Orthopaedic Manual Physical Therapy: A Modern Definition and Description.

Currently, orthopaedic manual physical therapy (OMPT) lacks a description of practice that reflects contemporary thinking and embraces advances across the scientific, clinical, and educational arms of the profession. The absence of a clear definition of OMPT reduces understanding of the approach across health care professions and potentially limits OMPT from inclusion in scientific reviews and clinical practice guidelines. For example, it is often incorrectly classified as passive care or incorrectly contrasted with exercise-therapy approaches. This perspective aims to provide clinicians, researchers, and stakeholders a modern definition of OMPT that improves the understanding of this approach both inside and outside the physical therapist profession. The authors also aim to outline the unique and essential aspects of advanced OMPT training with the corresponding examination and treatment competencies. This definition of practice and illustration of its defining characteristics is necessary to improve the understanding of this approach and to help classify it correctly for study in the scientific literature. This perspective provides a current definition and conceptual model of OMPT, defining the distinguishing characteristics and key elements of this systematic and active patient-centered approach to improve understanding and help classify it correctly for study in the scientific literature.

Cost-effectiveness of Physical Therapy vs Intra-articular Glucocorticoid Injection for Knee Osteoarthritis: A Secondary Analysis From a Randomized Clinical Trial.

Importance: Physical therapy and glucocorticoid injections are initial treatment options for knee osteoarthritis, but available data indicate that most patients receive one or the other, suggesting they may be competing interventions. The initial cost difference for treatment can be substantial, with physical therapy often being more expensive at the outset, and cost-effectiveness analysis can aid patients and clinicians in making decisions. Objective: To investigate the incremental cost-effectiveness between physical therapy and intra-articular glucocorticoid injection as initial treatment strategies for knee osteoarthritis. Design, Setting, and Participants: This economic evaluation is a secondary analysis of a randomized clinical trial performed from October 1, 2012, to May 4, 2017. Health economists were blinded to study outcomes and treatment allocation. A randomized sample of patients seen in primary care and physical therapy clinics with a radiographically confirmed diagnosis of knee osteoarthritis were evaluated from the clinical trial with 96.2% follow-up at 1 year. Interventions: Physical therapy or glucocorticoid injection. Main Outcomes and Measures: The main outcome was incremental cost-effectiveness between 2 alternative treatments. Acceptability curves of bootstrapped incremental cost-effectiveness ratios (ICERs) were used to identify the proportion of ICERs under the specific willingness-to-pay level ($50 000-$100 000). Health care system costs (total and knee related) and health-related quality-of-life based on quality-adjusted life-years (QALYs) were obtained. Results: A total of 156 participants (mean [SD] age, 56.1 [8.7] years; 81 [51.9%] male) were randomized 1:1 and followed up for 1 year. Mean (SD) 1-year knee-related medical costs were $2113 ($4224) in the glucocorticoid injection group and $2131 ($1015) in the physical therapy group. The mean difference in QALY significantly favored physical therapy at 1 year (0.076; 95% CI, 0.02-0.126; P = .003). Physical therapy was the more cost-effective intervention, with an ICER of $8103 for knee-related medical costs, with a 99.2% probability that results fall below the willingness-to-pay threshold of $100 000. Conclusions and Relevance: A course of physical therapy was cost-effective compared with a course of glucocorticoid injections for patients with knee osteoarthritis. These results suggest that, although the initial cost of delivering physical therapy may be higher than an initial course of glucocorticoid injections, 1-year total knee-related costs are equivalent, and greater improvement in QALYs may justify the initial higher costs. Trial Registration: ClinicalTrials.gov Identifier: NCT01427153.

Manual Therapy: Always a Passive Treatment?

