients for the three tests ranged in values from.73 to.91, with the AL test being the most reliable and the HAE test being the least reliable. The authors concluded that these tests would be helpful to the clinician in evaluating the components of function in multiple planes of motion for the lower extremity during the rehabilitation process. The Effect of Postsurgical Edema of the Knee Joint on Reflex Inhibition of the Quadriceps Femoris-A Case Study McDonough AL, Weir lp; Applied Physiology Laboratorv,.. De~artment. of Movement Sciences and Education, Teachers College, Columbia University, New York, NY The purpose of this case study was to investigate reflex inhibition of the quadriceps femoris in a subject with postsurgical edema of the left knee. It was hypothesized that an inverse relationship between knee joint swelling and electrical activity of the quadriceps would be demonstrated. The subject was a 45-year-old male with a traumatic knee injury with resultant edema who underwent elective arthroscopic surgery. Reflex inhibition was assessed by H-reflex elicitation in the femoral nerve and surface electromyography (EMG) in three heads of the quadriceps femoris: vastus medialis, vastus lateralis, and rectus femoris. To assess the degree of edema, direct circumferential measurements were taken. Descriptive statistics were used for the analysis. On the first presurgical visit, the left knee demonstrated mild edema with a decrease in mean EMG amplitudes for H-reflexes compared with the right knee in all three muscles studied. Two days after arthroscopic surgery, a 10% reduction in mean H-reflex amplitudes collapsed across all muscles (-65.7 pv) and more swelling (40.0 cm) was demonstrated in the left knee compared with preoperative values (-61.8 pv; 38.5 cm). On the 28th postoperative day, mean EMG amplitudes for H-reflexes across all muscles increased 3O0/0 compared with the second postoperative day. Vastus medialis and rectus femoris absolute mean amplitudes increased to -33.8 pv and -73.6 pv, respectively, while the mean amplitude for vastus lateralis decreased to -31.2 pv. An increase in total mean H-reflex amplitudes for the three muscles on the 28th postoperative day was accompanied by a decrease in circumference of the left knee to 39.5 cm. These findings document a relationship between reflex inhibition and joint swelling which was previously described in experimental models where joint edema was simulated. Clinically, the early and aggressive treatment of knee joint edema appears to be warranted to prevent neurogenic atrophy of the quadriceps. In light of the present findings and previous investigations, it seems reasonable to expect that full force production capabilities of all parts of the quadriceps will not be realized until edema can be controlled. Volume 23 Number 1 Januay 1996 JOSPT

Copyright 1996. All rights reserved. Comparison of Electromyographic Activity of the Quadriceps During Two Knee Extension Movement Patterns Pedersen AM, Hasson SM; School of Physical Therapy, Texas Woman's University, Houston, TX Purpose: The purpose of this study was to compare the elearomyographic activity (EMG) of the quadriceps during an isotonic straight plane (SP) and an isotonic diagonal knee extension movement pattern (DP). Subjects: Eighteen normal healthy subjects without knee pain or pathology, aged 20-40 years old, participated in this study. Methods: The right leg was prepared for EMG surface electrodes, which were placed over the vastus medialis oblique (VMO), vastus lateralis (VL), and the rectus femoris (RF) muscles. Testing of one isotonic movement, either SP or DP (random order), consisting of five maximal repetitions was then initiated. The subject rested for 5 minutes and then the second pattern was tested. Raw EMG data were processed for frequency content [mean power frequency (MPF)] and signal amplitude [root mean square (RMS)] via 512-point fast Fourier transformation. Data Analysis: The independent variable was a type of movement pattern [straight leg (SP) or diagonal (DP)I. The dependent variables were RMS and MPF. In addition, a third variable was created, which was a relative contribution of each muscle to the total EMG-RMS. The data were analyzed using paired t tests with a level of significance of p < 0.05. Results: All three muscles had significantly greater RMS values during SP (p < 0.05). Straight plane motion increased the activity of the VMO by 50.1%, VL by 48.5% and RF by 26.2% vs. DP. In addition, the relative contribution of the VMO was not different when comparing the two motions [34.2% (SP) vs. 33.3% (DP)]. Finally, MPF was significantly higher for the VMO and RF during the SP vs. DP. Conclusions: In normal subjects, it does not appear that a movement pattern focusing on increased adduction of the lower limb specifically initiates VMO activity. Furthermore, the SP produced greater activation of all three muscles, since a greater force could be produced with this type of motion. In addition, the data would indicate that more type II motor units are fired during a straight leg pattern. Perhaps motor units, particularly type II are inhibited during a diagonal pattern, since significant medial-lateral force is produced across the knee joint. Clinical Implications: The implication of this study is that for normal subjects an efficient method for increasing EMG activity for the quadriceps femoris muscles is an isotonic straight plane knee extension motion, and that a diagonal pattern does not specifically target the VMO. Reliability and Validity of a Shoulder Outcome Scoring System leggin BG, Neurnan RM, Shaffer MA, lannotti)p, Williams GR )r, Brenneman SK; Hospital of the University of Pennsylvania, Philadelphia, PA The shoulder scoring system we present is a new, practical way of assessing the current state of shoulder function. Injured shoulders can be measured as a comparison with the uninjured contralateral side or individually in the case of bilateral shoulder involvement. The scoring system is based on a 100-point scale. Points are awarded for the patient's self report of pain, satisfaction, and function as well as objective measures of active range of motion and strength. The purpose of this study was to determine the test-retest, intrarater, and interrater reliability of this scoring system. In addition, we determined the correlation of this shoulder scoring system to the existing Constant Shoulder Score. Forty patients with various shoulder pathologies gave their informed consent to participate in this study. Each patient was tested by two of the three investigating therapists on separate occasions. All testing occurred within a 1-week period. One therapist tested every patient with the new shoulder scoring system and the Constant Shoulder Score. Testretest ICC (2,l) values for the patient's selfreport sections are as follows: pain =.87; satisfaction =.93; and function =.88. Intrarater reliability ICC (3,l) values for range of motion, strength, and total scores are as follows: range of motion =.98; strength =.95; and total =.97. Range of interrater reliability ICC (2,1) values for range of motion, strength, and total scores are as follows: range of motion =.97; strength =.84-.91; and total =.94-.98. Pearson cor-.relation coefficient between the total scores of the new scoring system and the constant score is.87. The results of this study indicate that the shoulder scoring system presented is reliable with good correlation to an existing shoulder score. This shoulder scoring system is a comprehensive way to document status and outcome of patients with shoulder problems. Future studies should be performed to demonstrate responsiveness to change of this shoulder scoring system with a large sample of cases involving various shoulder pathologies. Joint Mobilization: Stretch Specificity Using a Distraction Zito M; School of Allied Health Professions, - University of Connecticut, Storrs, CT A distraction of a joint, a passive movement applied perpendicular to the joint's treatment plan, is a joint play commonly used to restore joint mobility. Although not generally believed to be tissue specific, a distraction mobilization can be modified to localize joint structure and improve stretching effectiveness. Prior to stretching using a distraction, a four-step treatment set-up is recommended. This set-up involves: 1) distraction; loosen grade; 2) glide (the direction depends upon the limited physiological movement and the shape of the moving joint surface); tighten grade; 3) physiological motion (the limited motion); tighten grade; and 4) distraction; stretch grade. Each step serves a purpose and has a rationale to support it. Concluding with a distraction minimizes compressive forces. The technique is a modification of the Kaltenborn approach to manual mobilization of extremity joints. In addition to the known merits of this approach, the modifications to localize the effectiveness of a distraction have been subject to the review of students, clinicians, and manual therapists over a 15- year period. Controlled studies would need to be done to establish the effectiveness of the modification as compared with the traditional approach. The importance of this technique is that the benefits of minimizing joint compression when needed can be combined with strategies to enhance stretching effectiveness through joint structure specificity. JOSPT Volume 23 Number 1 January 1996

Copyright 1996. All rights reserved. Improvements in Pain, Disability, and Grip Strength Following A Series of Craniosacral Treatments: A Case Study Cook M; The Chambersburg Hospital, Chambersburg, PA The purpose of this case study was to measure objective, functional improvements in a patient following a series of craniosacral treatments. The subject was a 40- year-old female with a 4-year, 2-month history of pain, weakness, and numbness in her neck and upper extremities following a car accident. She was working throughout data collection and was not taking medication prior to or during data collection. Pain was assessed using the McGill short form pain questionnaire, disability was assessed using the Pain Disability Index, and grip strength was measured using a hand-held dynamometer. The patient received six 1 -hour craniosacral treatments outlined in Upledger's Ten-Step Protocol and a home program. Pain and disability scores were taken prior to the first, third, and sixth treatments, and then 5 weeks following discharge. Grip strength was measured prior to and following all six treatment sessions. Raw scores from the McGill short form and Pain Disability Index were compared using the percent change between sessions. Mean grip strength was analyzed using a splitmiddle technique and binomial test with data from the initial evaluation used to create a baseline. Pain scores decreased by 52% from pretreatment to discharge and remained 45% below baseline 5 weeks following discharge. Disability scores decreased by 93% from pretreatment to discharge and remained 86% decreased 5 weeks following discharge. Pain decreased by 45% from session one to session three and by 12O/0 from session three to session six. Disability decreased by 88% from session one to three and by 40% from session three to six. The binomial test revealed a statistically significant increase in grip strength (p = 0.016) which continued throughout the course of treatment. This subject significantly improved her