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Objective. No study to our knowledge has investigated the effects longer than 1 year of manual therapy in carpal tunnel syndrome (CTS). The purpose of this study was to investigate the effects of manual therapy versus surgery at 4-year follow-up and to compare the post-study surgery rate in CTS. Methods. This randomized controlled trial was conducted in a tertiary public hospital and included 120 women with CTS who were randomly allocated to manual therapy or surgery. The participants received 3 sessions of physical therapy, including desensitization maneuvers of the central nervous system or carpal tunnel release combined with a tendon/nerve gliding exercise program at home. Primary outcome was pain intensity (mean and the worst pain). Secondary outcomes included functional status, symptom severity, and self-perceived improvement measured using a global rating of change scale. Outcomes for this analysis were assessed at baseline, 1 year, and 4 years. The rate of surgical intervention received by each group was assessed throughout the study. Results. At 4 years, 97 (81%) women completed the study. Between-group changes for all outcomes were not significantly different at 1 year (mean pain: mean difference [MD] = -0.3, 95% CI = -0.9 to 0.3; worst pain: MD = -1.2, 95% CI = -3.6 to 1.2; function: MD = -0.1, 95% CI = -0.4 to 0.2; symptom severity: MD = -0.1, 95% CI = -0.3 to 0.1) and 4 years (mean pain: MD = 0.1, 95% CI = -0.2 to 0.4; worst pain: MD = 0.2, 95% CI = -0.8 to 1.2; function: MD = 0.1, 95% CI = -0.1 to 0.3; symptom severity: MD = 0.2, 95% CI = -0.2 to 0.6). Self-perceived improvement was also similar in both groups. No between-group differences (15% physical therapy vs 13% surgery) in surgery rate were observed during the 4 years. Conclusions. In the long term, manual therapy, including desensitization maneuvers of the central nervous system, resulted in similar outcomes and similar surgery rates compared with surgery in women with CTS. Both interventions were combined with a tendon/nerve gliding exercise program at home. Impact. This is the first study to our knowledge to report clinical outcomes and surgical rates during a 4-year follow-up and will inform decisions regarding surgical versus conservative management of CTS. Lay summary. Women with CTS may receive similar benefit from a more conservative treatment--manual therapy--as they would from surgery., Carpal tunnel syndrome (CTS) is considered the most common entrapment neuropathy of the upper extremity. The estimated incidence of CTS in the United States has been reported to be 542 [...]

Background. Physical therapy and opioid prescriptions are common after hip surgery, but are sometimes delayed or not used. Objective. The objective of this study was to compare downstream health care utilization and opioid use following hip surgery for different patterns of physical therapy and prescription opioids. Design. The design of this study was an observational cohort. Methods. Health care utilization was abstracted from the Military Health System Data Repository for patients who were 18 to 50 years old and were undergoing arthroscopic hip surgery between 2004 and 2013. Patients were grouped into those receiving an isolated treatment (only opioids or only physical therapy) and those receiving both treatments on the basis of timing (opioid first or physical therapy first). Outcomes included overall health care visits and costs, hip-related visits and costs, additional surgeries, and opioid prescriptions. Results. Of 1870 total patients, 82.7% (n = 1546) received physical therapy only, 71.6% (n = 1339) received prescription opioids, and 1073 (56.1%) received both physical therapy and opioids. Because 24 patients received both opioids and physical therapy on the same day, they were eventually removed from the final timing-of-care analysis. Adjusted hip-related mean costs were the same in both groups receiving isolated treatments ($11,628 vs $11,579), but the group receiving only physical therapy had significantly lower overall total health care mean costs ($18,185 vs $23,842) and fewer patients requiring another hip surgery. For patients receiving both treatments, mean hip-related downstream costs were significantly higher in the group receiving opioids first than in the group receiving physical therapy first ($18,806 vs $16,955) and resulted in greater opioid use (7.83 vs 4.14 prescriptions), greater total days' supply of opioids (90.17 vs 44.30 days), and a higher percentage of patients with chronic opioid use (69-5% vs 53.2%). Limitations. Claims data were limited by the accuracy of coding, and observational data limit inferences of causality. Conclusions. Physical therapy first was associated with lower hip-related downstream costs and lower opioid use than opioids first; physical therapy instead of opioids was associated with less total downstream health care utilization. These results need to be validated in prospective controlled trials., Prognosis, the forecast of the likely course of a disease or condition, can be influenced by many different factors. One such factor is the timing of an interventions. In some [...]