SYNOPSIS: The use of manual therapy as an intervention has garnered intense debate, one that is often mired in a straw-man argument that manual therapy is a purely passive intervention. When passive interventions are equated with low-value care, it is easy to deride manual therapy as low-value care. However, manual therapy describes a wide variety of treatments, some with passive components and some that are primarily passive in certain scenarios. But manual therapy can be an integral part of highly active treatment strategies. We implore investigators to describe manual therapy interventions in sufficient detail so that they can be reproduced and thereby help the end users of research (including clinicians) to better assess the value of such interventions. This Viewpoint challenges the assumption that manual therapy is always a passive treatment of low value. J Orthop Sports Phys Ther 2021;51(10):474-477. Epub 1 Jul 2021. doi:10.2519/jospt.2021.10330.

Physical Therapy versus Glucocorticoid Injection for Osteoarthritis of the Knee.

BACKGROUND: Both physical therapy and intraarticular injections of glucocorticoids have been shown to confer clinical benefit with respect to osteoarthritis of the knee. Whether the short-term and long-term effectiveness for relieving pain and improving physical function differ between these two therapies is uncertain. METHODS: We conducted a randomized trial to compare physical therapy with glucocorticoid injection in the primary care setting in the U.S. Military Health System. Patients with osteoarthritis in one or both knees were randomly assigned in a 1:1 ratio to receive a glucocorticoid injection or to undergo physical therapy. The primary outcome was the total score on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at 1 year (scores range from 0 to 240, with higher scores indicating worse pain, function, and stiffness). The secondary outcomes were the time needed to complete the Alternate Step Test, the time needed to complete the Timed Up and Go test, and the score on the Global Rating of Change scale, all assessed at 1 year. RESULTS: We enrolled 156 patients with a mean age of 56 years; 78 patients were assigned to each group. Baseline characteristics, including severity of pain and level of disability, were similar in the two groups. The mean (±SD) baseline WOMAC scores were 108.8±47.1 in the glucocorticoid injection group and 107.1±42.4 in the physical therapy group. At 1 year, the mean scores were 55.8±53.8 and 37.0±30.7, respectively (mean between-group difference, 18.8 points; 95% confidence interval, 5.0 to 32.6), a finding favoring physical therapy. Changes in secondary outcomes were in the same direction as those of the primary outcome. One patient fainted while receiving a glucocorticoid injection. CONCLUSIONS: Patients with osteoarthritis of the knee who underwent physical therapy had less pain and functional disability at 1 year than patients who received an intraarticular glucocorticoid injection. (ClinicalTrials.gov number, NCT01427153.).

MANAGEMENT OF ACUTE GRADE II LATERAL ANKLE SPRAINS WITH AN EMPHASIS ON LIGAMENT PROTECTION: A DESCRIPTIVE CASE SERIES.

BACKGROUND AND PURPOSE: Lateral ankle sprain the most common injury in physically active populations. Individuals who sustain an acute lateral ankle sprain may not receive timely formal rehabilitation and are at an increased risk to have subsequent sprains which can lead to chronic pain and instability. Attention to essential factors for ligament protection and healing while preserving ankle movement, may result in a more stable yet mobile ankle offering improved outcomes. The purpose of this case series was to describe the methods and observe the outcomes associated with a comprehensive strategy for managing acute first episode grade II lateral ankle sprains. STUDY DESIGN: Prospective case series. CASE DESCRIPTIONS AND INTERVENTIONS: Ten patients (mean age 26.7 years, range 16-51 years, mean 2.3 days from injury) with acute grade II lateral ankle sprain were treated with an approach to protect the injured ligament, prevent impairments to movement, restore strength and proprioception, and progress to full function. Patient outcomes were assessed at four, eight and 12 weeks. Follow-up interviews at six and 12 months assessed injury recurrence. OUTCOMES: Patients were treated for an average of eight sessions over a mean of seven weeks. Rapid change in self-reported function, ankle ROM, and pain were observed in the first four weeks of care. Clinically meaningful improvements in function and ankle ROM were also noted at eight weeks and maintained at 12-week follow-ups. All patients returned to desired physical activity with only a single re-sprain event within one year after injury. CONCLUSION: The results of this prospective case series suggest that a treatment approach designed to protect the injured ligament, maintain and restore normal ankle motion, and provide a tailored functional pathway to return to run and sport demonstrated resolution of symptoms and improvement in reported functional outcomes in a group of patients following grade II acute primary ankle sprain. LEVEL OF EVIDENCE: Level IV, Case Series.