pain level, disability, and grip strength following a series of craniosacral treatments. The subject's pain and disability scores had not changed greatly 5 weeks following discharge, indicating a lasting effect of treat- ment. These results indicate a preliminary, measurable, functional treatment effect of craniosacral therapy. Further research is necessary to better describe, document, and quantify the effects of this treatment approach. Platfrom presentation, 1996 APTA Combined Fibromyalgia (FMS): A Six-Step Physical Therapy Treatment Program Danish D; CORE Physical Therapy, Bethlehem, PA Fibromyalgia (FMS) is characterized by widespread diffuse musculoskeletal tenderness and pain in all four quadrants and the axial skeleton. Research has demonstrated that an aerobic fitness program can minimize the pain associated with FMS; however, there are no specific programs outlining physical therapy treatment for FMS. This paper presents a 6-step (visit) program that emphasizes self-treatment. Additional sessions can be established based on a comprehensive evaluation that documents myofascial pain in addition to FMS. The following is the 6-step treatment program: I) evaluationlpatient educationbreathing techniques; 2) flexibility upper extremity1 lower extremitylspine; 3) postural instruction-sittin@standing/sleeping-work set-up; 4) discuss aerobic program-incremental approach; 5) postural stabilization exercises1 light resistance training; and 6) review previous concepts-introduce manual therapy techniques if indicated. By using a structured approach emphasizing self-management techniques during the first six sessions, the importance of patients taking control of their own rehabilitation is established. At that point, manual therapy may be integrated to manage specific trigger points, myofascial restrictions, or movement dysfunction since these factors frequently overlap with FMS. This six-step program can easily be adapted to both a private practice or hospital setting. The concise format also works well within the limits of the managed care environment. Outcomes Management-A Comprehensive Approach Greco MA; Caremark Orthopedic Services, Inc., Schaumburg, IL Purpose: Because health care costs have continued to escalate, physical therapists are being asked by payers and employers to justify what they do. An outcomes management approach was developed to measure the effectiveness of physical therapy and to provide information to payors and employers. Description: The outcomes management approach developed consists of four components: clinical effectiveness, utilization, cost, and patient satisfaction. Data were collected at 120 centers. Data consist of patient responses to a functionoriented survey, utilization data, patient satisfaction data, and clinician assessment of a patient's progress. Data collected about knee patients will be shared. Summary of Experience: Therapists often regard outcomes as a time-consuming process. Clinicians have not totally integrated outcomes management into their clinical practice. The data collected have helped physical therapists better understand their clinical practice. Data have been used to demonstrate clinical effectiveness to payers and physicians. Conclusions: Outcomes management is a requirement in today's health care environment. The outcomes management process developed satisfies the need to demonstrate the value of physical therapy to payers and physicians. The Incidence of Nontraumatic Musculoskeletal Injury in White Water River Guides Martin T, Cornwall MW; Department of Physical Therapy, Northern Arizona Universify, Flagstafl, A2 Serving as a white water river boat guide requires a great deal of physical strength and endurance. Because of the repetitive nature of the job, the propensity for overuse-type injuries is high. Therefore, the purpose of this study was to document the incidence and pattern of work-related, nontraumatic, musculoskeletal injuries among river guides who work on the Colorado Volume 23 Number 1 Janualy 1996 JOSPT

Copyright 1996. All rights reserved. River in the Grand Canyon in Arizona. Additionally, this study identifies which types of activities are associated with the greatest musculoskeletal system complaints. To answer these questions, a survey was mailed to guide members of the Grand Canyon River Guides organization. Of the 844 surveys mailed, 225 (26.7%) were returned. To eliminate individuals who do not regularly guide in the Grand Canyon, only those respondents that worked the 1994 season (N = 164) were selected for further analysis. It was found that 73.7% of the surveys analyzed reported symptoms consistent with musculoskeletal overuse injuries. These nontraumatic symptoms consisted primarily of pain and/or numbness that developed while guiding in the Grand Canyon. In addition, there was no pre-existing complaint of pain and/or numbness. An analysis of these 121 surveys revealed that 55.9% of the respondents had complaint of pain in their low back, 18.6% had complaint of pain in their upper back, 20.3% had complaint of pain in their shoulders, and 10.3% had complaint of pain in their hands. Further analysis indicated that the activities which caused the greatest frequency of symptoms were: 1) rowing, 2) the daily loading and unloading of the boats, and 3) rigging the boats at the start of the trip and derigging the boats at the end of the trip. Cross tabulation of the location of the pain complaints and the three most often cited types of activities performed indicated that all three activities are associated with low back pain. It was also found that hand pain was more frequently associated with rowing while upper back pain was related to the daily loading and unloading of the boats. Shoulder pain was more frequently associated with rigging and derigging of the boats. Ninety percent of the respondents who stated that rowing caused them numbness reported that it occurred in their hands. Within the limitations of this study, it is clear that Grand Canyon river guides have a high incidence of musculoskeletal overuse- type symptoms which are related to the type of tasks they are required to perform daily. Although further research needs to be performed, the results of this study should make health care professionals, guides, and their employers aware of the physical demands of river guiding and assist them in developing appropriate programs to prevent these injuries. Radiographic Assessment and Reliability Study of the Craniovertebral Sidebending Test Olson KA, Paris SV, Spohr C, Gorniak G; institute of Physical Therapy, St. Augustine, FL In orthopaedic manual physical therapy, passive intervertebral joint testing of the upper cervical spine is widely used for clinical assessment. However, the test position has not been standardized and the tester reliability has not been well established. The purpose of this study is to find which position of cervical forward bending gives the best tester reliability and provides the greatest range of motion when passively testing craniovertebral sidebending for mobility and end feel. Ten subjects participated in both the radiographic and clinical assessment portion of this study with a mean age of 32.5 + 6.9 years. Open-mouth position radiographs were used to measure passive craniovertebral sidebending at the "erect" neutral and the "physiological" neutral positions. lntertester and intratester reliability was determined on the same group of subjects using six physical therapists to assess end feel and mobility grades for passive craniovertebral sidebending in five positions. The mean total sidebending motion for COC2 was 8.6' for the "physiological" neutral position and 7.2" for the "erect" neutral position. In the clinical assessment portion of the study, Kappa scores ranged from -.027 to.i82 for intertester reliability and from -.022 to.i37 for intratester reliability for mobility grade assessment with minimal difference noted between the five test positions. For end feel assessment, the Kappa scores ranged from -.043 to.i19 for intertester reliability and from.o1 to.308 for intratester reliability with the "physiological" neutral position demonstrating the highest intratester reliability. The results of this study offer support for the use of the "physiological" neutral position as the standard position of the cervical spine for testing passive craniovertebral sidebending motion. All the test positions showed poor intertester reliability. Follow-up studies are needed which allow the testers to work in a more clinical environment where correlations can be made between evaluation findings. Better understanding of what happens to soft tissues under repeated testing and improved training techniques are also needed. Outcome Following Anterior Cervical Discectom y Without Fusion lohnson ]G, McClure P, Post EM; Medical College of Pennsylvania, Hahnemann University, Philadelphia, PA The purpose of this study was to describe short term postoperative outcome in patients undergoing anterior cervical discectomy (ACD) without fusion for herniated disc and/or spondylosis. Specific questions include the effect on active cervical range of motion, active and passive shoulder abduction range of motion, pain intensity and distribution, and perceived disability. Twenty-seven patients who underwent simple discectomy were observed between February 1994 and July 1995. Multiple measurements were obtained within 4 weeks before surgery, at approximately 6 weeks, and again at approximately 1 2 weeks following surgery. Measurements included active cervical range of motion in three planes using the cervica! range of motion device, goniometric measurement of active and passive shoulder abduction in the coronal plane, and isometric force output of the shoulder external rotators. Quantitative subjective data were obtained using a visual analogue scale, pain diagram, and perceived neck disability using a variation of the Oswestry disability index modified for upper quarter functional tasks. Mean age of the subjects was 45 years, ranging from 30 to 67. Nineteen patients underwent ACD at one level; eight were operated on at two levels. Data were analyzed using a repeated measures analysis of variance to analyze change in all variables pre- to post-operatively. A Pearson correlation coefficient was performed to assess correlation between change in range of motion, pain intensity, and perceived disability. Significant differences were noted in most planes of cervical range of motion pre- vs. post-operatively. Subjects with a significant lack of active and passive shoulder abduction preoperatively showed a significant increase in motion postoperatively. Correlations between visual analogue scale and neck disability index changes pre- to post-operatively were JOSPT Volume 23 Number 1 January 1996