Background. The Outpatient Physical Therapy Improvement in Movement Assessment Log (OPTIMAL) is a recently developed self-report outcome instrument designed to measure the extent of activity limitation as defined by the World Health Organization. Objective. The purposes of the study were to replicate some aspects of the original study of the OPTIMAL Difficulty and Confidence scales and to conduct additional psychometric tests. Design. A cross-sectional design was used in the study. Methods. of a total of 1,150 patients who received treatment at 4 outpatient centers over the study period, 1,030 patients were recruited for this study and completed the OPTIMAL instrument and previously validated region-specific functional status measures. A variety of analytic methods were used to examine the extent of redundancy between the OPTIMAL Difficulty and Confidence scales, as well as the internal consistency reliability, standard error of measurement, known-groups validity, and convergent validity of OPTIMAL Difficulty Scale scores. Results. The OPTIMAL Difficulty and Confidence scale scores were found in a factor analysis to be load-based on anatomical region rather than on difficulty and confidence concepts. Internal consistency reliability for the subscales of the Confidence Scale varied and was .80 or higher for the lower-extremity subscale but .50 or less for the trunk and upper-extremity subscales. Limitations. Only cross-sectional relationships were examined, and another pure measure of activity limitation was not used for comparison. Conclusions. The findings generally did not support the psychometric properties of the OPTIMAL instrument. Although not conclusive, the data suggested that the OPTIMAL Difficulty and Confidence scales demonstrate substantial overlap. Reliability was generally low, with the exception of the lower-extremity subscale. Scores for the subscales of the Difficulty Scale differentiated among patients with lower-extremity versus trunk or upper-extremity diagnoses, but associations with previously validated region-specific measures were generally weak or absent. Clinicians treating outpatients with musculoskeletal disorders should consider alternative measures when attempting to quantify the extent of activity limitations., The Outpatient Physical Therapy Improvement in Movement Assessment Log (OPTIMAL) was developed by Guccione and colleagues (1) to measure the 'activity' component from the International Classification of Functioning, Disability and [...]

highlights the findings and application of Cochrane reviews and other evidence pertinent to the practice of physical therapy. The Cochrane Library is a respected source of reliable evidence related to health care. Cochrane systematic reviews explore the evidence for and against the effectiveness and appropriateness of interventions--medications, surgery, education, nutrition, exercise--and the evidence for and against the use of diagnostic tests for specific conditions. Cochrane reviews are designed to facilitate the decisions of clinicians, patients, and others in health care by providing a careful review and interpretation of research studies published in the scientific literature. (1) Each article in this PTJ series summarizes a Cochrane review or other scientific evidence on a single topic and presents clinical scenarios based on real patients or programs to illustrate how the results of the review can be used to directly inform clinical decisions. This article focuses on a 32-year-old woman with chronic neck pain with headaches. Could an exercise program help reduce her neck pain and headaches?, It has been reported that 1 in 5 people are currently experiencing neck pain, greater than 50% of the population has had neck pain in the last 6 months, and [...]

