Physical Therapy

Published by American Physical Therapy Association
Online ISSN: 1538-6724
Print ISSN: 0031-9023
Publications
The profession of physical therapy has a obligation to evaluate its many treatment and testing methods to ascertain their value, importance, and usefulness. Our evaluation of what we do must be based on measurement and research in physical therapy. The principles of measurement and research are discussed in some detail. The four scales of measurement, and the data they produce, are described. Test reliability and validity are discussed. Research is defined and its two principal forms, experimental and correlational, are discussed. The use of these principles in evaluating physical therapy treatment and testing methods is described by using clinical examples.
 
To the Editor The article by Morris et al¹ on the status of the motor program (August 1994) provides an excellent review of the research and theory literature in an area that should be of special interest to readers whose practice, research, or teaching focuses on the movement problems of persons with central nervous system deficits. Unfortunately, the level of reduction at which the authors weigh the theoretical arguments and the available evidence, like that at which Gordon² offers the invited commentary on the article, is more abstract than that at which physical therapists observe and try to alter the movement behavior of patients. The more abstract level of reduction is absolutely essential to further developments in research and theory on human motor performance and learning.…
 
Research is important to physical therapy because it provides a more scientific framework through basic and applied investigations; improves individual patient care through clinical and applied research; and improves the delivery of health services through clinical studies and research in teaching methodology. Every therapist can, and should, participate in clinical research. Those who ignore the fact that research is the foundation of every viable discipline should expect a sterile science and a decreased rate of growth.
 
To the Editor As with many other health care providers, recent and impending changes in the delivery of health care have forced physical therapists to wrestle with several aspects of their professional practice. Yet, another equally serious issue awaits our urgent attention: professional education. In less than 15 years, all alert and professionally conscious physical therapists will be called on to take a second look at this freshly brewing debate on the means and methods to attain the professional (doctoral) degree in physical therapy. Physical therapists who want to practice in the 21st century need to set their goals now. In many ways, this is an especially critical time. Action or inaction on our part now can make or break our future role. The writing on the wall is clear: Heed the call of the times, or suffer professional slavery and socioeconomic decline for all times to come.…
 
Scientific rigor is being demanded to assess our clinical effectiveness. The rationale for failing to hold our education programs to such outcomes data prior to making a sweeping change eludes me. If data can be presented that the professional doctoral degree is necessary and sufficient for achieving the professional outcomes espoused by Threlkeld et al and other leaders in the profession who endorse the professional doctorate, I will not hesitate to support this professional initiative. Until such evidence presents itself, however, I will remain skeptical, and I encourage others in the profession to require data-based evidence before endorsing such a move. The change of professional degree credential is likely to have an enormous impact on the profession in the 21st century. Such a change surely demands that we ascribe to our own standards of evidence.
 
Techniques of the systems approach and systems analysis are applied to the physical therapy system. The fundamental premises of the systems approach are discussed. The approach is then applied to physical therapy by determining the objectives of the physical therapy system and describing the operations of physical therapy in terms of seven functional subsystems, each of which functions to attain the system’s objectives. A seven-stage paradigm of the systems analysis technique is presented, and each of the stages of analysis is applied to the physical therapy system.
 
To the Editor I was sorry to see that in their response to my October 1991 letter to the editor (Phys Ther. 1991;71:763–764) about their May 1991 article on the first-year results of the Association's 3-year study of physical therapy practices (Phys Ther. 1991; 71:366–381), Jette and Davis chose not to document the source of their contention that “the probability of falsely rejecting K true null hypotheses in a series of N independent t tests (N>K) increases as N increases, even if the tests are on different variables [italics added]” (Phys Ther. 1991;71:764–765). Response Alan M Jette, PhD, PT, Senior Research Scientist, New England Research Institute Inc, 9 Galen St, Watertown, MA 02172 Kenneth D Davis, PT, Assistant Director for Operations, Mid-America Rehabilitation Hospital, 5701 W 110th St, Overland Park, KS 66211
 
This excerpt was created in the absence of an abstract. After being asked to deliver this most prestigious lectureship (Figure), one of the first things I did was look at the list of previous Mary McMillan Lecturers. Looking at the cast that preceded me, I was nothing short of awestruck. I graduated from my entry-level [professional] physical therapy training in 1979 and attended my first APTA annual conference in 1980. I vividly remember attending Florence Kendall's Mary McMillan address.1 I have not missed many McMillan Lectures since then. In fact, I can count on one hand those I have missed. My fondest memories of these lectures involve the highly spirited debate about some of the more pressing issues of our time. Suffice it to say that you [McMillan Lecturers] did not always agree about these issues. Why should we be surprised that this group would have differences of opinion?
 