- - - -- - -. - - - -- Copyright 1996. All rights reserved. also significant to p <.05. Overall, shortterm follow-up revealed positive changes in a majority of subjects. A 1- to 2-year follow-up is planned to observe long term effects. This information should be helpful in providing the physical therapist with postoperative expectations regarding range of motion changes, pain, and disability in patients undergoing ACD. Correlation of Postural Deviations and Temporomandibular Joint Dysfunction McCandless S; McCandless Physical Therapy, lackson, MS. Grant # 1 R43DE09768-0 1 NIH- Division of Dental Research. The purpose of this study was to explore the possibility of a correlation between postural deviations and temporomandibular joint dysfunction. Control and experimental groups consisting of 50 subjects each were evaluated for postural deviations using the Scan-0-Graph designed by Reedco Research. Goniometric measurements of cervical and lumbar spine were recorded. Tender points in the sacrum and throughout the paraspinals were palpated. Radiating pain was recorded. Both groups were evaluated for temporomandibular disorder using the Craniomandibular Index. The two groups were analyzed statistically using a one-way analysis of variance with the two groups on the continuous variables. They were followed by a Student- Newman-Kuels multiple range test to find the differences in the treatment means. The categorical values were analyzed using the chi square analysis or Fisher's exact test where appropriate. When the overall p values were significant, subsequent chi square or Fisher's exact test were used to find group differences. Statistically significant differences were noted in the two groups in the CMI, cervical range of motion, pain referral patterns, and in sitting postures. Postural differences occurred in heights of shoulders, levelness of pelvis, and position of the head. The pvalues were significant at.05. The results of this study suggests posture may contribute to temporomandibular disorder. It is important that therapists consider posture in the successful evaluation and treatment of the patient with temporomandibular disorder. Scapular Kinematics During Arm Elevation in Healthy Subjects and Patients With Shoulder Impingement Syndrome - Cok A, McClure P, Pratt N; Medical College of Pennsylvania, Hahnemann University, Philadelphia, PA The purpose of this study was to compare scapular motion patterns between subjects with and without impingement syndrome. There were 20 healthy subjects with a mean age of 34.3 and 17 patients with impingement syndrome with a mean age of 45.8. All subjects in the impingement group had at least three of the following: I) positive Neer test, 2) positive Hawkins test, 3) pain with active shoulder elevation, 4) pain with palpation of the rotator cuff tendons, 5) pain with resisted abduction, and 6) pain in the C5 or C6 dermatome region. Subjects with cervical pathology or glenohumeral instability were excluded. Subjects were stabilized in a sitting position and scapular position was measured using a Metrecom, a three-dimensional digitizer. Measurements were taken with the arm at rest, at 30, 60, 90, 1 20, and at maximal elevation in the plane of the scapula. In each position, the following points were palpated and digitized: C7 spinous process, T7 spinous process, base of the spine of the scapula, AC joint, inferior angle of the scapula, and the olecranon. We then calculated position and orientation of the scapula in three dimensions. Prior to the study, reliability of the measurement procedure was established by repeated tests on 20 healthy subjects. The ICC (3,l) values were above.9 for all measures except two, which were above.8. Independent t tests were used to compare healthy subjects with the impingement group and paired t tests were used to compare the symptomatic and asymptomatic sides within the impingement group. Our data indicated that subjects with impingement demonstrated significantly greater forward tilting of the scapula in the sagittal plane at 90" and at maximal elevation compared with healthy subjects. Im- pingement subjects also had less total arm elevation and showed a trend toward greater scapular protraction at rest and in arm positions above 90". These results suggest that altered scapular kinematics may be an important aspect of the impingement syndrome. Increased forward scapular tilting may be the result of selective muscle (pectoralis minor) tightness which may be a cause of impingement or the result of impingement. Future research should address the effects of stretching and strengthening exercise programs on kinematics and might further clarify the relationship between altered kinematics and symptoms. Use of the Flexible Ruler to Assess the Relationship Among Lumbar, Thoracic, and Cervical Spine Curves lkeda ER, Christian DM, Drake 11; Department of Physical Therapy, University of Montana, Missoula, MT The purpose of this study was to: 1) determine intratester reliability of measurements from the lumbar, thoracic, and lumbar sagittal plane spine curves taken by the flexible ruler and 2) to determine the relationship among those curves. Thirty healthy men and women, ages 20-39, volunteered for testing. A test-retest design was used for measurements of the three curves. The flexible ruler was conformed to the spine of each subject and the curves were traced on paper. Measurements were calculated using the formula: 4 x arc tan (2h/l). lntraclass correlation coefficients (KC) were used to determine intratester reliability. The ICCs were 0.57, 0.90, and 0.71 for the lumbar, thoracic, and cervical curves, respectively. Multiple regression was used to assess the relationship among the three curves. The multiple regression statistic, R = 0.347, demonstrated a weak correlation among the curves. This study revealed lower values for intratester reliability than previously reported for this measurement of the lumbar and cervical spine. Due to the weak relationship among the spinal curves, clinicians should use caution in predicting how distal changes will affect a specific curve. Volume 23 Number 1 January 1996 JOSPT

Copyright 1996. All rights reserved. The Reliability and Validity of a New Occupational Outcomes Measurement Scale Dobrzykowski EA; Formations in Health Care, Inc., Chicago, If; University of Illinois, Chicago, 11. The scale development was funded by the American Occupational Therapy Foundation. The purpose of this study was to develop a reliable and valid scale as part of an overall outcomes measurement system in order to measure and compare outcomes of work injury/occupational rehabilitation programs. The interval scale includes a work capacity measure reported by both the clinician and patient. The occupational outcome scale was conceptualized and designed through the gathering of consensus expert opinion and a literature review. The work capacity scale measures 10 commonly measured items of physical job demands. A field test of the new scale was conducted at 27 sites nationally which treat occupationally injured patients in either work hardening or work conditioning programs. While data were received from a total of 230 patients, only patients with low back pain (N = 124) were used for the study. The age of the patients ranged from 21.0 to 65.0 years with a mean of 38.1 years. Admission and discharge scores were analyzed with Rasch methodology. All items of the work capacity scale fit the Rasch model except handling rated by the patient. It was determined that a single construct exists (with handling removed), and person separation reliability was.92. The findings suggest that the new scale was highly effective and reliable in separating patients in terms of different work capacity abilities. The use of this scale in combination with additional measures of work behaviors, descriptive indicators, and a clinician training process pertinent to successful outcomes management can result in reliable and valid reporting and comparison of rehabilitation programs which treat occupationally injured workers. Effect of Lower Extremity Position and Stretching on Hamstring Muscle Flexibility - Ross M; 74th Medical Group, Wright-Patterson Air Force Base, Dayton, OH Hamstring muscle injury is a common occurrence for the individual participating in athletic activities. Lack of hamstring flexibility has been proposed as a possible etiology of hamstring injury. Therefore, hamstring stretching is often recommended. Many authors recommend stretching the hamstring with the distal segment of the lower extremity in a fixed (closed kinetic chain) position. However, no research is available that compares the effectiveness of stretching the hamstring muscle in a closed kinetic chain (CKC) vs. an open kinetic chain (OKC) position. Therefore, the purpose of this study was to compare CKC and OKC hamstring stretching techniques. Twelve healthy subjects (eight males and four females) stretched 5 days per week for 2 weeks with one leg in a CKC position and the other leg in an OKC position. Each stretch was held 30 seconds for five repetitions. Prestretching and poststretching hamstring flexibility was assessed by measuring active knee extension range of motion with the hip held at 90" of flexion, ie., active knee extension test (AKET). Each subject lacked at least 20" of knee extension as measured with the AKET prior to the initiation of the stretching protocols. A two-way analysis of variance (stretching technique and time) was used to analyze the data. The data analysis revealed a significant increase in hamstring flexibility between the preand post-stretching AKET (p <.05, CKC = +21.5%, OKC = +15.2%) but no significant difference between stretching techniques (p >.05). It was concluded that both the CKC and OKC stretching techniques were effective for increasing the flexibility of the hamstring muscle in healthy subjects with limited hamstring flexibility. Note: The opinions expressed herein are those of the author and do not necessarily reflect the opinions of the Department of Defense, the United States Air Force, or of other federal agencies. Quantification of Patellar Tracking Using Dynamic Resonance Imaging: Implications for Research and Clinical Assessment Powers CM; Department of Biokinesiology, University of Southern California, Los Angeles, CA. Supported by a grant from the Foundation for Physical Therapy, Inc. Purpose: With the development of dynamic magnetic resonance imaging (DMRI), assessment of patellar tracking patterns during resisted movement is now possible. This form of imaging offers important diagnostic information, which includes the ability to assess the contribution of activated muscles and other soft tissues in contributing to patellar motion and alignment. Up to this point, however, only qualitative assessment of patellar tracking patterns using this technique has been reported. The purpose of this project was to develop a method to quantify patellar motion that could be used for both clinical and research purposes. Description: Dynamic magnetic resonance imaging of the patellofemoral joint was conducted using a nonferromagnetic device that permitted resisted knee extension from 45" flexion to full extension. Ths resistance of this device was set at 15% body weight. Imaging was performed with a 1.5T, 64 MHz imager (General Electric Systems) using an ultrafast spoiled GRASS pulse sequence. Six evenly spaced images were obtained throughout the arc of motion on a group of normal subjects and patients with patellofemoral pain (PFP). Patellofemoral pain subjects were also imaged using patellar bracing and taping techniques. Lateral patellar displacement and patellar tilt indices were assessed for each image using a computer-aided program. Observations: Using DMRI and computer-aided measurement techniques, we have been able to objectively document patellar tracking pattern throughout a 45" arc of resisted knee extension. In addition, this measurement system demonstrated good intratester reliability. Preliminary data from normal and PFP subjects will be presented as well as data documenting the effects of patellar taping and bracing on patellar motion. Clinical Relevance: Using DMRI, patellofemoral measurements can be reliably obtained for research and clinical purposes. Information gained from this technique will be valuable JOSPT Volume 23 Number 1 January 1996