Physical therapists consider many factors in the treatment of patients with musculoskeletal pain. The current literature suggests expectation is an influential component of clinical outcomes related to musculoskeletal pain for which physical therapists frequently do not account. The purpose of this clinical perspective is to highlight the potential role of expectation in the clinical outcomes associated with the rehabilitation of individuals experiencing musculoskeletal pain. The discussion focuses on the definition and measurement of expectation, the relationship between expectation and outcomes related to musculoskeletal pain conditions, the mechanisms through which expectation may alter musculoskeletal pain conditions, and suggested ways in which clinicians may integrate the current literature regarding expectation into clinical practice., Physical therapy interventions for musculoskeletal pain conditions often address impairments with the implication that pain and function will improve in response to stretching a tight muscle or strengthening a weak [...]

Background. A clinical prediction rule (CPR) purported to identify patients with neck pain who are likely to respond to thoracic spine thrust manipulation has recently been developed, but has yet to be validated. Objective. The purpose of this study was to examine the validity of this CPR. Design. This was a multi-center randomized clinical trial. Methods. One hundred forty patients with a primary report of neck pain were randomly assigned to receive either 5 sessions of stretching and strengthening exercise (exercise-only group) or 2 sessions of thoracic spine manipulation and cervical range of motion exercise followed by 3 sessions of stretching and strengthening exercise (manipulation + exercise group). Data on disability and pain were collected at baseline, 1 week, 4 weeks, and 6 months. The primary aim (treatment group x time x status on the prediction rule) was examined using a linear mixed model with repeated measures. Time, treatment group, and status on the rule, as well as all possible 2-way and 3-way interactions, were modeled as fixed effects, with disability (and pain) as the dependent variable. Effect sizes were calculated for both pain and disability at each follow-up period. Results. There was no 3-way interaction for either disability or pain. A 2-way (group x time) interaction existed for both disability and pain. Pair-wise comparisons of disability demonstrated that significant differences existed at each follow-up period between the manipulation + exercise group and the exercise-only group. The patients who received manipulation exhibited lower pain scores at the 1-week follow-up period. The effect sizes were moderate for disability at each follow-up period and were moderate for pain at the 1-week follow-up. Limitations. Different exercise approaches may have resulted in a different outcome. Conclusions. The results of the current study did not support the validity of the previously developed CPR. However, the results demonstrated that patients with mechanical neck pain who received thoracic spine manipulation and exercise exhibited significantly greater improvements in disability at both the short- and longterm follow-up periods and in pain at the 1-week follow-up compared with patients who received exercise only., More than 50% of individuals typically will experience neck pain (1) at some point in their life, and the incidence of neck pain appears to be increasing. (2) The economic [...]

Background. It has been reported that manipulative therapy directed at the cervical and thoracic spine may improve outcomes in patients with shoulder pain. To date, limited data are available to help physical therapists determine which patients with shoulder pain may experience changes in pain and disability following the application of these interventions. Objective. The purpose of this study was to identify prognostic factors from the history and physical examination in individuals with shoulder pain who are likely to experience rapid improvement in pain and disability following cervical and thoracic spine manipulation. Design. This was a prospective single-arm trial. Setting. This study was conducted in outpatient physical therapy clinics. Participants. The participants were individuals who were seen by physical therapists for a primary complaint of shoulder pain. Intervention and Measurements. Participants underwent a standardized examination and then a series of thrust and nonthrust manipulations directed toward the cervicothoracic spine. Individuals were classified as having achieved a successful outcome at the second and third sessions based on their perceived recovery. Potential prognostic variables were entered into a stepwise logistic regression model to determine the most accurate set of variables for prediction of treatment success. Results. Data for 80 individuals were included in the data analysis, of which 49 had a successful outcome. Five prognostic variables were retained in the final regression model. If 3 of the 5 variables were present, the chance of achieving a successful outcome improved from 61% to 89% (positive likelihood ratio=5.3). Limitations. A prospective single-arm trial lacking a control group does not allow for inferences to be made regarding cause and effect. The statistical procedures used may result in 'overfitting' of the model, which can result in low precision of the prediction accuracy, and the bivariate analysis may have resulted in the rejection of some important variables. Conclusions. The identified prognostic variables will allow clinicians to make an a priori identification of individuals with shoulder pain who are likely to experience short-term improvement with cervical and thoracic spine manipulation. Future studies are necessary to validate these findings., Shoulder pain can present a diagnostic challenge. One study on nonspecific shoulder pain showed rotator cuff tendinopathy in 85% of patients, but 77% were diagnosed with more than one shoulder [...]