To help advance theory in physical therapy, the 1987 Annual Conference Call for Participants will invite a new type of presentation, Theory Papers. Each paper is to address the kind of theory being presented, the explanatory or predictive purpose of the theory, the evidence on which the theory is based, the testability of the theory, and the importance of the theory. Theory connects practice and ideas. Prediction of new treatment techniques, explanation of existing methods, and discrimination between fruitless and potentially fruitful areas of research inquiry depend on integration of ideas, empirical research data, and practice in the clinic. This integrator of facts and ideas is theory.¹ Much of the basic biology and physiology required to generate theory in physical therapy is in place. Physical therapists are beginning to accumulate the empirical, clinical data required for sophisticated theory germination.
 
This study examined the personal and technical characteristics used in an investigation of role modeling in physical therapy. Recently graduated physical therapists performed a forced-choice Q sort composed of 49 physical therapist characteristics to describe 1) themselves, 2) their model academic instructor, and 3) their model clinical instructor. A significant difference between the frequency of personal and technical characteristics placed in the Most Descriptive section resulted for the self sort. The 10 characteristics ranked by highest mean values were all personal for self sorts, the majority were personal for the clinical model and combined sorts, and were equally divided between personal and technical for the academic model sorts.
 
To the Editor In their May 1991 article on the first-year results of the Association's 3-year study of physical therapy practices (Phys Ther. 1991;71:366–381), Jette and Davis urged that caution be used in interpreting statistical significance from the multiple t tests they reported, “because at least 1 of every 20 tests undertaken will achieve statistical significance by chance alone.” In commenting on the report, Selker asserts this conclusion may be too optimistic after “61 repeated t tests on the same data.” The article by Jette and Davis reveals some problems with data analysis and interpretation that the authors and commentator either did not address or did not address satisfactorily. Response Alan M Jette, PhD, PT Senior Research Scientist, New England Research Institute Inc, 9 Galen St, Watertown, MA 02172 Kenneth D Davis, PT Assistant Administrator for Operations, Mid-America Rehabilitation Hospital, 5701 W 110th St, Overland Park, KS 66211
 
Studies have demonstrated a bactericidal effect of laser irradiation when lasers with power outputs of (6 mW are directed toward pathogenic or opportunistic bacteria previously treated with a photosensitizing agent. The purpose of this study was to determine the bactericidal capabilities of irradiation from lasers with power outputs of less than 6 mW on photosensitized microorganisms. Two bacteria that commonly infect skin lesions, Staphylococcus aureus and Pseudomonas aeruginosa, were used. The 2 lasers used, the 0.95-mW helium -neon laser and the 5-mW indium-gallium-aluminum-phosphate laser, emit light at a wavelength close to the absorption maxima of the sensitizing agent chosen, toluidine blue O. This agent was used because of its proven effectiveness in sensitizing bacteria. For each bacterial strain, toluidine blue O was added to a 108 cells/mL solution until a 0.01% weight/volume ratio was obtained. These mixtures were spread on agar-coated petri dishes, which were then exposed to 1 of the 2 lasers for 30, 60, and 120 seconds. The cultures were then grown overnight and examined for one or more visible zones of inhibition. The areas surrounding the irradiated zone provided a control for the effects of toluidine blue O alone. To determine the effects of laser irradiation without prior toluidine blue O sensitization, separate plates were established using unsensitized bacteria. Although inconsistencies between plates were noted, both lasers produced at least one zone of inhibition in both bacterial species at all 3 time periods. The 5-mW laser, however, produced a greater number of these zones. Laser-induced microbial killing of photosensitized organisms could have clinical applications in the treatment of infected skin lesions, pending in vivo studies.
 