Copyright 1996. All rights reserved. in documenting the effectiveness of the treatment of PFP and provide a better understanding of the pathomechanics of this disorder. Effect of Patellar Taping and Bracing on Patellar Position as Determined by MRI in Patients With Anterior Knee Pain Worrell W, lngersoll C, Brockrath K, Minus P; Krannert School of Physical Therapy, University of Indianapolis, Indianapolis, IN. St. Francis Hospital provided MRI support for this research project. Patients with anterior knee pain represent a complex problem for patients and clinicians. During rehabilitation, patella taping and bracing are commonly used; however, they have not been directly compared in patients with anterior knee pain. Therefore, the purpose of this study was to determine the effects of patellar taping, bracing, and no taping or bracing on patellar position at eight angles of knee flexion as determined by magnetic resonance imaging. Twelve subjects (10 females and two males) diagnosed with anterior knee pain participated in this study. Magnetic resonance images were determined at eight angles of knee flexion (10, 16, 25, 30, 34, 39, 41, and 45'). In addition, visual analogue scale pain ratings were obtained for each experimental condition during a stepdown procedure. Repeated measure analysis of variance was used to compare experimental conditions and visual analogue scale pain rating. Results revealed lateral patella displacement (LPD) was more medial for the braced condition (1.7 mm) than the tape (2.7 mm) or control (2.6 mm) conditions across all knee angles (F(2,284) = 4.6, p =.01), but this difference was only significant at 10" of knee flexion. Patellofemoral congruence angle (PFC) was more medial for the brace condition (-7.1') than for the control condition (-4.1"). But the taped condition (-6.1") was not different than braced or control conditions. This difference was also only significant at 10" of knee flexion. No differences were detected between conditions for lateral patellar angle. Visual analogue scale pain ratings were not significantly different during the braced (4.6 mm) and taped (4.6 mm) conditions than the control (6.13 mm) condition (F(2,22) = 2.7, p =.09). We conclude that in this group of patients with anterior knee pain who had normal patella alignment that bracing and taping influence patellar position at selective knee angles. These results reveal the complex nature of anterior knee pain. Muscle Dysfunction: A comparison of Symptomatic Patients and Controls Headley Bl; Movement Assessment, Research and Education Center, Boulder, CO Purpose: The purpose of this study was to quantify any differences in muscle recruitment dysfunction in symptomatic patients and controls using a standardized dynamic functional muscle testing (FMT) protocol and surface EMG (semg). Hypothesis: Difference between symptomatic patients and controls in regard to movement dysfunction. Subjects: A total of 29 symptomatic subjects were evaluated with a standardized protocol. Fifteen were referred for upper quarter complaints and 14 for low back complaints. Twelve control subjects were evaluated. Materials and Methods: A Noraxon Myosystem 2000 and upper and lower quadrant protocols in their NorQuest software were used. Patients were evaluated by the protocol most appropriate for their symptoms. The protocols consist of 12-15 dynamic activities that are performed according to a standardized format. Activities are active, resistive, static, repetitive, and loaded in nature, with a standardized isometric contraction used for fatigue analysis. Data Analysis: A numerical score was obtained for each subject based on criteria established to determine whether muscle recruitment was appropriate or impaired. Numerical values for the two symptomatic groups were compared with controls using a t test and analysis of variance (ANOVA). The ANOVA was followed by a Student-Newman-Keuls test to establish the level of significance. Results: Comparison of upper and lower quadrant groups with respective controls scores established a 95% confidence interval. The Student- Newman-Keuls test resulted in a p value < 0.05 level for both upper and lower quadrant patient groups as compared with controls. Conclusion: Symptomatic patients with movement dysfunction can be separated from nonsyrnptomatic controls by a quantitative scoring of a comprehensive dynamic functional muscle testing procedure. The use of such a standardized scoring method can assist in establishing the degree of severity of a movement dysfunction. Clinical Relevance: The ability to quantify movement dysfunction in symptomatic patients may assist in predicting treatment needs, costs, and duration with less reliance on changes in subjective complaints. Specific targeting of the dysfunction correlating with symptoms assists in treatment planning and outcome measure. lntraexaminer Reliability, lnterexaminer Reliability, and Normal Values for Nine Lower Extremity Skeletal Measures lonson SR, Gross MT; Division of Physical Therapy, University of North Carolina at Chapel Hill, Chapel Hill, NC Physical therapists, athletic trainers, and other health care professionals commonly evaluate static postures and dynamic motions in patients with skeletal malalignments of the lower extremity. Accurate clinical evaluation of these malalignments depends on reliable and valid measures as well as established normal values. The purpose of this study was to document the intraexaminer and interexaminer reliability and normal values for nine lower extremity skeletal measures. The measures studied were femoral torsion, ankle dorsiflexion, tibia1 length, leg length, genu varus/valgus, medial talonavicular bulge, rearfoot angle, arch angle, and foot type classification. Subjects were 63 healthy Naval midshipmen (57 males and six females) between the ages of 18 and 30. Two investigators (with 11 and 15 years clinical experience) measured each of the nine variables on 18 subjects and one of the investigators measured the variables a second time on the same subjects. One of the investigators performed the measurements on all (63) subjects to obtain normal values for the variables. Intraexaminer and interexaminer reliability ICC(2, I) values ranged between 0.65 and 0.97, and percentage agreements for subjective assessments ranged between 88.8% and 94.4%. Mean absolute differences val- Volume 23 l Number 1 ~ Janua~ 1996 JOSR

Copyright 1996. All rights reserved. ues for intraexaminer and interexaminer measurements all were within acceptable limits for clinical measurement. A foot type classification scheme is suggested. The results of this study indicate that the variables investigated can be measured reliably. Suggestions for further research are offered. Muscle Recruitment Changes Secondary to Myofacial Trigger Points. An Approach to Studying Soft Tissue Dysfunction Headley B; Movement Assessment, Research and Education Center, Boulder, CO Purpose: The purpose of this study was to evaluate single trigger point phenomenon as it may relate to muscle dysfunction before and after treatment of the active trigger point (TrP). Hypothesis: The hypothesis for this study was that active TrPs may be interfering with function and symptom resolution in some patients. Subjects: Six subjects were solicited from the working population who developed single TrP symptoms and who fit the criteria of an active trigger point of recent onset. Materials and Methods: Prior to any treatment, a thorough evaluation was performed on each subject using a pressure algometer to record trigger point sensitivity. Diagrams were completed by both subject and evaluator of the symptom referral pattern. Limitations in muscle length were noted and a Microfet recorded the force output of the involved muscle during a manual muscle test. A Mega 3000P semg system recorded the muscle dysfunction, with electrode sites chosen based on typical secondary and satellite TrP locations, referred pain, and presenting symptoms. The semg data were collected prior to, during, and after digital stimulation of the TrP. Algometer measurements were repeated after treatment of the TrP to note changes in TrP sensitivity, muscle length, strength, and referred phenomenon. Data Analysis: Data were quantified and an aggregate score compiled for all evaluative components pre- and post-treatment. Results: The results of this pilot study suggest that there are changes in muscle recruitment associated with active TrPs. Loss of strength, hyperirritability, and inhi- bition of a muscle may be related to stimulation of an active TrP. Conclusions: The use of semg may be helpful in documenting the pattern of muscle dysfunction related to each TrP, clarifying findings of muscle weakness and pain found on clinical exam. Reduction in TrP sensitivitv does show a correlation with the reduction of secondary muscle dysfunction. Clinical Relevance: The presence of active TrPs may be a major contributing factor to some soft tissue injuries. Knowledge of how specific TrPs may affect muscle dysfunction may assist in directing treatment and ensuring that perpetuating factors associated with myofascial pain syndrome are corrected immediately, enhancing treatment response and reducing long-term compensatory dysfunction. lntertester Reliability Between Novice and Experienced KT-1 000 Users Turenne )K, Kramer KA, Binkley )M, Hunter S, Binkley GA, Brown HK; North Georgia College, Dahlonega, GA Purpose: A vast amount of research has been conducted on the reliability, validity, and diagnostic accuracy of the KT-1000 arthrometer. The effect of tester experience and training in the use of the KT-1 000 has not been addressed to date. The purpose of this study was to compare the intertester reliability of KT-1 000 measurements of novice and experienced testers. Subjects: Four physical therapists from four clinics served as testers. Two testers were novice KT-1 000 users while two had in excess of 8 years of KT-1 000 experience. All testers performed KT-1 000 measurements on 29 subjects who either had an ACL reconstruction or were ACL deficient. Methods: All four testers performed two KT-1000 measurements at the 131 Newton force level on each patient. The testing order used for each subject was balanced to prevent the order of testing influencing consecutive measurements. All testers used all devices and displacement was recorded in millimeters. lntertester and intertrial reliability coefficients [interclass correlation coefficient (KC) and standard error of measurement (SEM)] were estimated from a single two-way analysis of variance using the approach described by Eliasziw. Results: There was a systematic difference in the mean novice ratings which was not apparent in expert results. Intertester lccs were r = 0.65 for novice testers and r = 0.79 for experienced testers. Intertrial lccs were r = 0.97 for novice testers and r = 0.98 for exwrienced testers. Novice means were 9.76 mm and 8.33 mm and experienced means were 10.5 mm and 10.5 mm. Standard error of measurement was 1.47 mm for the novice testers and 1.23 mm for the experienced testers. Discussion: The results indicate that there is a systematic difference between ratings performed by novices resulting in lower reliability than that of the experts. The high intertrial reliability suggests that between-trial error did not contribute to the lower novice intertester reliability. These results indicate that training is an important factor when using the KT-1 000 clinically. The low novice intertester reliability suggests a need for the same clinician to perform initial and follow-up measurements, particularly if they are a novice KT-1 000 user. Evaluation and Treatment of a Sample of Pediatric Patients Complaining of Mediai Tibial and Medial Ankle Pain: A Case Series Kelo MI; Virginia Rehabilitation, Richmond, VA This case series describes the evaluation and treatment of 30 children between the ages of 2 and 12 referred to physical therapy for complaints of medial tibia1 and/or medial ankle pain. It was hypothesized in each case that the tissue of pain origin was the tibialis posterior and/or flexor hallucis longus. A standardized evaluation was performed by the same examiner on each subject. Emphasis was placed on identifying the following: varus foot deformities in nonweight-bearing subtalar neutral position, the everted angle of the weight-bearing calcanei, the presence of abnormal gait patterns, degree of femoral anteversion, decreased hip external rotation, and inflexibility of hamstrings and gastrocs. Subjective exam revealed the presence of pain complaints for a duration of 7 months-1 0 years prior to patient referral for treatment. All children 5 years of age or younger were IOSPT Volume 23 Number 1 January 1W6