DRY NEEDLING IN THE MANAGEMENT OF PATIENTS MEETING CLINICAL DIAGNOSTIC CRITERIA FOR SUBACROMIAL PAIN SYNDROME: A CASE SERIES.

BACKGROUND: Physical therapy interventions of exercise and manual therapy provide benefit in treatment of subacromial pain syndrome (SAPS). Dry needling is an emerging technique for treating musculoskeletal conditions; however, conflicting investigative evidence exists regarding the use of dry needling for SAPS. PURPOSE: The purpose of this case series was to describe the use of dry needling, in conjunction with exercise, as a management strategy for patients meeting clinical diagnostic criteria of SAPS and to observe the short- and intermediate-term effects of dry needling with therapeutic exercise in this population. A secondary purpose was to describe a framework of clinical reasoning to guide the pragmatic application of dry needling and exercise in clinical practice. STUDY DESIGN: Case series. METHODS: Twenty-five patients met criteria for SAPS and provided informed consent. Patients received examination-based dry needling for the first two visits with exercises added beginning at the third treatment session to help distinguish treatment effects. The primary outcome measure used in this study was the Quick Disabilities of the Arm, Shoulder, and Hand (Q-DASH) survey assessed at their third clinical visit, at four-weeks after starting intervention and again at a three-month follow up visit. RESULTS: On the Q-DASH survey 21 of 24 patients reported improvement at the third visit (range 4.5 to 38.6 points) and 19 of 22 reported improvement at the 3-month follow-up (range 0.1-54.5 points) relative to baseline. Sixteen of 24 patients at the third visit and 19 of 22 patients at the 3-month follow-up reported Global Rating of Changes scores of +3 or greater. CONCLUSION: This case series provides insight to the observed short- and intermediate-term effects of dry needling combined with exercise for SAPS. Additionally, it discusses the framework of clinical reasoning when applying this intervention. The results are encouraging for dry needling as an adjunct to exercise for treating patients with SAPS. LEVEL OF EVIDENCE: Therapy, level 4.

Calcaneal Osteosarcoma in a Patient Referred for Plantar Heel Pain.

A 28-year-old man was referred to physical therapy from his primary care provider with variable and intermittent left lateral plantar heel pain that began insidiously about 10 months prior. Radiographs of the foot and ankle were completed prior to the physical therapy evaluation and interpreted as noncontributory. Because his pain and function were minimally improved after 4 weeks, the patient was referred for magnetic resonance imaging. An abnormal mass in the calcaneus prompted an urgent referral to an orthopaedic oncologist. Percutaneous biopsy confirmed a diagnosis of calcaneal osteogenic sarcoma. J Orthop Sports Phys Ther 2019;49(4):285. doi:10.2519/jospt.2019.8430.

A manual physical therapy intervention for symptoms of knee osteoarthritis and associated fall risk: A case series of four patients.

BACKGROUND AND PURPOSE: Patients with knee osteoarthritis (OA) are at an increased risk of falling. Further, the symptoms associated with knee OA are correlated with fall risk. A manual physical therapy (MPT) approach consisting of mobilizing techniques and reinforcing exercise improves the symptoms and functional limitations associated with knee OA. The purpose of this case series is to evaluate an MPT intervention of mobilization techniques and exercise for knee OA on improving symptoms and quantify the secondary benefit of improving stumble recovery. CASE DESCRIPTION: Four patients with symptomatic knee OA and four matched controls completed a fall risk assessment. Following 4 weeks of intervention, patients were reevaluated. OUTCOMES: Initial Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores indicated notable symptoms and functional limitations in all patients. In addition, all patients displayed elevated fall risk and/or impaired stumble responses. Following 4 weeks of intervention, all patients reported meaningful reductions in all three WOMAC subscales and demonstrated improvements in at least two of the three fall risk measures. DISCUSSION: We identified potential connections between symptom relief in patients with knee OA, stumble response, and ultimately fall risk. The results suggest that MPT intervention designed to improve the signs and symptoms of knee OA may lead to a secondary benefit of improved gait stability and stumble response.