[ Editor's note: Both the letter to the editor by Bjordal and colleagues and the response by White and colleagues are commenting on the author manuscript version of the article that was published ahead of print September 15, 2014. ] We have read “The American Physical Therapy Association's Top Five Choosing Wisely Recommendations”1 (CWR) with interest. The article will probably have great impact as an official white paper originating from APTA, and it joins a national initiative aimed at reducing health care costs across professions. This is an important and timely initiative, and it is welcomed. The first of the 5 specific recommendations is to limit the use of “passive” physical agents (PAs) because: “A carefully designed active treatment plan has a greater impact on pain, mobility, function, and quality of life.” Within our profession, other interventions such as massage, manipulation, and mobilization also are “passive” modalities (cf, exercise), but they are very seldom labeled as such. Similarly, analgesic medications, injections, and surgery also are “passive” treatments. All of these non–physical therapy-related interventions come with higher risk than physical agents or even manual therapies. Physical agents can provide safe, low-cost management as an alternative to analgesic medications or more invasive procedures, such as injections or surgery. Some physical agents also can be provided to the patient for home use as part of a self-management plan. Additionally, this recommendation is not based on the best available evidence. It is important to remember that the framework for CWR demands identification of certain tests or treatments commonly used “in the absence of evidence demonstrating benefit.” The ABIM Foundation even strengthens the evidence criterion to say that: “there is strong evidence that demonstrates that the service offers no benefit to most patients.”1 The first CWR states, “Don't use passive physical agents except …
 
Measurements of the integrity of knee ligaments are used to diagnose injuries as well as to document the state of recovery. Many factors, such as gender and experience of the examiner, are capable of influencing the reliability of such measurements. The purpose of this study was to determine the effects on interrater reliability of measurements obtained using the KT-1000 arthrometer of experience, gender, and leg tested. Two experienced examiners (1 male, 1 female) and two inexperienced examiners (1 male, 1 female) tested 22 subjects with unilateral anterior cruciate ligament (ACL) pathology. The leg with an ACL injury and the uninjured leg of each subject were evaluated by all four examiners within one test session using 67-N, 89-N, maximum manual, and active anterior drawer tests. Greater anterior displacement values were found in the legs with ACL injury than in the uninjured legs. Reliability estimates, as assessed by intraclass correlation coefficients (2,k) and measurement error (SEM), suggest that therapist experience may be a more important factor influencing reliability than gender. Given the magnitude of the errors obtained for tests routinely conducted in the clinic using the KT-1000 arthrometer, we recommend that repeated measurements should be taken by the same examiners whenever possible. [Ballantyne BT, French AK, Heimsoth SL, et al. Influence of examiner experience and gender on interrater reliability of KT-1000 arthrometer measurements.
 
We would like to congratulate Janssens et al on their case report1 published in the July 2014 issue of PTJ . Their findings are important in that following application of LSVT BIG® treatment to 3 individuals with Parkinson disease (PD), they demonstrated clinically significant improvements in gait, balance, and bed mobility through their standardized outcome assessments. In addition, their documentation of the more than 5-point drop (5.6) in the Unified Parkinson's Disease Rating Scale motor score is consistent with that previously documented by Ebersbach et al …
 
I commend the authors on exposing physical therapists to the International Classification of Functioning, Disability and Health (ICF) model.1 However, I take issue with the comment that they “found scarce evidence to indicate that the ICF has …
 
As physical therapists who have been working since the 1980s with patients diagnosed with HIV, it was a pleasure to read this well-done study.1 The Bauer et al article clearly reflects the fact that many individuals with HIV today have a greatly different set of problems and comorbidities than those affected in the 1980s, a time when HIV …
 
