Safety Events and Privilege Utilization Rates in Advanced Practice Physical Therapy Compared to Traditional Primary Care: An Observational Study.

INTRODUCTION: The general practitioner shortage in the United States coupled with a growing number of Americans living with disability has fueled speculation of non-physician providers assuming a greater role in musculoskeletal healthcare. Previous physician shortages have been similarly addressed, and expanding physical therapy (PT) scope of practice may best serve to fill this need. Resistance to expanding PT practice focuses on patient safety as PTs assume the roles traditionally performed by primary care providers. While studies have shown advanced practice PT to be safe, none have compared safety events in advanced practice PT compared to primary care to determine if there are increased patient risks. Therefore, the purpose of our study is to examine the rate of safety events and utilization of services in an advanced practice PT clinic compared to a primary care clinic. A secondary aim of our study was to report safety events associated with spinal manipulation and dry needling procedures. MATERIALS AND METHODS: Productivity and safety data were retrospectively collected from Malcolm Grow Medical Center from 2015 to 2017 for the Family Health Clinic (FHC) and an advanced practice Physical Therapy Clinic (PTC). Chi-square tests for independence, risk ratios (RR) and 95% confidence intervals (95%) were used to compare the relationship between the frequency of (1) patient encounters and clinical procedures and (2) clinical procedures and safety events. RESULTS: Seventy-five percent (12/16) of safety events reported in the PTC were defined as near misses compared to 50% (28/56) within the FHC (RR 1.5; 95% CIs: 1.0 to 2.2). Safety events were more likely to reach patients in the FHC compared to the PTC (RR 1.9; 95% CIs: 0.8 to 4.7). Safety events associated with minor harm to patients was n = 4 and n = 3 in the FHC and PTC respectively. No sentinel events, intentional harm events, nor actual events with more than minor harm were reported in either clinic. Significant relationships indicated that prescriptions, laboratory studies, imaging studies and referrals, were all more likely to be ordered in the FHC than the PTC (p < 0.01). The PTC ordered one diagnostic imaging study for every 37 encounters compared to one in every 5 encounters in the FHC. The PTC similarly referred one patient to another healthcare provider for every 52 encounters, fewer than the one per every 3 encounters in the FHC. There was a significant relationship between encounters and diagnoses, indicating a higher number of diagnoses per encounter in the FHC, though the difference of 0.31 diagnoses per encounter may not be clinically meaningful (p < 0.01). A total of 1,818 thrust manipulations and 2,910 dry needling procedures were completed without any reported safety events. CONCLUSION: These results suggest advanced practice PT has a similar safety profile to primary care. The authority to order musculoskeletal imaging and refer to other clinicians were among the most commonly utilized privileges and may be of primary importance when establishing an advanced practice PT clinic. These results support research showing advanced practice PT may lead to reductions in specialty referrals, diagnostic imaging, and pharmaceutical interventions.

SHORT-TERM EFFECTS OF TRIGGER POINT DRY NEEDLING ON PAIN AND DISABILITY IN SUBJECTS WITH PATELLOFEMORAL PAIN SYNDROME.

BACKGROUND: Patellofemoral pain syndrome (PFPS) is a prevalent knee disorder. A novel yet increasingly popular treatment for PFPS is trigger point dry needling (DN). PURPOSE: The purpose of this study was to determine if DN is more effective at reducing pain and disability than a sham treatment in individuals with PFPS. STUDY DESIGN: Randomized trial. MATERIALS/METHODS: Sixty military health care beneficiaries (36 males) with a clinical diagnosis of PFPS were recruited and completed the study. Subjects underwent a standardized clinical examination and were randomized into a DN or sham treatment group. DN treatment consisted of insertion of an acupuncture-like needle into six sites in the quadriceps femoris muscles of the symptomatic lower extremity based on a palpation examination. The sham grouped received a simulated treatment with a sharp object and needle guide tube without puncturing the skin. Self-reports of pain, disability, and overall status were collected before treatment, immediately after treatment and at 72 hours. Data were analyzed with separate 2x2 repeated measures analysis of variance, with independent variables being Group (DN vs. sham) and Time (pre-treatment vs. immediately post-treatment, and pre-treatment vs. 72 hours). The hypothesis of interest in each case was the Group*Time interaction. The alpha-level was set a priori to .05 using 2-tailed tests. RESULTS: Both groups exhibited a clinically meaningful reduction in pain based on numeric pain rating scale scores immediately post-treatment and at 72 hours, but there was no statistically significant difference between groups (p = 0.219, 0.310). There was no significant difference between groups for any other outcome measures. CONCLUSION: These data suggest that DN treatment is not more effective than a sham DN treatment at reducing short-term pain and disability in individuals with PFPS when used as an isolated treatment approach. LEVEL OF EVIDENCE: 2.

