PAST ISSUES OF THE JOURNAL OF MANUAL AND MANIPULATIVE THERAPY

Interrater Reliability of Palpation of Myofascial Trigger Points in Three Shoulder Muscles

Carel Bron, PT, MT, Jo Franssen, PT, Michel Wensing, PhD, Rob A.B. Oostendorp, PhD, PT, MT

Abstract: This observational study included both asymptomatic subjects (n=8) and patients with unilateral or bilateral shoulder pain (n=32). Patient diagnoses provided by the referring medical physicians included subacromial impingement, rotator cuff disease, tendonitis, tendinopathy, and chronic subdeltoid-subacromial bursitis. Three raters bilaterally palpated the infraspinatus, the anterior deltoid, and the biceps brachii muscles for clinical characteristics of a total of 12 myofascial trigger points (MTrPs) as described by Simons et al. The raters were blinded to whether the shoulder of the subject was painful. In this study, the most reliable features of trigger points were the referred pain sensation and the jump sign. Percentage of pair-wise agreement (PA) was ≥ 70% (range 63-93%) in all but 3 instances for the referred pain sensation. For the jump sign, PA was ≥ 70% (range 67-77%) in 21 instances. Finding a nodule in a taut band (PA = 45-90%) and eliciting a local twitch response (PA = 33-100%) were shown to be least reliable. The best agreement about the presence or absence of MTrPs was found for the infraspinatus muscle (PA = 69-80%). This study provides preliminary evidence that MTrP palpation is a reliable and, therefore, potentially useful diagnostic tool in the diagnosis of myofascial pain in patients with non-traumatic shoulder pain.

The Journal of Manual & Manipulative Therapy Vol. 15 No. 4 (2007), 203-215

Use of Anterior Tibial Translation in the Management of Patellofemoral Pain Syndrome in Older Patients: A Case Series

Doug Creighton, DPT, OCS, FAAOMPT, John Krauss, PhD, PT, OCS, FAAOMPT, Melodie Kondratek, DScPT, OMPT, Peter A. Huijbregts, PT, DPT, OCS, FAAOMPT, FCAMT, Andrea Will, DPT, OMPT

Abstract: The currently most plausible pathophysiologic theory for the etiology of pain in patients with patellofemoral pain syndrome involves abnormal mechanical stress to the patellofemoral joint. At this time, there is no consensus nor is there a suficient body of research evidence to guide management of patients with patellofemoral pain syndrome. This means that clinicians have to rely to some extent on a mechanism-based approach. Decreased quadriceps flexibility and muscular endurance have been identified as possibly relevant impairments in patients with patellofemoral pain syndrome. Surgical anterior translation of the tibial tuberosity with the Maquet procedure has a proven positive effect on patellofemoral contact forces. This case series studied the effects of a physical therapy management approach that included translating the tibia anteriorly while performing open kinetic chain quadriceps training and manual muscle stretching of the rectus femoris muscle. Outcome measures used included the numeric pain rating scale and goniometric measurement of rectus femoris muscle length in a standardized test position. Anterior tibial translation reduced pain during both interventions and also produced clinically and statistically significant pre- to post-intervention improvements in pain during manual muscle testing and rectus femoris length testing in addition to statistically signiicant pre- to post-intervention increases in rectus femoris muscle length. The results of this quasi-experimental study indicate the need for future experimental study. Future study should include functional in addition to impairment-based outcome measures, standardization and blinding for the rectus femoris muscle length test (should future researchers chose to again use this outcome measure), a pilot study establishing reliability of outcome measures collected by the therapist, younger subjects, and the collection of longer-term outcome data.

The Journal of Manual & Manipulative Therapy Vol. 15 No. 4 (2007), 216-224

Relationship between the Duplex Doppler Ultrasound and a Questionnaire Screening for Positional Tolerance of the Cervical Spine in Subjects with Suspected Vascular Pathology: A Case Series Pilot Study

Eric G. Johnson, PT, DPTSc, NCS, Shaunna Houle, DPT, Andrea Perez, DPT, Summer San Lucas, DPT, Diane Papa, RVT

Abstract: Manual therapy healthcare practitioners routinely perform the vertebral artery test (VAT) to determine cervical positional tolerance and to screen for vertebrobasilar insuficiency (VBI) prior to manipulating the cervical spine. Because the safety and validity of the VAT has been questioned in the literature, the purpose of this study was to determine if a relationship existed between a new tool, the cervical positional tolerance questionnaire (CPTQ), and the duplex Doppler ultrasound indings for patients with suspected VBI. Subjects were 39 consecutive patients referred by their physician for a duplex Doppler ultrasound with suspicion of VBI. On the CPTQ, patients reported whether they avoided certain cervical positions due to symptoms consistent with VBI prior to undergoing the ultrasound. The CPTQ had a sensitivity = 1.00 (95% CI: 0.34-1.00); specificity = 0.78 (95% CI: 0.64-0.92); negative likelihood ratio = 0.00 (95% CI: 0.02–2.73); and positive likelihood ratio = 4.50 (95% CI: 1.67-7.89). The results of this case series study, while preliminary, are encouraging. Further research with larger sample sizes is warranted in the development of the CPTQ regarding pre-cervical manipulation clinical decision-making. Inclusion of subjects from a cohort including asymptomatic people (no suspicion of VBI) would also strengthen the screening ability of the CPTQ. In addition to duplex Doppler ultrasound, using a gold standard test of vertebral artery testing by way of magnetic resonance angiography (MRA) would further improve data on the diagnostic utility of the CPTQ.