Background. To date, optimal strategies for the management of patients with cervical radiculopathy remain elusive. Preliminary evidence suggests that a multimodal treatment program consisting of manual therapy, exercise, and cervical traction may result in positive outcomes for patients with cervical radiculopathy. However, limited evidence exists to support the use of mechanical cervical traction in patients with cervical radiculopathy. Objective. The purpose of this study was to examine the effects of manual therapy and exercise, with or without the addition of cervical traction, on pain, function, and disability in patients with cervical radiculopathy. Design. This study was a multicenter randomized clinical trial. Setting. The study was conducted in orthopedic physical therapy clinics. Patients. Patients diagnosed with cervical radiculopathy (N=81) were randomly assigned to 1 of 2 groups: a group that received manual therapy, exercise, and intermittent cervical traction (MTEXTraction group) and a group that received manual therapy, exercise, and sham intermittent cervical traction (MTEX group). Intervention. Patients were treated, on average, 2 times per week for an average of 4.2 weeks. Measurements. Outcome measurements were collected at baseline and at 2 weeks and 4 weeks using the Numeric Pain Rating Scale (NPRS), the Patient-Specific Functional Scale (PSFS), and the Neck Disability Index (NDI). Results. There were no significant differences between the groups for any of the primary or secondary outcome measures at 2 weeks or 4 weeks. The effect size between groups for each of the primary outcomes was small (NDI= 1.5, 95% confidence interval [CI] =-6.8 to 3.8; PSFS=0.29, 95% CI=- 1.8 to 1.2; and NPRS=0.52, 95% CI=-1.8 to 1.2). Limitations. The use of a nonvalidated clinical prediction rule to diagnose cervical radiculopathy and the lack of a control group without treatment were limitations of this study. Conclusions. The results suggest that the addition of mechanical cervical traction to a multimodal treatment program of manual therapy and exercise yields no significant additional benefit to pain, function, or disability in patients with cervical radiculopathy., The annual incidence of cervical radiculopathy (CR) has been reported to be 83 cases per 100,000 people in the population, with an increased prevalence noted in the fifth decade of [...]

Background and Purpose. Physical therapists often attend continuing education (CE) courses to improve their overall clinical performance and patient outcomes. However, evidence suggests that CE courses may not improve the outcomes for patients receiving physical therapy for the management of neck pain. The purpose of this study was to investigate the effectiveness of an ongoing educational intervention for improving the outcomes for patients with neck pain. Participants. The study participants were 19 physical therapists who attended a 2-day CE course focusing on the management of neck pain. All patients treated by the therapists in this study completed the Neck Disability Index (NDI) and a pain rating scale at the initial examination and at their final visit. Methods. Therapists from 11 clinics were invited to attend a 2-day CE course on the management of neck pain. After the CE court, the therapists were randomly assigned to receive either ongoing education consisting of small group sessions and an educational outreach session or no further education. Clinical outcomes achieved by therapists who received ongoing education and therapists who did not were compared for both pretraining and posttraining periods. The effects of receiving ongoing education were examined by use of linear mixed-model analyses with time period and group as fixed factors; improvements in disability and pain as dependent variables; and age, sex, and the patient's initial NDI and pain rating scores as covariates. Results. Patients treated by therapists who received ongoing education experienced significantly greater reductions in disability during the study period (pretraining to posttraining) than those treated by therapists who did not receive ongoing training (mean difference=4.2 points; 95% confidence interval [CI]=0.69, 7.7). Changes in pain did not differ for patients treated by the 2 groups of therapists during the study period (mean difference=0.47 point; 95% CI= -0.11, 1.0). Therapists in the ongoing education group also used fewer visits during the posttraining period (mean difference=1.5 visits; 95% CI=0.81, 2.3). Discussion and Conclusion. The results of this study demonstrated that ongoing education for the management of neck pain was beneficial in reducing disability for patients with neck pain while reducing the number of physical therapy visits. However, changes in pain did not differ for patients treated by the 2 groups of therapists. Although it appears that a typical CE course does not improve the overall outcomes for patients treated by therapists attending that course, more research is needed to evaluate other educational strategies to determine the most clinically effective and cost-effective interventions., More than 50% of all patients with neck pain are referred t to physical therapists, and this population comprises approximately 25% of all patients seeking outpatient physical therapy for musculoskeletal [...]