Effectiveness of translational manipulation under interscalene block for the treatment of adhesive capsulitis of the shoulder: A nonrandomized clinical trial.

Study Design: Nonrandomized controlled trial. Objective: To determine whether translational manipulation under anesthesia/local block (TMUA) adds to the benefit of mobilization and range of motion exercise for improving pain and functional status among patients with adhesive capsulitis of the shoulder (AC). Background: TMUA has been shown to improve pain and dysfunction in patients with AC. This intervention has not been directly compared to physical therapy treatment without TMUA in a prospective trial. Methods: Sixteen consecutive patients with a primary diagnosis of AC were divided into two groups. Patients in the first (TMUA) group received a session of translational manipulation under interscalene block, followed by six sessions of manipulation and exercise. Patients in the comparison group received seven sessions of manipulation and exercise. Outcome measures taken at baseline and 3, 6, 12 months and 4 years included Shoulder Pain and Disability Index (SPADI) scores. Four-year outcomes included percent of normal ratings, medication use, and activity limitations. Results: Both groups showed improved SPADI scores across all follow-up times compared to baseline. The TMUA group showed a greater improvement in SPADI scores than the comparison group at 3 weeks, with no significant differences in SPADI scores at other time points. However, at 4 years, significantly more subjects in the comparison group (5 of 8) had activity limitations versus subjects in the TMUA group (1 of 8). No subject experienced a complication from either intervention protocol. Conclusion: Physical therapy consisting of manual therapy and exercise provides benefit for patients with AC. Translational manipulation under local block may be a useful adjunct to manual therapy and exercise for patients with AC.

Systematic Clinical Reasoning in Physical Therapy (SCRIPT): Tool for the Purposeful Practice of Clinical Reasoning in Orthopedic Manual Physical Therapy.

Background and Purpose: Clinical reasoning is essential to physical therapist practice. Solid clinical reasoning processes may lead to greater understanding of the patient condition, early diagnostic hypothesis development, and well-tolerated examination and intervention strategies, as well as mitigate the risk of diagnostic error. However, the complex and often subconscious nature of clinical reasoning can impede the development of this skill. Protracted tools have been published to help guide self-reflection on clinical reasoning but might not be feasible in typical clinical settings. Case Description: This case illustrates how the Systematic Clinical Reasoning in Physical Therapy (SCRIPT) tool can be used to guide the clinical reasoning process and prompt a physical therapist to search the literature to answer a clinical question and facilitate formal mentorship sessions in postprofessional physical therapist training programs. Outcomes: The SCRIPT tool enabled the mentee to generate appropriate hypotheses, plan the examination, query the literature to answer a clinical question, establish a physical therapist diagnosis, and design an effective treatment plan. The SCRIPT tool also facilitated the mentee's clinical reasoning and provided the mentor insight into the mentee's clinical reasoning. The reliability and validity of the SCRIPT tool have not been formally studied. Discussion: Clinical mentorship is a cornerstone of postprofessional training programs and intended to develop advanced clinical reasoning skills. However, clinical reasoning is often subconscious and, therefore, a challenging skill to develop. The use of a tool such as the SCRIPT may facilitate developing clinical reasoning skills by providing a systematic approach to data gathering and making clinical judgments to bring clinical reasoning to the conscious level, facilitate self-reflection, and make a mentored physical therapist's thought processes explicit to his or her clinical mentor.

Manual physical therapy combined with high-intensity functional rehabilitation for severe lower extremity musculoskeletal injuries: a case series.