Copyright 1996. All rights reserved. unable to stand or walk for 2 hours without requesting to parents that they be held. Twentv-two of 30 children had at least one parent'who had a history of mechanical foot pain or had worn corrective shoes as a child. Twenty-five of 30 patients were awakened by night pain following days with longer than usual weight bearing. Parents of 22 patients were concerned that their children were clumsy and tripping over their own feet during ambulation. All patients were treated with orthotics to reduce the amount of pronation during weight bearing. Patients whose evaluation revealed inflexibilities were given appropriate range of motion exercises. For patients ambulating with excessive hip internal rotation or toe-in gait patterns, movement reeducation and gait training exercises were prescribed. All patients had their pain associated with weight bearing fully alleviated in a course of treatment which ranged between two and six visits. Parents of all children reported that by discharge they no longer noticed episodes of tripping and falling during ambulation. This case series informs the clinician that they should assess to determine if a biomechanical foot dysfunction is the causative factor in their w- diatric patients with complaints of medlial tibia1 or medial ankle pain. Effective treatment strategies and tactics are also discussed. A Managed Care Approach to ACL Reconstruction Wellen M, Dymek K, Bylund B; Fallon Clinic, Fallon Medical Center, Worcester, MA In a managed care environment, it has been a challenge to devise a creative, low cost alternative to traditional outpatient physical therapy. We have devised a program for anterior cruciate ligament recon- struction that has streamlined documentation, decreased costs, provided us with a means for program evaluation, and will help us to ensure quality of care and patient satisfaction. The program follows a system clinical path that takes the patient from the preoperative visit to 6 months postoperative. Outpatient visits have been reduced from 38 to six over 6 months using home exercise videos, comprehensive patient education, contracts, and follow-up phone calls. Critical path flow sheets, a functional assessment tool, the Lyshome Knee Rating Scale, and specific admission and discharge sheets have streamlined documentation. The documentation is predominantly check-off and requires less therapist time while ensuring that all therapists look at the same criteria and provide consistent exercises and education as well as high quality care throughout our hospital and outpatient facilities. Our documentation and education tools enable the therapist to deliver a uniform message and provide important verbal and written reinforcement. A continuum of care is facilitated through the system by booking postoperative outpatient visits at the preoperative visit. The program includes outcome and program evaluation measures that facilitate interdixiplinary quality improvement. We feel this program may be of help to other therapists struggling with reduced numbers of visits. A Prospective Outcome Study of Home Rehabilitation Programs Following ACL Reconstruction Blaschak MI, Holmes CF, Lance ED, Turtutto TC, Schenck RC; University of Texas Health Science Center at San Antonio, San Antonio, TX. Funded through a grant from the Arthroscopy Association of North America. Purpose: Reconstruction of the anterior cruciate ligament (ACL) is a commonly performed procedure in a sports active population. The success of ACL reconstructions and efficacy of functional rehabilitation programs have been well documented. The purpose of this study was to prospectively compare a physical therapist directed functional home rehabilitation program to a clinic-based one following ACL surgery utilizing objective and subjective measurements of function, quality of life, patient satisfaction, and cost. Hypothesis: The hypothesis was that no difference in functional or objective outcome would be noted between the treatment groups. Subjects: Patients over the age of 18 with a diagnosis of a torn ACL were considered candidates for this study. A total of 34 subjects were enrolled in this study: 10 females (average age = 22.4 years, range = 18-30), and 24 males (average age = 23.2 years, range = 18-32). Fifteen of the subjects received tra- ditional clinic-based functional rehabilitation. The remaining 19 patients received home-based therapy. Methods: Patients were enrolled in the service of one surgeon and underwent a mid-third patellar autograft reconstruction of the ACL without tourniquet after giving informed consent to participate in this institutional review board approved study. Patients were randomized to either a clinic-based (three times per week for 6 weeks) or a home rehabilitation program (home rehabilitation based upon patient response as previously described). Knee range of motion, Lysholm, and Cinti knee rating scales, visual analogue scale (VAS) pain rating, hop test, KT-1000, and Sickness Impact Profile (SIP) were evaluated pre- and post-operatively by an independent observer. Data taken preoperatively, 3 months and 1 year after surgery, formed the data base for this study. Results: All 37 subjects reported satisfaction with the function of their knee at 3 months and 1 year following surgery. Sickness lmpact Profile scores at 1 year were significantly lower (p <.01) than preoperative scores, averaging 0.66 and 9.74 (range = 0.43-26.3), respectively. Full knee range of motion was obtained in 32 of 34 patients by 3 months. Visual analogue scale pain scores averaged 5.1 (range = 3-10) preoperatively. By 3 months, the pain scores for all subjects reverted to 0, except for complaints of pain with weather changes (VAS < 2). All patients had an abnormal hop test prior to surgery which normalized by 3 months in 29 of 34 patients. Subjects managed by home-based rehabilitation averaged 4.1 visits as compared with 12.4 for clinic centered subjects (p <.01) with respective average cost of $225 vs. $930. Conclusion: Subjects in the study reported high satisfaction and improved quality of life following ACL reconstruction as demonstrated by SIP and VAS values at 3 months and 1 year follow-up in both treatment arms. Clinical Relevance: There were significant cost savings in the home rehabilitation group. There were no differences in functional or subjective outcome in the different postoperative rehabilitation regimens. Volume 23 Number 1 January 1996 JOSPT

The Reliability and Validity of a New Orthopaedic Outcomes Measurement Scale Incorporating Back Care Education in a Vocational School Curriculum Investigation of the Relationship Between Pelvic Tilt and Unilateral Sacroiliac Copyright 1996. All rights reserved. Dobrzykowski A; Formations in Health Care, Inc., Chicago, IL; Rehability Cop, Brentwood, TN. The research was funded by the Reliability Corporation. The purpose of this study was to develop a reliable and valid clinician-reported scale to assist in the measurement of outcomes in patients with orthopaedic disorders. The study evaluated the reliability of a clinician's translation of patient impairments routinely assessed, including strength, active range of motion, passive range of motion, endurance, posture, sensation, gait, and various functional activities to functional goals using an interval-based scale. Data were collected from 23 facilities nationally, including outpatient practices of hospitals, private practices, and multi-site corporations. Data from 176 patients receiving orthopaedic rehabilitation were analyzed. The age range of the patients was 11.8-83.2 years (2 = 44.5 years). Ratings at admission and discharge were analyzed through Rasch methodology. The findings revealed good measurement qualities with the scale generally measuring a unidimensional construct and sensitive to patient improvements. Pearson separation reliability was.61-.73. A new scale has been developed which assists in the measurement of functional outcomes in patients with orthopaedic disorders. The outcome scale is part of an overall outcomes management system which includes the measurement of patient reported general health status and satisfaction and additional clinical and descriptive indicators. The orthopaedic outcomes measurement scale may provide utility as a reliable and valid method of measuring outcomes from a clinical perspective in patients with orthopaedic disorders. Sheldon MR, Risigo I, Broyles I, Cartwright C; Department of Physical Therapy, University of New England, Biddeford, ME. Grant funding through the Maine Department of Labor. The socioeconomic impact of the back painlinjury problem among workers in the United States is well documented. There are numerous examples of back care educational programs for adults in the work place. It seems reasonable that educational programs designed to prevent back injuries should begin before the worker begins hid her career. Back care education incorporated into school curricula would instruct students in safety principles early in life with the goal of decreasing the risk of injury as they enter the work force. Graduates with knowledge of strategies to prevent back injuries may also be more desirable to an employer. This presentation describes a four-phase pilot program designed to instruct vocational school teachers how to incorporate back care education into their respective courses in automotive repair, secretarial/computer work, health occupations, building trades, welding trades, and machine trades. Phase I involves work task and environment observation by a physical therapist in the individual classrooms~laboratories to enable more individualized instruction to the respective teachers about specific