Exercise capacity, muscle function and physical activity levels remain reduced in lung transplant recipients. Factors associated with this deficiency in functional exercise capacity have not been studied longitudinally. Analyze the longitudinal change in 6-minute walking distance and identify factors contributing to this change. Longitudinal historical cohort study METHODS: Data of patients that received a lung transplantation between September 2003 and September 2013 were analyzed for course of 6-minute walking distance and contributing factors at screening, discharge, 6-months and 12 months after transplantation. Linear mixed model and logistic regression analyses were performed with data on patients' characteristics, diagnosis, waiting list time, length of hospital stay, rejection, lung function and peripheral muscle strength. Data of 108 recipients were included. Factors predicting 6-minute walking distance were measuring moment, diagnosis, gender, quadriceps and grip strength, forced expiratory volume in 1 second (% pred.) and length of hospital stay. After transplantation, 6-minute walking distance considerably increased. This initial rate of increment was not continued between 6 and 12 months. At 12 months post-lung transplantation, 58.3% of recipients did not reach the cutoff point of 82% of the predicted 6-minute walking distance. Logistic regression demonstrated that discharge values of forced expiratory volume in 1 second combined with quadriceps or grip strength were predictive for reaching this criterion. Lack of knowledge on the course of disease during the waiting list period, type and frequency of physical therapy after transplantation and the number of missing data points. Peripheral muscle strength predicts 6-minute walking distance, this suggests that quadriceps strength training should be included in physical training to increase functional exercise capacity. Attention should be paid to further increasing 6-minute walking distance between 6 and 12 months after transplantation. © 2014 American Physical Therapy Association.
 
It was with interest and some concern that we read the report by Cotchett et al1 published in the August 2014 issue of PTJ . Although the authors reported statistically significant differences in first-step pain and foot pain in favor of trigger point dry needling over sham dry needling, it appears that the actual palpatory methods used by Cotchett et al1 to identify the location of the target trigger points and, therefore, the entry point, angulation, and depth of needle insertion have not yet been found to possess accurate diagnostic validity or acceptable intra- or inter-examiner reliability for muscles in the foot or lower leg. Therefore, the results of the study by Cotchett et al,1 including the reported frequency counts of myofascial trigger points in specific foot intrinsic and lower leg muscles, should be questioned, or at least viewed cautiously. There are several original trials, literature reviews, and meta-analyses that support our contention on this issue. In a recent systematic review, Tough et al concluded, “There is a lack of robust empirical evidence validating the clinical diagnostic criteria [for trigger point identification or diagnosis] proposed by both Travell & Simons (1999) and Fischer (1997).”2 In another systematic review on the reliability of physical examination for the diagnosis of myofascial trigger points, Lucas et al concluded, “There is no accepted reference standard for the diagnosis of trigger points, and data on the reliability of physical examination for trigger points is conflicting.”3 In addition, a predictable pattern of pain referral and the local twitch response are each no longer considered sufficient or necessary for diagnosing trigger points.2–4 Yet, regardless of the existing evidence, Cotchett et al1 still decided to use “a characteristic pattern of referred pain” and “a local twitch response” as 2 …
 
Figure.  
Background: Despite increasing clinical and research use of the 11-item version of the Tampa Scale for Kinesiophobia (TSK-11) in people with neck pain, little is known about its measurement properties in this population. Objective: The purpose of this study was to rigorously evaluate the measurement properties of the TSK-11 when used in people with mechanical neck pain. Design: This study was a secondary analysis of 2 independent databases (N=235) of people with mechanical neck pain of primarily traumatic origin. Methods: The TSK-11 was subjected to Rasch analysis and subsequent evaluation of concurrent associations with the Neck Disability Index and a numeric rating scale for pain intensity. Results: The TSK-11 conformed well to the Rasch model for interval-level measurement, but less so for acute or nontraumatic etiologies. A transformation matrix suggested that small changes at the extremes of the scale are more meaningful than in the middle. Cross-sectional convergent validity testing suggested relationships of expected magnitude and direction compared with pain intensity and neck-related disability. The use of the linearly transformed TSK-11 led to potentially important differences in distribution of data compared with use of the raw scores. Limitations: The sample size was slightly smaller than desired for Rasch analysis. The 2 databases were similar in terms of symptom duration, but differed in pain intensity and age. Conclusions: The TSK-11 can be considered an interval-level measure when used in people with neck pain. It provides potentially important information regarding the nature of neck-related disability. Clinically important difference may not be consistent across the range of the scale.
 