Background and Purpose The purpose of this prospective cohort study was to identify whether variables from the baseline examination or physical therapy interventions received could predict clinical outcomes for people with cervical radiculopathy. Subjects and Methods A total of 96 consecutive patients referred for physical therapy for cervical radiculopathy were the sources of data for this study. All subjects underwent a standardized examination and completed the Neck Disability Index (NDI), the Patient-Specific Functional Scale (PSFS), and the Numeric Pain Rating Scale (NPRS) at baseline and at discharge. The subjects were treated according to the discretion of the individual therapists. At the time of discharge, the subjects completed the Global Rating of Change as well. Subjects surpassing the minimal clinically important change for all 4 outcome tools were categorized as achieving short-term success. Individual variables from the examination and interventions provided were tested for univariate relationships with outcomes. Variables with a significance level of less than. 10 were retained as potential predictor variables and were entered into a stepwise logistic regression model to determine the most accurate set of variables for predicting outcomes. Results The pretest probability for the likelihood of short-term (28-day follow-up) success was 53%. A 4-variable model optimally identified subjects who were most likely to achieve success with physical therapy interventions (age of < 54 years; dominant arm is not affected; looking down does not worsen symptoms; and multimodal treatment including manual therapy, cervical traction, and deep neck flexor muscle strengthening for at least 50% of visits). When 3 of these 4 variables were present, the positive likelihood ratio (+LR) was 5.2 (95% confidence interval [CI]=2.4, 11.3), and the posttest probability of success was 85%. When all 4 variables were present, the +LR was 8.3 (95% CI = 1.9, 63.9), and the posttest probability of success was 90%. Discussion and Conclusion These results suggest that a subset of predictor variables can accurately identify which people with cervical radiculopathy are likely to experience short-term successful outcomes. The study design did not allow for the identification of a cause-and-effect relationship, but it appears that intermittent cervical traction, manual therapy, and deep neck flexor muscle strengthening may be beneficial in the management of cervical radiculopathy. Future research is needed to substantiate these findings., Cervical radiculopathy is a common condition with a reported annual incidence of approximately 83 per 100,000 and an increased prevalence in the fifth decade of life (203 per 100,000). (1-7) [...]

Background and Purpose The purpose of this multicenter randomized clinical trial was to examine the effectiveness of an extension-oriented treatment approach (EOTA) in a subgroup of subjects with low back pain (LBP) who were hypothesized to benefit from the treatment compared with similar subjects who received a lumbar spine strengthening exercise program. Methods Subjects with LBP and symptoms distal to the buttocks that centralized with extension movements were included. Forty-eight subjects were randomly assigned to groups that received an EOTA (n= 26) or a strengthening exercise program (n= 22). Subjects attended 8 physical therapy sessions and completed a home exercise program. Follow-up data were obtained at 1 week, 4 weeks, and 6 months after randomization. Primary outcome measures were disability (modified Oswestry Low Back Pain Disability Questionnaire) and pain (Numeric Pain Rating Scale). Results Subjects in the EOTA group experienced greater improvements in disability compared with subjects who received trunk strengthening exercises at 1 week (mean difference between groups from baseline=8.9, 95% confidence interval [CI]=2.0, 15.9), 4 weeks, (mean difference=14.4, 95% CI=4.8, 23.9), and 6 months (mean difference= 14.6, 95% CI=4.6, 24.6). The EOTA group demonstrated greater change in pain at the 1-week follow-up only. Discussion and Conclusion An EOTA was more effective than trunk strengthening exercise in a subgroup of subjects hypothesized to benefit from this treatment approach. Additional research is needed to explore whether an EOTA may benefit other subgroups of patients., Next to the common cold, low back pain (LBP) is the most common reason individuals visit a physician's office, (1) resulting in billions of dollars in medical expenditures and lost [...]