safety concerns in their courses. Phase II involves teacher instruction. As part of this instruction, teachers are provided with teaching guides, lesson plans, audiovisual aids, an anatomical model of the spine, class handouts, homework assignments, and testing instruments. In phase Ill, teachers incorporate back care education principles into their classrooms and laboratories throughout their courses. Phase IV involves postinstruction assessment of student knowledge and performance. Our experience with this program thus far indicates that the teachers and students are very receptive to the incorporation of back care education in their courses. This pilot program provides one model for educating future workers about back injury prevention. Clinicians should be aware of the potential for early intervention in this setting. )ones B-AM; Old Dominion University, Norfolk, VA Low back pain is the nation's leading cause of disability. Differential diagnosis of a low back injury can be complicated and uncommon disorders can be overlooked. Many of the signs and symptoms related to low back pain may in fact be caused by sacroiliac dysfunction. Reliability of the current clinical tests for detection of sacroiliac involvement has been of concern. Recently, more focus has been given to the use of pelvic tilt measurement as a source of clinical information on the sacroiliac joint. The purpose of this study was to examine the correlation of unilateral sacroiliac dysfunction with asymmetrical changes in pelvic tilt measurement. This study measured pelvic tilt angles in symptomatic (N = 8) and asymptomatic (N = 8) subjects. Results indicated reliability of r = 0.95 for all data collected. There was a statistically significant difference (using separate matched paired t tests at a = 0.025) between right and left pelvic tilt in symptomatic subjects but not in asymptomatic subjects. The absolute difference in pelvic tilt between the right and left sides within the symptomatic subjects was found to be statistically significant (using a group comparison t test at a = 0.025) when compared with the absolute difference in asymptomatic subjects. It appears that our current methods of differential diagnosis, which rely on visual and palpation methods to detect patients who may have sacroiliac involvement, are valid. Inclusion of symptomatic subjects in this study was linked to the investigator accurately seeing these changes in pelvic symmetry. The data objectively confirmed the subjects' inclusion. Furthermore, if the difference between the right and left pelvic tilt angle was 2 1.22", the therapist can, with 90% confidence, place the patient in the symptomatic category. Therapeutic goals should be addressed at attempting to reduce the absolute difference in right to left pelvic tilt angles to below the 1.1 1 " level. JOSPT Volume 23 Number 1 Janualy 1996

Copyright 1996. All rights reserved. lntertester and lntratester Reliability of the Pelvic Meter for Measurement of Pelvic Position Iimenez L H, Chiarello CM; Program in Physical Therapy, Columbia University, New York, NY The purpose of this study was to examine the intertester and intratester reliability of the Pelvic Meter (patent pending) for measurement of pelvic position in relaxed stance, anterior, posterior, and hip hike positions in the sagittal and frontal planes. The Pelvic Meter is a recently developed tool. It is an instrument to measure individual innominate position and pelvic position in the sagittal and frontal planes. The Pelvic Meter consists of three inclinometers attached to a self-supporting aluminum frame secured to the subject's pelvis at four locations. A total of 32 adult females asymptomatic for low back pain and ranging in age from 22 to 38 years participated in this study. Twelve measurements were recorded from the Pelvic Meter representing two sagittal plane measurements (right and left) and one frontal plane measurement in four different stance positions consisting of relaxed stance, anterior, posterior, and hip hike positions. In measures of 28 subjects by two testers, the interclass correlation coefficients (ICCs) for intertester reliability for sagittal plane measures ranged from 0.87 to 0.95 and for frontal plane measures from 0.74 to 0.89. In measures of six subjects by one tester four times, the lccs for intratester reliability for sagittal plane measures ranged from 0.73 to 0.95 and for frontal plane measures from 0.35 to 0.57. The results demonstrate that the Pelvic Meter is highly reliable for intertester measurements of the pelvis in the sagittal plane and the frontal plane in the hip hike position and moderately reliable in the frontal plane in relaxed stance, anterior, and posterior pelvic positions. The intratester reliability for measurements in the frontal plane is questionable, yet is moderate to high in the sagittal plane. Assessment of pelvic alignment and obliquities may be quantifiably documented using this device. Sidebending With the Back Range of Motion Device Ambra LN, Ostarello 1; California State University, Hayward, CA Purpose: Low back pain is one of the most common dysfunctions for which physical therapy care is sought. Quantitative, reliable, valid, and cost-effective measures of active range of motion (AROM) are critical in musculoskeletal care of the spine. The back range of motion device (BROM) promises to render such measurements of lumbar AROM. Various sources of test-retest error also need to be differentiated. This study evaluated intra- and intertester reliability, error due to the variability of the subject's motor performance, error in reading the device, and time-cost of measuring lumbar flexion and sidebending with the BROM. Subjects: Twenty-nine healthy adults without low back pain were measured. Method: The back range of motion manufacturer's procedures were followed except that S-2, rather than S-1, was used as the inferior landmark. Two testers each measured three flexions and sidebends after which two "restricted" flexions and sidebends were measured; for the latter, the subjects bend until their middle fingertips touched the table top. The table was adjusted so that subjects reached about half of their "free" lumbar motion. Each tester also positioned the BROM at 90 different angles with both testers reading each angle. Data Analyses: Statistics used included probability plots, analysis of variance, two-tailed paired t tests, error mean squares, lccs and Pearson's product moment correlations, and scatter diagrams with regression lines. Results: All data were normally distributed, although means for all motions were 18% higher for Tester 2 than for Tester 1. Less variability was found for the "restricted" than for the "free" motions both within and between testers. The largest range occurred for the three "free" flexions for Tester 1 (19"); the smallest range occurred for the two restricted right sidebends measured by Tester 2 (4O). The average of the error mean squares was 9.7O for the free motions and 2.4' for the restricted motions. The average of the intratester lccs and Pearson's product moment correlations was.82 for the "free" motions and.90 for the "restricted" motions. It took an average of 6 minutes 40 seconds to measure the "free" movements. lntertester reliability was poor for all mo- tions (between -.34 and.66). lntertester reliability of reading the BROM was excellent (between.89 and 1.0). Conclusions: In measuring lumbar flexion and sidebending with the BROM, a significant portion of test-retest measurement error may be due to variability in the subjects' movement. Reading the BROM seems to have outstanding accuracv. With the BROM. lumbar flexion and sidkbending may be ' measured with good intratester reliability and efficiency. Subjects may be more motivated for some testers. Lastly, up to a 19O difference in lumbar flexion measurements may be due entirely to error. Clinical Relevance: The BROM might be useful to render quantitative, cost-efficient, and reliable measures of lumbar flexion and sidebending when the same tester is used. In measuring lumbar AROM test-retest error, a large degree of error may be subject variability and not instrument and method errors. Lastly, a large amount of spread (up to lgo) can occur among any three lumbar flexion measurements even though the reliability coefficient for those measurements show a good reliability (.77). Kinematic Analysis of Lumbar and Hip ~otion While Rising From a Forward Flexed Position in Subjects With and Without a ~istbty of Low Back Pain McClure PW, Esola M, Schreier R, Siegler S; Drexel-Hahnemann Biomechanics Research Laboratory, Philadelphia, PA The purposes of this study were to I) establish the amount and pattern of lumbar spine and hip motion while rising from forward flexed position and 2) determine if there were differences between subjects with and without a history of low back pain (LBP). We analyzed two groups of subjects during return to upright (extension) from a forward bent position. Group 1 (N = 12) contained subjects with a history of LBP but who were currently asymptomatic for at least 2 weeks and Group 2 (N = 12) included subjects without a history of LBP. A three-dimensional optoelectric motion analysis system was used to measure the amount and velocity of lumbar and hip ex- Volume 23 Number 1 January 1996 JOSPT

Copyright 1996. All rights reserved. tension motion. Each subject performed three trials which were averaged and used for statistical analysis. Hamstring flexibility was also determined using two clinical tests, the passive straight leg raise and active knee extension tests. Total extension was separated into four equal intervals based on the total amount of extension motion. For each interval, the amount of lumbar and hip motion and the lumbarhip ratio were calculated as well as velocity. Two-way analysis of variance (group X interval) was used to analyze data. The average lumbarhip ratios for all subjects were 0.26 for the first 25%, 0.61 for the 25-50% interval, 0.81 for the 50-75% interval, and 2.3 for the final 25% of extension motion. Lumbarhip ratios were different in each 25% interval, suggesting that the hips had a greater contribution to early extension, with the lumbar spine contribution increasing in the middle intervals and becoming the primary source of motion in the final interval. Subjects with a history of LBP tended to move from the lumbar spine earlier compared with those without a history of LBP, especially in the initial 25% of the extension motion (p <.05). There were no differences between groups for the final three phases of extension motion. A correlation between hamstring flexibility and hip extension velocity was found, demonstrating that as hamstring flexibility decreased, hip extension velocity increased. When lumbarhip extension ratios were compared with corresponding ratios previously calculated during intervals of flexion, three of four were highly correlated, demonstrating a reversible lumbopelvic rhythm. The subjects with a history of LBP in this study averaged 9.8 months since their last episode and the average Oswestry score based on their recall of the last LBP episode was 25.7. Therefore, they may not have been representative of subjects with more severe or chronic LBP. Further research could be conducted on subjects with more chronic and severe LBP. The effects of common stretching and strengthening procedures on lumbopelvic