We were interested to read the article by Gabel and colleagues,1 who conducted a head-to-head comparison study of the psychometric properties of the Lower Extremity Functional Scale (LEFS),2 an instrument we developed in 1999, and the Lower Limb Functional Index (LLFI), an instrument developed by the authors. We have long been advocates of head-to-head comparisons of competing instruments to determine which has the greatest potential to positively affect clinical care.3 We would like to make some general comments regarding the conceptual framework, and then make more specific comments regarding the methods and literature interpretation in Gabel and colleagues' article. We developed the LEFS2 based on the World Health Organization's model of disability and handicap.4 The more contemporary terms consistent with the current version of the International Classification of Functioning, Disability and Health (ICF)5 that guided instrument development are “activity limitations” and “participation restrictions.” Because our focus was on people with musculoskeletal disorders of the lower extremity, all of the items in our scale captured the person-level activity limitations and participation restrictions most relevant to people with disorders of the lower extremity. Notably absent from the LEFS are questions related to impairments (eg, pain, joint stiffness) or mental health status (eg, irritability, depression). Our rationale for this approach was that we saw problems with other functional status instruments available at the time because they combined questions related to impairments, such as pain and joint stiffness, with items dealing with person-level function and items related to psychological distress. An example of …
 
The purposes of this article are to describe an early passive motion program for the healing extensor tendon and to report the results and trends noted in a review of 112 complex extensor tendon injuries treated with this therapeutic technique. The rationale for this technique is based on a review of the physiologic response of healing tendon to controlled stress. Clinical application is dependent on a biomechanical study of extensor tendon excursion, which allows the therapist to apply controlled stress to the healing tendon with precision. The early passive motion technique is considered in terms of physiology, biomechanics, clinical application, and results. The author concludes that early controlled passive motion for the complex extensor tendon injury in zones V, VI, VII, T IV, and TV is a safe and effective rehabilitation technique that reduces complications associated with extensor tendon injury and repair.
 
We commend the authors for undertaking a systematic review on this topic,1 but we have serious reservations about their methods and conclusions. Clinical prediction rules (CPRs) or clinical decision rules can be used to make a diagnosis, predict disease progression, predict prognosis, or select therapy. Benecuik et al reviewed CPRs that were developed to select therapy but then evaluated the quality of these CPRs using criteria designed for prognosis studies. This is unfortunate because the optimal design and analysis strategies for a prognosis …
 
[ Editor's note: Both the letter to the editor by Franchignoni and Giordano and the response by Padgett and colleagues are commenting on the accepted but unedited author manuscript version of this article that was published ahead of print on June 7, 2012. ] We read with interest the article by Padgett et al1 in which they presented a new short version of the BESTest (Brief-BESTest) and compared some of its metric properties against the established BESTest2 and the Mini-BESTest.3 A few shortcomings of the authors' work and a misinterpretation of our article3 prompt us to respond. Padgett et al explained the necessity of a new shortened version of BESTest, different from the Mini-BESTest, on the basis of anecdotal reports suggesting that the latter remains too lengthy (about 15 minutes) given increasing constraints on patient contact time in the clinic.1 Moreover, the authors felt the lack of a scale more in line with the theoretical objective of the BESTest, which is to provide a global assessment of multiple constructs that influence postural control. Thus, the authors created the Brief-BESTest, selecting the “most representative item” in each of the 6 balance domains listed in BESTest,2 based on item-total correlation.1 Although conceptually appealing, choosing …
 
We would like to respond to the statement by Armijo-Olivo and colleagues1 that the Physiotherapy Evidence Database (PEDro) scale has not been adequately developed or adequately tested for reliability and validity. Because no citations …
 
In the interest of full disclosure, Dr Dennis Hart is a director of Focus on Therapeutic Outcomes, Inc (FOTO), which develops outcome measures and services for physical therapy and rehabilitation . The work by Costa et al1 represents a step forward in the assessment of treatments that are helpful for patients with lumbar spine impairments. The strength of their study lies in their design, which has been nicely reviewed by Fritz.2 However, we would like to direct attention to a psychometric matter that appears to have been overlooked by Fritz, the editors and reviewers, and the authors. Costa et al used the Patient-Specific Functional Scale (PSFS)3,4 to assess change in “activity” in their sample. Using aggregated PSFS scores to assess change in groups of patients represents a major conceptual and psychometric error, which makes interpretation of results difficult. In the present study, the authors also used the Roland-Morris Disability Questionnaire5 to assess “activity,” which provided results similar to those obtained using the aggregated PSFS scores, so our discussion is entirely related to the psychometric appropriateness of using aggregated PSFS scores to assess change in function in groups of patients, not the ultimate results of the study. If one starts with the assumption that the reported purpose of the PSFS is to assess functional ability and its change in …
 