The Journal of Manual & Manipulative Therapy Vol. 15 No. 4 (2007), 225-230

Slump Test: Sensory Responses in Asymptomatic Subjects

Jeremy Walsh, BSc (Hons), M Manip Ther, MMACP, Miriam Flatley, BSc (Hons), Niall Johnston, BSc (Hons), Kathleen Bennett, PhD

The Slump Test is used as a fast, low-cost diagnostic tool in the evaluation of leg and back pain disorders. The purpose of this study was to identify the normative sensory responses to the Slump Test in asymptomatic subjects. Eighty-four subjects were tested using a standardized procedure by the same examiner to ensure consistency. Prevalence, intensity, location, and nature of responses at each stage of the Slump Test [Slumped Sitting (SS), Knee Extension (KE), Ankle Dorsiflexion (AD), and Cervical Extension (CE)] were recorded. Of the subjects, 97.6% reported a sensory response during the Slump Test. Prevalence of responses increased signiicantly from 29.8% at SS to 94% at KE and decreased signiicantly from 97.6% at AD to 65.5% at CE. Median intensity of responses increased significantly from 0/10 at SS, through 4/10 at KE, to 6/10 at AD, and then decreased significantly to 2/10 at CE. At SS, responses were located at the back or neck, but during the subsequent stages, responses were located most commonly in the posterior thigh, knee, and calf. In terms of nature, a number of different descriptors were used, the most common being "stretch," "tight," and "pull." Approximately 80% of subjects reporting a response had complete or partial relief of this response following cervical extension, indicating that the normal response to the Slump Test may be considered a neurogenic response. This normative data may be used as a reference point when using the Slump Test in the examination of leg and back pain disorders.

The Journal of Manual & Manipulative Therapy Vol. 15 No. 4 (2007), 231-238

Use of the Patellar-Pubic Percussion Test in the Diagnosis and Management of a Patient with a Non-Displaced Hip Fracture

Leah J. Borgerding, DPT, Pamela J. Kikillus, PT, DHSc, COMPT, OCS, FAAOMPT, William G. Boissonnault, PT, DHSc, FAAOMPT

This case report describes the diagnosis and subsequent medical and physical therapy management of a 68-year-old patient with an undiagnosed non-displaced hip fracture. Initial plain film radiographs and a computed tomography (CT) scan of the involved hip were both interpreted as negative. One of the findings on the physical examination included a positive patellar-pubic percussion test (PPPT). This finding in a female patient of this age raised the suspicion of an occult hip fracture and she was referred back to her primary care physician. Repeat radiographs revealed a non-displaced hip fracture and the patient was treated surgically. The PPPT is an easy-to-implement clinical examination tool that may be extremely useful in physical therapy practice to guide the decision-making process for patients with suspected hip fractures. The utilization of the PPPT by the treating physical therapist for the patient in this case report contributed to a timely diagnosis, potentially preventing the disabling sequelae associated with a displaced femoral fracture.
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Reliability And Measurement Error of Active Knee Extension Range of Motion in a Modified Slump Test Position: A Pilot Study

Neil Tucker, PT, MHSc, Duncan Reid, PT, MHSc, Peter McNair, PhD

The slump test is a tool to assess the mechanosensitivity of the neuromeningeal structures within the vertebral canal. While some studies have investigated the reliability of aspects of this test within the same day, few have assessed the reliability across days. Therefore, the purpose of this pilot study was to investigate reliability when measuring active knee extension range of motion (AROM) in a modiied slump test position within trials on a single day and across days. Ten male and ten female asymptomatic subjects, ages 20-49 (mean age 30.1, SD 6.4) participated in the study. Knee extension AROM in a modified slump position with the cervical spine in a flexed position and then in an extended position was measured via three trials on two separate days. Across three trials, knee extension AROM increased significantly with a mean magnitude of 2° within days for both cervical spine positions (P>0.05). The findings showed that there was no statistically significant difference in knee extension AROM measurements across days (P>0.05). The intraclass correlation coefficients for the mean of the three trials across days were 0.96 (lower limit 95% CI: 0.90) with the cervical spine flexed and 0.93 (lower limit 95% CI: 0.83) with cervical extension. Measurement error was calculated by way of the typical error and 95% limits of agreement, and visually represented in Bland and Altman plots. The typical error for the cervical lexed and extended positions averaged across trials was 2.6° and 3.3°, respectively. The limits of agreement were narrow, and the Bland and Altman plots also showed minimal bias in the joint angles across days with a random distribution of errors across the range of measured angles. This study demonstrated that knee extension AROM could be reliably measured across days in subjects without pathology and that the measurement error was acceptable. Implications of variability over multiple trials are discussed. The modified set-up for the test using the Kincom dynamometer and elevated thigh position may be useful to clinical researchers in determining the mechanosensitivity of the nervous system.
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Letters to the editor

[No abstract available]
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In Memoriam: Dr. Joseph C. Keating Jr.

On October 14th of this year, Dr. Joseph C. Keating passed away at the age of 57 in Kansas City, MO. Born on October 8th of 1950 Dr. Keating grew up in the Hudson River Valley. He studied clinical psychology and clinical research methods at the State University of New York at Albany and was awarded a PhD in 1981. After a post-doctoral residency program at a physical medicine and rehabilitation specialty hospital in Schenectady, NY, he specialized in the conservative treatment of lower urinary tract infections, working in a collaborative private practice with a urologist for two years. For 16 years Dr. Keating was a practicing clinical psychologist in the state of California [No abstract available].
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