kinematics also require further study. Platfom presentation, 1996 APTA Combined Sections Meeting, Atlanta, CA. Differences in Isometric and lsokinetic Torque for Trunk Flexion and ~xtension Sternen 0, Andres FF, Grabiner MD, Flynn MG, Drowatzky IN; University of Toledo, Toledo, OH Purpose: The purpose of the study was to determine if isometric and isokinetic torque for concentric trunk flexion and extension at selected trunk angles would vary with change in velocity. The null hypotheses for healthy subjects was that at selected trunk flexion angles (0, 15, 30, 45, 60, and 7s0), peak isometric torque and average isokinetic torque for concentric trunk flexion would not vary as a function of velocity (0, 30, 60, 90, 120, and 1 50 /second). The same null hypotheses was applied to concentric trunk extension. Subjects and Methods: Seventeen subjects (seven males, 10 females), age 22-41 years (X = 28.2 years), participated in the study. Subjects performed maximal isometric trunk flexion and extension contractions at 0, 15, 30,45, 60, and 75" trunk flexion on a Cybex Trunk ExtensionFlexion Unit. Subjects also completed an isokinetic protocol consisting of reciprocal trunk flexion/extension contractions at isokinetic speeds of 30,60,90, 120, and 1 50 /second. Analysis of variance with repeated measures was used to determine trunk angle-speed specific differences for trunk flexion and extension torque as a percent body weight at a significance level of p <.05. Results: At beginning range of motion, trunk flexor torque and trunk extensor torque did vary significantly as a function of velocity. At mid and end range of motion, trunk extensor torque followed a different pattern than trunk flexor torque with change in velocity of contraction. Trunk flexor torque was not significantly different at midrange and end range of motion (1 5-75" trunk flexion) at velocities less than 150 /second. Trunk extensor toque was not significantly different across the velocity spectrum at the 45 and 60" trunk flexion angles (midrange). At the 30" trunk flexion angle (midrange), isometric extensor torque was significantly greater than isokinetic extensor torque at the 30 /second (slow) and the 1 50 /second (fast) velocities. At the 15" trunk flexion angle (midrange) and 0" trunk flexion angle (end range), isometric extensor torque was greater than isokinetic extensor torque at all velocities. Also, at end range trunk extension (0" trunk flexion angle), isokinetic extensor torque at 30 /second (slow) was greater than isokinetic extensor torque at 150 /second (fast). Conclusion: Multiple angle isometric and multiple speed isokinetic testing is not necessary in the clinical setting. A nonredundant trunk testing protocol would include: 1) isometric trunk flexion beginning range (0" trunk flexion) 2) isometric trunk extension beginning range (7S0 trunk flexion), 3) isometric trunk extension midrange (15" trunk flexion), 4) isometric trunk extension end range (0" trunk flexion), and 5) one isokinetic speed at either 60, 90, or 120 / second. The 60 /second isokinetic speed is recommended because it is often used for normative data comparisons. Clinical Relevance: A s~ecific isometridisokinetic trunk testing pro&ol that replaces the multiple angle isometric and multiple speed isokinetic protocol has three advantages. Testing at one isokinetic meed and at four isometric angles can be completed in a realistic time frame to maximize clinician efficiency. Secondly, the above testing protocol will provide nonredundant and appropriate trunk extension and flexion strength information. Thirdly, a shorter test protocol poses less risk to the deconditioned back pain patient and optimizes patient safety. Sections Meeting, Atlanta, CA. The Effect of Scapular Retraction Exercise Program on Scapular Position and Scapular Muscle Force Baker-Sawyer K, McClure P, Fitzgerald K; Medical College of Pennsylvania, Hahnemann University, Philadelphia, PA The purposes of this study were to determine the effect of a 6-week exercise program for the scapular retractor muscles on: I) scapular position, 2) scapular muscle force (retraction and protraction), and 3) the relationship between scapular muscle force and scapular position. Subjects were 55 young, healthy volunteers (age range = 21-43) who were randomly assigned to either an exercise (N = 26) or control group (N = 29). Scapular position and muscle force measurements were taken on all subjects before and after a 6-week exercise period. Scapular position was measured using the Metrecom three-dimensional digitizer while subjects assumed a relaxed standing position. The digitizing probe was used to lo- JOSPT * Volume 23 * Number 1 * January 1996

Copyright 1996. All rights reserved. cate the root of the spine of the scapula, the tip of the acromion, and the inferior angle of the scapula. Using these coordinates, the angular position of the scapula could be described in all three planes. Scapular muscle force was measured isometrically using a Kin-Com dynamometer and a specially modified pad that conformed to the scapula. Retraction force was measured with the subject prone and protraction force was measured with the subject supine. Subjects in the exercise group were instructed to perform two exercises: I) scapular retraction while sitting with the arms by the side and the elbows bent, and 2) scapular retraction while lying prone with the arms abducted 90" and the elbows extended and the thumbs pointing up. These exercises were done for 6 weeks, three sessions per week, doing three sets of 10 repetitions of each exercise every- session. The data were analyzed using analysis of covariance (ANCOVA) with pretest scores used as the covariate. The relationship between normalized scapular muscle force (retraction1 protraction) and scapular position was analyzed using a Pearson's correlation coefficient. The ANCOVA failed to show a difference between the control and exercise groups in either scapular muscle force or scapular position. There was no correlation found between normalized scapular muscle force and any measure of scapular position (r<.l) for either group at pretest or posttest. These results suggest that a 6-week program of active exercise was insufficient to produce changes in isometric scapular muscle force or scapular position at rest. Further study in this area is indicated using patients and perhaps assessing scapular position during dynamic motion. Other measures of muscle performance may be required to detea changes that were not evident from this study and more intense exercise programs should be tested as well. Defining the Minimal Clinically Important Difference When the Roland-Morris Disability Questionnaire is Used to Assess Change in Patients With Low Back Pain Stratford P, Binkley ); School of Occupational and Physiotherapy, McMaster University, Hamilton, Ontario, Canada The purposes of this presentation are to provide an estimate of minimal clinically important difference (MCID) and to determine whether the magnitude of this difference can be detected on individual patients when the Roland-Morris questionnaire (RMQ) is used to assess change in disability on patients with low back pain. The minimal clinically important difference is defined as "the smallest difference in score in the domain of interest which patients perceive as beneficial and which would mandate, in the absence of troublesome side effects and excessive cost, a change in the patient's management." The study sample consisted of 226 patients (112 females) with a current episode of back pain less than 6 weeks. All were physician-referred outpatients receiving physical therapy. The sample's mean age was 40 years (minimummaximum age = 18-72). Patients completed the RMQ at the initial patientclinician assessment and following 4-6 weeks of therapy. An independent assessment of meaningful change was obtained at follow-up by having patients and clinicians complete independently two global rating scales. One scale addressed the magnitude of change and the other inquired about the importance of the change. The criterion measure of change was defined as the average of the patient's and clinician's ratings across both scales. Scores on the global rating scale were used to dichotomize patients into those who had changed an important amount from those who had not. Receiver operating characteristic (ROC) curve analysis was performed to identify the magnitude of MClD on the RMQ. Error estimates were obtained based on the standard error of measurement (SEM) and conditional standard errors of measurement (CSEM). The SEM assumes measurement error is the same for all RMQ scores, whereas CSEM are based on the assumption that the measurement error is a function of the mag- nitude of the RMQ scores being compared. The ROC curve analysis suggests that, on average, five RMQ points represent a MCID. Moreover, minimal levels of detectable change at the 95% confidence level were calculated to be five RMQ points when the SEM method was applied and four to five RMQ points when the CSEM approach was used. Inspection of the results showed that the RMQ has difficulty in detecting improvement in patients who present with low initial RMQ scores and deterioration in patients with high initial RMQ scores. In summary, this study reports the extent to which the RMQ can be used to assess important change over time on individual patients. The results suggest that, on average, a difference of five RMQ points represent a MClD and that a change of this magnitude can be detected on individual patients. The Effect of Lateral Step-up Exercise Protocol on lsokinetic and Functional Measures Lombardo G; The Mount Sinai Medical Center, New York, NY Despite the widespread use of the lateral step-up (LSU) exercise in rehabilitation, few published studies have examined the efficacy of this strengthening technique. The purpose of this study was to examine the effect of a 6-week LSU exercise protocol on 1) isokinetically measured quadriceps peak toque, average power, and endurance, and 2) lower extremity peak power, average power, peak impulse, and endurance measured functionally. Ten healthy, female subjects (X age = 27.5 2 3.6 years) were used for this randomized, controlled trial. The experimental group (N = 5) performed a 6-week LSU protocol 4 days per week. The height of the step and the amount of loading were progressed over the 6 weeks. lsokinetically and functionally measured data were collected prior to and following the LSU intervention. lsokinetic data were collected through a Cybex 11. Lower extremity power and impulse data were derived from force data obtained during vertical jumping from a force platform; functional endurance was determined by measuring maximum number of step-ups (to fatigue) from an 8-inch step while loaded with 25% of body weight. Statistical analysis using within-group t test Volume 23 Number 1 January 1996 JOSFT