To the Editor: We were glad when we discovered the article by Lenssinck et al, titled “Effect of Bracing and Other Conservative Interventions in the Treatment of Idiopathic Scoliosis in Adolescents: A Systematic Review of Clinical Trials,” because it relates to a field that today is not adequately covered.1,2 However, we believe that there was a relative failure in collecting all of the relevant articles on the topic, which is a big methodological problem in a …
 
Lyme disease is well documented in the literature; however, specific physical therapy interventions for the pediatric population with residual effects of Lyme disease have not been addressed. The purposes of this retrospective case report are: (1) to present an example of a therapeutic intervention for a pediatric patient in the late stages of Lyme disease with related musculoskeletal dysfunction and severely impaired quality of life, (2) to report the patient's functional outcomes from treatment, and (3) to discuss implications for treatment of patients with musculoskeletal dysfunction in the late stages of Lyme disease. The patient was a 14-year old girl who had contracted Lyme disease 1 year prior to initiation of physical therapy. She was unable to participate with her peers in school, church, and sporting events due to significant impairments in strength (force-generating capacity), endurance, and gait; fatigue; pain; and total body tremor. Therapeutic exercise and gait training were used for treatment. The patient actively participated in managing her care by providing feedback during interventions and setting goals. After 18 weeks of treatment, the patient achieved 96.7% of her predicted distance on the Six-Minute Walk Test with normal gait mechanics and returned to playing high school sports. She had a manual muscle test grade of 4/5 or greater in major extremity muscle groups. She returned to school and church participation with minimal total body tremor when fatigued and daily pain rated 0 to 3/10. Therapeutic exercise and gait training may facilitate return to function in an adolescent patient with late effects of Lyme disease. Further investigation is advised to establish treatment effects in a broader population.
 
I must protest the title of this systematic review.1 A review of this systematic review reveals that there is nothing in the review that indicates whether or not low amounts of ultrasound energy improve soft tissue shoulder pathology. In fact, the authors clearly state, “Our results suggest that the effectiveness of ultrasound on soft tissue pathologies has not yet been evaluated using optimal treatment parameters, and, therefore, it is premature to conclude through systematic review of existing literature that this treatment dose ‘is not effective.’” Given that, the reader has to wonder how and why this title came about. Why didn’t the title reflect the finding that there were some beneficial effects from higher exposure to ultrasound energy? …
 
The purposes of this paper is to orient physical therapists to Public Law 94-142 and to reflect upon the implications of this law for therapists in clinical settings and preservice training. Key phrases relative to this law are "least restrictive environment" and "free and appropriate education." Both phrases have direct implications for physical therapists because local educational agencies must provide services and experiences that are deemed appropriate for a child's educational needs. Physical therapists may deal in direct services, consultant roles, or evaluative processes. Public Law 94-142 has created unique opportunities for physical therapists in the public school setting.
 
Murray and colleagues1 are to be commended for their attempt to identify the role of the otolith organs in the clinical presentation of patients with unilateral vestibular disorders. With the advent of the subjective visual horizontal (SVH), subjective visual vertical (SVV), and vestibular evoked myogenic potential (VEMP) tests, it has become feasible to assess otolith function as a component of the vestibular function test battery. How the otolith organs influence symptoms, clinical signs, and recovery is not known and is a valid question. Murray and colleagues attempted to address this question by assessing both physical performance measures and self-report measures of symptom intensity and the impact of those symptoms in patients with either combined semicircular canal and otolith disorders or semicircular canal–only disorders. As the authors noted, this study was predicated on the ability to correctly classify these 2 groups of patients, and this is where the study suffers. First, with the exception of benign paroxysmal positional vertigo (BPPV) …
 