OBJECTIVES: Severe lower extremity trauma accounts for large healthcare costs and often results in elective amputation and poor long-term outcomes. The purpose of this case series is to describe an orthopedic manual physical therapy (OMPT) approach combined with a return to run (RTR) clinical pathway consisting of high-intensity functional rehabilitation with a custom energy-storing orthosis. METHODS: Three consecutive male patients, aged 21-23 years, with severe lower extremity musculoskeletal injuries were treated with a combined intervention that included a mean (SD) of 12 (2·1) OMPT sessions and 24 (8·7) functional rehabilitation sessions over a mean of 6 weeks (1·0). Additional training with a custom energy-storing orthosis consisted of a mean of 15 (1·2) additional sessions over 4 weeks. Patient self-report outcome measures and a variety of physical performance tests captured change in function. RESULTS: Baseline lower extremity functional scale (LEFS) and foot and ankle ability measure activities of daily living subscale (FAAM-ADL) scores indicated severe disability. All patients exceeded the minimal clinically important difference (MCID) in at least one self-report outcome or physical performance test without a brace. Two of three patients exceeded the MCID for at least two physical performance tests after training with and utilizing a custom energy-storing orthosis. DISCUSSION: Clinically meaningful changes in self-reported function or physical performance were observed in all patients. A multi-modal approach, including manual therapy and functional exercise, may address the entire spectrum of impairments in patients with severe lower extremity trauma, resulting in improvements in both braced and un-braced function.

A multicenter randomised, 1-year comparative effectiveness, parallel-group trial protocol of a physical therapy approach compared to corticosteroid injection on pain and function related to knee osteoarthritis (PTA Trial)

INTRODUCTION: Corticosteroid injections (CSIs) are commonly used as an initial or a primary intervention for knee osteoarthritis (OA). Consistent evidence indicates CSIs offer symptom relief with conflicting reports regarding long-term efficacy. Physical therapy (PT) offers a non-invasive alternative. There is moderate evidence suggesting short-term and long-term symptom relief and functional improvement with PT interventions. Patients with knee OA are more commonly prescribed CSI than PT prior to total joint replacement. UnitedHealthcare and Military Health System data show substantially more total knee replacement patients receive preoperative CSI than PT. There are no studies comparing CSI to a PT approach in individuals with knee OA. The primary objective of this study is to compare the effectiveness of CSI to PT in individuals with knee OA at 1, 2 and 12 months. METHODS AND ANALYSIS: We plan to recruit 156 participants meeting established knee OA criteria. Following informed consent, participants will be randomised to receive either CSI or PT. All participants will receive instruction on recommended exercise and weight control strategies plus usual medical care. The CSI intervention consisting of 3 injections and the PT intervention consisting of 8-12 sessions will be spaced over 12 months. Measures of the dependent variables (DVs) will occur at baseline, 4 weeks, 8 weeks, 6 months and 12 months post enrolment. This pragmatic, randomised clinical trial will be a mixed-model 2×5 factorial design. The independent variables are treatment (CSI and PT) and time with five levels from baseline to 1 year. The primary DV is the Western Ontario & McMaster Universities Arthritis Index (WOMAC). We will also compare healthcare utilisation between the 2 groups. ETHICS AND DISSEMINATION: The protocol was approved by the Madigan Army Medical Center Institutional Review Board. The authors intend to publish the results in a peer-reviewed source. TRIAL REGISTRATION NUMBER: NCT01427153.

Imaging in conjunction with physical therapy in management of a patient with history of thoracic tumour.