COMRINED SECTIONS MEETING Copyright 1996. All rights reserved. (one-tailed) revealed significant increases in average power and endurance measured functionally from pretest to posttest in the experimental group (p < 0.05) though not in the control group. The differences from pretest to posttest for the remaining functional measures (ie., peak power and impulse) and for all imkinetic measures were not significant. This suggests that some lower extremity performance parameters may be improved in healthy individuals through an LSU exercise protocol. lnterrater Reliability of Functional Excursion Tests Leighton RD, Bossie K, Currier L, Good B, McCormick R; Department of Physical Therapy, University of New England, Biddeford, ME Functional assessment in physical therapy has always been an important component of the physical therapy evaluation process. Third-party payers have recently become more concerned with functional improvement to justify further physical therapy intervention. Because of the importance of accurately assessing a patient's functional level as well as improvement of function, it is important to have a functional assessment tool that is valid and reliable. A group of physical therapists, under the guidance of Gary Gray, PT, have developed the Lower Extremity Functional Profile, a functional assessment handbook which is hoped to assist the therapist in making an accurate assessment of a patient's function. The present study took one section of the Functional Profile, the lunge tests, and tested it for interrater reliability. Four licensed physical therapists with no previous experience with the Functional Profile independently used three lunge tests (anterior, lateral, and posterior) on each of 16 subjects. The therapists were given directions on conducting the tests directly from the Functional Profile handbook, with no other instructions provided by the authors. The intraclass correlation coefficient was used to determine interrater reliability. Scores ranged from 0.63 to 0.80 for the three tests, which is described as moderate to good reliability. Also, the physical therapists were observed by the authors to determine if they administered the lunge tests correctly. Descriptive statistics were used to identify problem ar- eas consistent among the four therapists. The two major problematic areas were found to be taking measurements before the subject returned to the starting position and improper foot placement to begin the posterior lunge. Therefore, based on the high correlation values, it is recommended that the anterior, lateral, and posterior lunge tests as described by Gray et al show acceptable interrater reliability if performed as described in the Functional Profile handbook. These tests provide the physical therapist with a reliable way to measure one component of function in their patients. The Effects of Joint Angle on Electromyographic Indices of Fatigue Weir lp, McDonough A L, Hill V); Applied Physiology Laboratory, Department of Movement Sciences and Education, Teachers College, Columbia University, New York, NY The purpose of this study was to examine the effect of manipulation of joint angle on electromyographic (EMG) fatigue curves at different sites over the quadriceps femoris muscle group. Manipulation of joint angle causes changes in muscle and joint mechanics. Under isometric conditions, manipulation of joint angle has been shown to affect acute fatigue responses as well as strength adaptations following training. A common procedure during knee rehabilitation is to perform knee extension exercises through a limited range of motion. Eight subjects (R age = 26.6 years; range = 22-32 years) voluntarily participated in this study and gave written, informed consent. Each subject performed isometric knee extensions of the right limb at 15, 45 and 75" from full extension on an isokinetic dynamometer. At each joint angle, three maximal voluntary contractions (MVC) were followed by a 1-minute fatiguing contraction at 50% of MVC. Electromyographic signals were recorded with a branched electrode lead system at proximal and distal sites over the vastus lateralis (VL) and vastus medialis (VM). For a 1-minute contraction, each signal was divided into 1 -second intervals. The series of intervals were analyzed for changes in both amplitude and frequency characteristics over time. For the amplitude analysis, each interval was digitally full wave rectified and integrated (IEMG). For the frequency analysis, the median power frequency (MPF) was determined. The regression slopes of the IEMG and the MPF data vs. time were analyzed with univariate 2 (proximal, distal) x 2 (VL, VM) x 3 (15, 45, and 75") repeated measures analyses of variance with the Huynh-Feldt correction. For both analyses, there were significant main effects for angle (IEMG, p = 0.0049; MPF, p = 0.0102) and subsequent Tukey post hoc comparisons showed that the fatigue slopes for the IEMG data were greatest at 45". However, the MPF data showed the greatest slopes at 15". Differences in fatigue slopes derived from the same data indicate that changes in amplitude and frequency characteristics due to fatigue may be partially driven by different mechanisms. We hypothesize that the decline in MPF at 15" is due to activation failure while the increase in IEMG at 45" may be driven by contractile failure. The Muscular Consequences of Repetitive Dynamic Lifting Mercer SR, Rudy TE, Boston )R; Departments of Anesthesiology, Biostatistics, and Electrical Engineering, University of Pittsburgh, Pittsbuqh, PA. Supported by grant 2RO1 AR38698 from the U.S. National Institute of Arthritis and Mu~uloskeletal and Skin Diseases. This study evaluated the pattern of recruitment and fatigue of multifidus (M), longissimus thoracis (LT), and iliocostalis lumborum (IL) muscles during a repetitive dynamic lifting task. Fifty subjects, 25 randomly selected chronic back pain patients and 25 age- and gender-matched control subjects participated. Subjects performed an isoinertial lifting endurance task on the BTE Work Simulator. A Motion Analysis system recorded subjects' motion during the entire task and raw electromyography (EMG) recordings, digitized at 2 khz, also were collected continuously using surface electrodes. Spectral analyses were computed to evaluate muscle fatigue and waveform moment analyses followed by multivariate analyses of variance were used to determine muscle patterning. Compared with patients, controls used more of a torso lift and the point of maximum acceleration for their hip angles occurred later as the task progressed. Patients' starting lifting angles JOSPT Volume 23 Number 1 January 1996

Copyright 1996. All rights reserved. or acceleration patterns did not change significantly throughout the task. Patients demonstrated fatigue in M and LT muscles, particularly between early and middle phases of the task, while controls demonstrated only IL fatigue later in the task. Waveform moment analyses indicated: I) a significant proportion of IL integrated electromyographic activity preceded LT activity for controls, but these muscle groups were temporally synchronous for patients, and 2) for both groups, M activity occurred later than LT activity, but became more synchronous during the task. The association between lifting styles and muscle patterning will be discussed. This information ~rovides a new approach to characterize EMG activity and helps to advance our understanding of the muscular consequences of a dynamic endurance lifting task. Platform presentation,.l996 APTA Combined Utilization of Croup Treatment in Orthopaedic Populations in the Acute Rehabilitation Setting Fortin S; Fairlawn Rehabilitation Hospital, Worcester, MA Purpose: Current trends in health care are now focused on decreasing length of stay while attaining high functional outcomes. Group treatment is an integral part of this process. On the Musculoskeletal Serviceline, there is high utilization of group strategies. Description: Several groups are co-led by a physical therapist and a rehabilitation technician. These groups focus on patient education, functional mobility, and exercise programs designed specifically for ROM each patient. Other groups are co-led by an occupational therapist and emphasize up per and lower extremity strength and functional mobility. Observations: Interdisciplinary groups are beneficial because they foster a team approach with patients and increase consistency between physical therapy and occupational therapy. All groups allow patients to practice skills learned in their individual physical therapy sessions. Patients also demonstrate increased carryover of home exercise programs and improved knowledge about their diagnoses. Patients provide each other with emotional support and performance feedback. Patients in group treatment appear to gain higher levels of independence with advanced activities. Group treatment also benefits individual therapists. Therapists can focus on activities requiring individual attention such as new skills, manual techniques, and stretching. Conclusion: Use of group treatment allows this rehabilitation hospital to offer orthopaedic patients and third party payors a program with defined, higher level outcomes. Program goals appear to be achieved more quickly and patient satisfaction is high. Recommendations are to develop an orthopaedic group treatment program in the outpatient program. Future plans include completion of a patient satisfaction survey and a study on patient outcomes as they relate to group participation. Effectiveness of Two Back Modalities in Enhancing Cervical, Thoracic, and Lumbosacral Range of Motion in Healthy Females Graetzer DG, Kovacich )M, Richter ST; The University of Montana, Missoula, MT The influence of two back modalities (Backman Power Massage, Back Machine) on cervical, thoracic, and lumbosacral range of motion (ROM) was examined in 12 healthy, active females (27.6 2 5.8 years, 167.0 + 5.4 cm, 64.51 + 11.33 kg, 20.7 + 6.9% body fat). Trunk ROM measurements were assessed in triplicate immediately before and after 20 minutes of supine treatment using each modality following manufacturer protocols and control (supine rest) using a Dynatron 360 computerized ROM tester and goniometer. The trials were randomized and separated by 1 to 3 days. Repeated measures analysis of variance revealed significant (p 5.001) increases in posttreatment degrees of ROM of cervical flexion (CF), cervical extension (CE), thoracic flexion (TF), lumbosacral flexion (LF), lumbosacral extension (LE), right lateral flexion (RLF), and left lateral flexion (LLF) as compared with pretreatment degrees of ROM during both modality treatment trials. The ROM increases following a single treatment with either modality were similar. No significant changes in ROM were noted during the control trial or in heart rate or systolic or diastolic blood pressure during any of the three trials. None of the subjects experienced any adverse effects as a consequence of either modality treatment. These data (see Table at bottom of page 78) establish the effectiveness and safety of the Back- Backman Power Massage Back Machine Control Pretxt Post-txt Pretxt Post-txt Pretxt Post-txt CF ("1 69.7 2 6.8 81.3 + 5.3' 69.5 2 5.3 77.3 2 6.8' 71.8 + 6.1 72.3 t 6.1 CE ('1 61.8 f 8.5 72.8 2 6.9* 64.3 2 9.7 70.2 2 8.1 62.9 2 8.1 63.8 + 7.1 TF ("1 69.1 t 11.2 76.2 2 8.5* 66.0 f 8.8 73.8 2 8.1' 66.9 t 9.5 66.3 2 9.7 LF V) 102.0 2 15.9 110.21 t 11.6' 103.5 t 12.2 11 3.2 2 12.7* 103.2 t 11.9 104.0 t 12.0 LE ('1 39.0 f 10.2 46.9 + 9.2' 34.9 t 9.9 41.3 2 10.0* 36.9 t 10.9 36.3 t 11.1 RLF ("1 32.1 f 6.1 39.1 f 7.2* 33.4 + 6.7 37.4 t 7.1* 32.9 2 5.1 33.2 2 6.0 LLF ('1 31.5 t 6.2 38.7 2 6.0' 31.9 2 6.2 36.8 2 6.3* 33.3 + 5.6 33.2 t 6.0 * Posttreatment ROM significantly (p c.001) higher than pretreatment ROM (two-tailed test). Pre-txt = Pretreatment. Post-kt = Posttreatment. TABLE. Volume 23 Number 1 January 1996 JOSPT