I read with interest the perspective on the PASS meeting.1 Obviously, a great deal of work and thought went into the deliberations. Understandably, only general directions can be described at this stage of planning, but, for the naive reader, a few examples with some details would be useful. For example, there was frequent reference to the “paradigm shift” in health care delivery, yet a clear explanation of what the shift is going to be or even the potential possibilities was not evident. Possibly, the proposed “patient-centered” care is the paradigm shift, but the meaning and implications of this concept need additional explanation. In some ways, I always thought the patient was the focus. Maybe this is a way of saying that all of the individuals involved in a patient's care need to interact more than is currently the situation. This has been the “rehabilitation model,” but maybe not applied to other conditions. I believe that is because only relatively recently have we recognized the “lifestyle” relationship of most health-compromising conditions. I did note a specific recommendation that physical therapy will be more involved in fitness, wellness, and health and that technology would be important. I do believe that exercise is key to what defines physical therapy and key to our economic future. What worries me is the implementation of this direction. Such recommendations have been made before, as in Marilyn Moffat's 2004 Mary McMillan Lecture.2 In her lecture, the critical issue that Moffat posed was that “we have lost sight of what is necessary to make us exercise experts.”2(p1078) Moffat specifically cited the educational programs as losing sight; …
 
This case report on right anterior ilial rotation hypermobility (RAIRH) presented a successful outcome with a comprehensive approach in 33 visits.1 It was particularly inspiring to read of the use of film, which clearly identified a problem with the patient's tennis stroke. After resolving RAIRH, the client's tennis stroke was retrained to address prevention of recurrence. The authors were thorough in their literature review, revealing some research that could discourage evaluation and treatment of RAIRH, while providing a good rationale for including treatment of RAIRH as part of a comprehensive approach. There were many insightful statements within the article, and my copy is well highlighted. I would like to share some general thoughts and observations I have made regarding the topic. In the case report,1 the term “altered function of the pelvis” was part of the definition of sacroiliac joint dysfunction (SIJD). This is very appropriate, as research and opinion have been presented …
 
I was pleased to find the article about sacroiliac joint dysfunction (SIJD) by Vaughn and Nitsch1 in the December 2008 issue of PTJ . Reading the paper gave me some thoughts on how evidence is being interpreted and used in the clinic. Current evidence suggests that the diagnosis of sacroiliac joint syndrome (SIJS) is difficult because of the paucity of tests with good measurement properties. Thus, I agree with Vaughn and Nitsch's statement that “there is a lack of sensitive and specific tests to diagnose SIJ [sacroiliac joint] pain, which is commonly referred to as ‘sacroiliac joint syndrome’ (SIJS).”1(p1579) However, a few paragraphs later the authors state, “Accurate diagnosis of the type of SIJD [sacroiliac dysfunction] is essential in determining the appropriate therapeutic intervention.”1(p1579) How do we interpret the apparent contradiction between not having the evidence and yet needing this evidence to …
 
I was surprised by the content of the article by Vaughn and Nitsch1 and the inductive and often contradictory logic used throughout the case report. The current evidence-based literature on low back pain is leaning heavily toward a treatment-based classification system, with an active treatment paradigm.2,3 This article seems to fly in the face of this evidence and proposes a structural-based diagnostic classification based on poor tests and passive treatment, namely bed rest, transcutaneous electrical nerve stimulation, ice, ultrasound, massage, and taping.4–8 The active treatment provided to the patient appears to be based on inductive reasoning to address the pseudo-diagnostic category arrived at by a series of nonvalid tests, proposed by the authors, and poorly supported by the evidence and anecdotal reference to opinion-based papers. In the introduction, the authors do review the current evidence-based literature and outline that most testing procedures for the sacroiliac (SI) complex have poor validity, yet proceed to ignore this and use the nonvalid tests …
 
Univariate and Multivariate Analyses of Variance Comparing Variables Recorded by the Two Gait Analysis Methods 
The purpose of this study was to compare a clinical gait analysis method using videography and temporal-distance measures with 16-mm cinematography in a gait analysis laboratory. Ten children with a diagnosis of cerebral palsy (means age = 8.8 +/- 2.7 years) and 9 healthy children (means age = 8.9 +/- 2.4 years) participated in the study. Stride length, walking velocity, and goniometric measurements of the hip, knee, and ankle were recorded using the two gait analysis methods. A multivariate analysis of variance was used to determine significant differences between the data collected using the two methods. Pearson product-moment correlation coefficients were determined to examine the relationship between the measurements recorded by the two methods. The consistency of performance of the subjects during walking was examined by intraclass correlation coefficients. No significant differences were found between the methods for the variables studied. Pearson product-moment correlation coefficients ranged from .79 to .95, and intraclass coefficients ranged from .89 to .97. The clinical gait analysis method was found to be a valid tool in comparison with 16-mm cinematography for the variables that were studied.
 