BACKGROUND: Physical therapy care for musculoskeletal conditions includes an ongoing process that systematically considers and prioritises diagnostic hypotheses. These diagnostic hypotheses include those that are typical for common musculoskeletal conditions, and must also include more rare conditions that would require care outside the scope of practice of the physical therapist. When additional screening is required, physical therapists collaborate with other providers or directly order the appropriate tests to rule out suspected pathology. CASE DESCRIPTION: This article illustrates the use of musculoskeletal imaging ordered by a physical therapist to guide ongoing management of a patient with back pain and a history of cancer. OUTCOMES: The patient successfully returned to moderate-intensity sport activities after a course of physical therapy. DISCUSSION: This case provides an example of how clinical diagnostic reasoning combined with clinical privileges to order musculoskeletal imaging can facilitate diagnostic accuracy in a timely and cost-efficient manner.

Manual Physical Therapy Following Immobilization for Stable Ankle Fracture: A Case Series.

STUDY DESIGN: Case series. BACKGROUND: Ankle fractures commonly result in persistent pain, stiffness, and functional impairments. There is insufficient evidence to favor any particular rehabilitation approach after ankle fracture. The purpose of this case series was to describe an impairment-based manual physical therapy approach to treating patients with conservatively managed ankle fractures. CASE DESCRIPTION: Patients with stable ankle fractures postimmobilization were treated with manual physical therapy and exercise targeted at associated impairments in the lower limb. The primary outcome measure was the Lower Extremity Functional Scale. Secondary outcome measures included the ankle lunge test, numeric pain-rating scale, and global rating of change. Outcome measures were collected at baseline (performed within 7 days of immobilization removal) and at 4 and 12 weeks postbaseline. OUTCOMES: Eleven patients (mean age, 39.6 years; range, 18-64 years; 2 male), after ankle fracture-related immobilization (mean duration, 48 days; range, 21-75 days), were treated for an average of 6.6 sessions (range, 3-10 sessions) over a mean of 46.1 days (range, 13-81 days). Compared to baseline, statistically significant and clinically meaningful improvements were observed in Lower Extremity Functional Scale score (P = .001; mean change, 21.9 points; 95% confidence interval: 10.4, 33.4) and in the ankle lunge test (P = .001; mean change, 7.8 cm; 95% confidence interval: 3.9, 11.7) at 4 weeks. These changes persisted at 12 weeks. DISCUSSION: Statistically significant and clinically meaningful improvements in self-reported function and ankle range of motion were observed at 4 and 12 weeks following treatment with impairment-based manual physical therapy. All patients tolerated treatment well. Results suggest that this approach may have efficacy in this population. LEVEL OF EVIDENCE: Therapy, level 4.

Knee extension and stiffness in osteoarthritic and normal knees: a videofluoroscopic analysis of the effect of a single session of manual therapy.

STUDY DESIGN: Descriptive biomechanical study using an experimental repeated-measures design. OBJECTIVE: To quantify the response of participants with and without knee osteoarthritis (OA) to a single session of manual physical therapy. The intervention consisted primarily of joint mobilization techniques, supplemented by exercises, aiming to improve knee extension. BACKGROUND: While manual therapy benefits patients with knee OA, there is limited research quantifying the effects of a manual therapy treatment session on either motion or stiffness of osteoarthritic and normal knees. Methods The study included 5 participants with knee OA and 5 age-, gender-, and body mass index-matched healthy volunteers. Knee extension motion and stiffness were measured with videofluoroscopy before and after a 30-minute manual therapy treatment session. Analysis of variance and intraclass correlation coefficients were used to analyze the data. RESULTS: Participants with knee OA had restricted knee extension range of motion at baseline, in contrast to the participants with normal knees, who had full knee extension. After the therapy session, there was a significant increase in knee motion in participants with knee OA (P = .004) but not in those with normal knees (P = .201). For stiffness data, there was no main effect for time (P = .903) or load (P = .274), but there was a main effect of group (P = .012), with the participants with healthy knees having greater stiffness than those with knee OA. Reliability, using intraclass correlation coefficient model 3,3, for knee angle measurements between imaging sessions for all loading conditions was 0.99. Reliability (intraclass correlation coefficient model 3,1) for intraimage measurements was 0.97. CONCLUSION: End-range knee extension stiffness was greater in the participants with normal knees than those with knee OA. The combination of lesser stiffness and lack of motion in those with knee OA, which may indicate the potential for improvement, may explain why increased knee extension angle was observed following a single session of manual therapy in the participants with knee OA but not in those with normal knees. Videofluoroscopy of the knee appears reliable and relevant for future studies attempting to quantify the underlying mechanisms of manual therapy. J Orthop Sports Phys Ther 2014;44(4):273-282. Epub 25 February 2014. doi:10.2519/jospt.2014.4710.