Background and Purpose Evidence supports the use of manual physical therapy interventions directed at the thoracic spine in patients with neck pain. The purpose of this study was to compare the effectiveness of thoracic spine thrust mobilization/manipulation with that of nonthrust mobilization/manipulation in patients with a primary complaint of mechanical neck pain. The authors also sought to compare the frequencies, durations, and types of side effects between the groups. Subjects The subjects in this study were 60 patients who were 18 to 60 years of age and had a primary complaint of neck pain. Methods For all subjects, a standardized history and a physical examination were obtained. Self-report outcome measures included the Neck Disability Index (NDI), a pain diagram, the Numeric Pain Rating Scale (NPRS), and the Fear-Avoidance Beliefs Questionnaire. After the baseline evaluation, the subjects were randomly assigned to receive either thoracic spine thrust or nonthrust mobilization/manipulation. The subjects were reexamined 2 to 4 days after the initial examination, and they again completed the NDI and the NPRS, as well as the Global Rating of Change (GROC) Scale. The primary aim was examined with a 2-way repeated-measures analysis of variance (ANOVA), with intervention group (thrust versus nonthrust mobilization/manipulation) as the between-subjects variable and time (baseline and 48 hours) as the within-subject variable. Separate ANOVAs were performed for each dependent variable: disability (NDI) and pain (NPRS). For each ANOVA, the hypothesis of interest was the 2-way group x time interaction. Results Sixty patients with a mean age of 43.3 years (SD=12.7) (55% female) satisfied the eligibility criteria and agreed to participate in the study. Subjects who received thrust mobilization/ manipulation experienced greater reductions in disability, with a between-group difference of 10% (95% confidence interval [CI] = 5.3-14.7), and in pain, with a between-group difference of 2.0 (95% CI=1.4-2.7). Subjects in the thrust mobilization/manipulation group exhibited significantly higher scores on the GROC Scale at the time of follow-up. No differences in the frequencies, durations, and types of side effects existed between the groups. Discussion and Conclusion The results suggest that thoracic spine thrust mobilization/manipulation results in significantly greater short-term reductions in pain and disability than does thoracic nonthrust mobilization/ manipulation in people with neck pain., The prevalence of neck pain in the general population has been reported to be 15% for men and 23% for women, with nearly half of these individuals experiencing constant unremitting [...]

Background and Purpose To date, no studies have investigated the predictive validity of variables from the initial examination to identify patients with neck pain who are likely to benefit from thoracic spine thrust manipulation. The purpose of this study was to develop a clinical prediction rule (CPR) to identify patients with neck pain who are likely to experience early success from thoracic spine thrust manipulation. Subjects This was a prospective, cohort study of patients with mechanical neck pain who were referred for physical therapy. Methods Subjects underwent a standardized examination and then a series of thoracic spine thrust manipulation techniques. They were classified as having experienced a successful outcome at the second and third sessions based on their perceived recovery. Potential predictor variables were entered into a stepwise logistic regression model to determine the most accurate set of variables for prediction of treatment success. Results Data for 78 subjects were included in the data analysis, of which 42 had a successful outcome. A CPR with 6 variables was identified. If 3 of the 6 variables (positive likelihood ratio = 5.5) were present, the chance of experiencing a successful outcome improved from 54% to 86%. Discussion and Conclusion The CPR provides the ability to a priori identify patients with neck pain who are likely to experience early success with thoracic spine thrust manipulation. However, future studies are necessary to validate the rule., Neck pain is a common occurrence with a lifetime incidence ranging from 22% to 70%. (1,2) Over a third of patients will develop chronic symptoms lasting more than 6 months [...]