Walking economy at speeds from 0.8 mph to 4 mph. The control group participated in a home-based program of exercises recommended by the National Parkinson Foundation, 18 the AE group participated in a standard aerobic endurance program, and the FBF group participated in a flexibility/balance/function program specifically designed for people with Parkinson disease (PD). Oxygen uptake (V ˙ O 2 , in mL/min/kg) is presented for each group at 4 time points (baseline, 4, 10, and 16 months), illustrating the improvement (less oxygen required) for the AE group, but not for the other 2 groups. Walking speeds (increased by 0.5 mph for 4 speeds) are determined for each participant by the maximum walking speed achieved during the graded exercise test. 
Background Exercise confers short-term benefits for individuals with Parkinson disease (PD).Objective The purpose of the study was to compare short- and long-term responses among 2 supervised exercise programs and a home-based control exercise program.DesignThe 16-month randomized controlled exercise intervention investigated 3 exercise approaches: flexibility/balance/function exercise (FBF), supervised aerobic exercise (AE), and home-based exercise (control).SettingThis study was conducted in outpatient clinics.PatientsThe participants were 121 individuals with PD (Hoehn & Yahr stages 1-3).InterventionThe FBF program (individualized spinal and extremity flexibility exercises followed by group balance/functional training) was supervised by a physical therapist. The AE program (using a treadmill, bike, or elliptical trainer) was supervised by an exercise trainer. Supervision was provided 3 days per week for 4 months, and then monthly (16 months total). The control group participants exercised at home using the National Parkinson Foundation Fitness Counts program, with 1 supervised, clinic-based group session per month.Measurements OUTCOMES: obtained by blinded assessors, were determined at 4, 10, and 16 months. The primary outcome measures were overall physical function (Continuous-Scale Physical Functional Performance [CS-PFP]), balance (Functional Reach Test [FRT]), and walking economy (oxygen uptake [mL/kg/min]). Secondary outcome measures were symptom severity (Unified Parkinson's Disease Rating Scale [UPDRS] activities of daily living [ADL] and motor subscales) and quality of life (39-item Parkinson's Disease Quality of Life Scale [PDQ-39]). RESULTS: /b>Of the 121 participants, 86.8%, 82.6%, and 79.3% completed 4, 10, and 16 months, respectively, of the intervention. At 4 months, improvement in CS-PFP scores was greater in the FBF group than in the control group (mean difference=4.3, 95% confidence interval [CI]=1.2 to 7.3) and the AE group (mean difference=3.1, 95% CI=0.0 to 6.2). Balance was not different among groups at any time point. Walking economy improved in the AE group compared with the FBF group at 4 months (mean difference=-1.2, 95% CI=-1.9 to -0.5), 10 months (mean difference=-1.2, 95% CI=-1.9 to -0.5), and 16 months (mean difference=-1.7, 95% CI=-2.5 to -1.0). The only secondary outcome that showed significant differences was UPDRS ADL subscale scores: the FBF group performed better than the control group at 4 months (mean difference=-1.47, 95% CI=-2.79 to -0.15) and 16 months (mean difference=-1.95, 95% CI=-3.84 to -0.08).LimitationsAbsence of a non-exercise control group was a limitation of the study. CONCLUSIONS:/b>Findings demonstrated overall functional benefits at 4 months in the FBF group and improved walking economy (up to 16 months) in the AE group.
 
Top-cited authors
Chris G Maher
  • The University of Sydney
Jane Latimer
  • The University of Sydney
Steven J Linton
  • Örebro University
Fay Horak
  • Oregon Health and Science University
James H Mcauley
  • Neuroscience Research Australia