Clinical reasoning and advanced practice privileges enable physical therapist point-of-care decisions in the military health care system: 3 clinical cases.

BACKGROUND AND PURPOSE: Physical therapists frequently make important point-of-care decisions for musculoskeletal injuries and conditions. In the Military Health System (MHS), these decisions may occur while therapists are deployed in support of combat troops, as well as in a more traditional hospital setting. Proficiency with the musculoskeletal examination, including a fundamental understanding of the diagnostic role of musculoskeletal imaging, is an important competency for physical therapists. The purpose of this article is to present 3 cases managed by physical therapists in unique MHS settings, highlighting relevant challenges and clinical decision making. CASE DESCRIPTION: Three cases are presented involving conditions where the physical therapist was significantly involved in the diagnosis and clinical management plan. The physical therapist's clinical privileges, including the ability to order appropriate musculoskeletal imaging procedures, were helpful in making clinical decisions that facilitate timely management. The cases involve patients with an ankle sprain and Maisonneuve fracture, a radial head fracture, and a pelvic neoplasm referred through medical channels as knee pain. OUTCOMES: Clinical pathways from point of care are discussed, as well as the reasoning that led to decisions affecting definitive care for each of these patients. In each case, emergent treatment and important combat evacuation decisions were based on a combination of examination and management decisions. DISCUSSION: Physical therapists can provide important contributions to the primary management of patients with musculoskeletal conditions in a variety of settings within the MHS. In the cases described, advanced clinical privileges contributed to the success in this role.

Manual physical therapy and perturbation exercises in knee osteoarthritis.

OBJECTIVES: Knee osteoarthritis (OA) causes disability among the elderly and is often associated with impaired balance and proprioception. Perturbation exercises may help improve these impairments. Although manual physical therapy is generally a well-tolerated treatment for knee OA, perturbation exercises have not been evaluated when used with a manual physical therapy approach. The purpose of this study was to observe tolerance to perturbation exercises and the effect of a manual physical therapy approach with perturbation exercises on patients with knee OA. METHODS: This was a prospective observational cohort study of 15 patients with knee OA. The Western Ontario and McMaster Universities Arthritis Index (WOMAC), global rating of change (GROC), and 72-hour post-treatment tolerance were primary outcome measures. Patients received perturbation balance exercises along with a manual physical therapy approach, twice weekly for 4 weeks. Follow-up evaluation was done at 1, 3, and 6 months after beginning the program. RESULTS: Mean total WOMAC score significantly improved (P = 0.001) after the 4-week program (total WOMAC: initial, 105; 4 weeks, 56; 3 months, 54; 6 months, 57). Mean improvements were similar to previously published trials of manual physical therapy without perturbation exercises. The GROC score showed a minimal clinically important difference (MCID)≥+3 in 13 patients (87%) at 4 weeks, 12 patients (80%) at 3 months, and 9 patients (60%) at 6 months. No patients reported exacerbation of symptoms within 72 hours following each treatment session. DISCUSSION: A manual physical therapy approach that also included perturbation exercises was well tolerated and resulted in improved outcome scores in patients with knee OA.

Disruption of a patellar tendon repair.

The patient was a 38-year-old man evaluated by a physical therapist 14 weeks after repair of the left patellar tendon. The physical therapist requested radiographs, which revealed findings consistent with a patellar tendon retear. The radiologist recommended further evaluation with magnetic resonance imaging, which showed a left patellar tendon tear.