To the editor: I enjoyed reading the update by Childs and Cleland titled 'Development and Application of Clinical Prediction Rules to Improve Decision Making in Physical Therapist Practice' (January 2006) [...]

Clinical prediction rules (CPRs) are tools designed to improve decision making in clinical practice by assisting practitioners in making a particular diagnosis, establishing a prognosis, or matching patients to optimal interventions based on a parsimonious subset of predictor variables from the history and physical examination. (1,2) Clinical prediction rules have been developed to improve decision making for many conditions in medical practice, including the diagnosis of proximal deep vein thrombosis (DVT), (3) strep throat, (4) coronary artery disease, (5) and pulmonary embolism. (6) Clinical prediction rules also have been developed to assist in establishing a prognosis such as determining when to discontinue resuscitative efforts after cardiac arrest in the hospital, (7) determining the likelihood of death within 4 years for people with coronary artery disease, (7) identifying children who are at risk for developing urinary tract infections, (8) and identifying the characteristics of patients who are likely to develop postoperative nausea and vomiting after anesthesia. (9) Clinical prediction rules have recently been developed that can improve decision making in physical therapist practice. Examples include prediction rules to improve the accuracy of diagnosing ankle fractures (ie, 'the Ottawa Ankle Rules') (10) and knee fractures (ie, 'the Ottawa Knee Rules') (11) in people with acute injuries and to determine when to order radiographs in patients with neck trauma. (12) Other prediction rules have been developed to diagnose patients with cervical radiculopathy (13) and carpal tunnel syndrome. (14) A CPR also has been developed to establish the prognosis of patients with neck pain following a rear-end motor vehicle accident. (15) Key Words: Clinical decision rule, Decision, Diagnosis, Diagnostic accuracy, Likelihood ratio, Prognosis, Sensitivity, Specificity., With increasing attention focused on the rising costs of health care, CPRs provide practitioners with powerful diagnostic information from the history' and physical examination that may serve as an accurate [...]

Is radiologic examination necessary for a 9-year-old girl with a knee injury? The purpose of "Evidence in Practice" is to illustrate the literature search process to obtain evidence that can [...]

Background and Purpose. As direct access evolves, physical therapists will increasingly encounter patients with pathology that might have an underlying systemic origin. The purpose of this case report is to describe the diagnostic process that led a patient's physical therapist to recognize signs and symptoms of dermatomyositis. Case Description. The patient was an 18-year-old woman who was referred for physical therapy by her primary care physician on 3 occasions with 3 separate musculoskeletal diagnoses. During the third episode, the physical therapist recognized signs and symptoms that could be indicative of dermatologic disease and referred the patient to a dermatologist. Outcomes. A rheumatologist diagnosed the patient's condition as dermatomyositis and referred her for physical therapy. The physical therapy plan of care focused on strengthening and stretching, with an emphasis on a home exercise program. The Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) indicated that the patient continually made functional improvements over an 18-month period. Discussion. Although diagnosis of diseases such as inflammatory myopathies is not within a physical therapist's scope of practice, this case demonstrates the role a physical therapist can play in recognition of underlying systemic pathology by using the diagnostic process. [Cleland JA, Venzke JW. Dermatomyositis: evolution of a diagnosis. Phys Ther. 2003;83:932-945.] Key Words: Dermatomyositis, Diagnosis, Inflammatory, myopathies, Physical therapy., One of the many changes in health care is the shifting boundary of the practice of physical therapy in outpatient orthopedic clinics. (1) Direct access and primary care physical therapy [...]