US Army Physical Therapist Roles and Contributions in Operations Enduring Freedom and Iraqi Freedom.

Musculoskeletal injuries are a leading cause of health care utilization, medical evacuation, and disability. US Army physical therapists (PTs) have served as physician extenders for the management of nonsurgical neuromusculoskeletal injuries since the Vietnam conflict. The roles and evidence supporting US Army physical therapy continue to evolve. This article discusses the different levels of care and roles of US Army PTs, the contributions and evidence regarding US Army physical therapy, and physical therapy lessons learned during Operations Enduring Freedom and Iraqi Freedom. Since 2001, US Army PTs and enlisted physical therapy technicians have provided care from Levels 1 to 5 and assignments have expanded to special operations and brigade combat teams. Evidence suggests US Army PTs serving both in referral and direct access roles provided safe and definitive care that maximized readiness while reducing evacuation. Key physical therapy lessons learned include: (1) a continued focus on a Soldier sports medicine forward care model, (2) a need for injury risk assessment, physical performance screenings, and reconditioning programs that optimize readiness, and (3) continued support for physical therapy structure, training, and research that maximizes Soldier readiness and health.

Impact of an innovative clinical internship model in the US Army-Baylor Doctoral Program in physical therapy.

STUDY DESIGN: Retrospective case-control. BACKGROUND AND PURPOSE: Physical therapy education has been characterized by positive reform including the transition to doctoral level education and the emergence of evidence-based practice as a standard part of the curricula. However, clinical education remains largely unaffected by these advancements and continues as a highly fragmented and ill-equipped model marked by an inefficient 1:1 student to faculty ratio. Current clinical educational models provide highly variable and suboptimal learning experiences for many students, which contribute to disjointed and noncollaborative learning. The purpose of this study is to examine the implications of a one-year collaborative internship model in the US Army-Baylor University Doctoral Program in Physical Therapy in which interns train in groups rather than 1:1 on productivity and efficiency of care. CASE DESCRIPTION: The Army-Baylor program culminates in a 12-month clinical internship conducted at 4 locations within south central Texas (3 military academic medical centers and one multisite outpatient privately-owned physical therapy practice). Each site can accommodate up to 8 (range=4 to 8) students who complete a standardized internship curricula across the full continuum of learning experiences. In this retrospective case-control design, productivity and staffing metrics were extracted for the 3 military sites using the Department of Defense M2 database during the period from 2006-2010. A separate analysis was conducted for each site with descriptive statistics used to assess clinic productivity and efficiency. OUTCOMES: Data from all 3 sites indicate the presence of interns resulted in little variability in clinic productivity and efficiency. Decreased productivity and/or efficiency would bring into question the long term viability and sustainability of the collaborative internship model. Additionally, this model maximized the opportunity for highly engaged mentorship, individual attention, and quality instruction. COMMENT: The findings suggest clinics can accommodate multiple interns and provide high quality education in a collaborative model without a decline in productivity or efficiency. In addition to the standardized curricula across sites, this model facilitates a highly collaborative and peer learning environment in which the intern class supports, challenges, and holds one another accountable to a more standardized and higher level of practice. Each site contributes 1-2 clinical faculty who no longer engage their own patient schedule but rather are able to serve in a full time clinical mentorship role with the interns. In return, the clinical site receives 3-4 full time equivalents of productivity delivered by closely supervised interns who are afforded sufficient time to conduct their examinations and treatments in collaboration with the clinical faculty. Finally, the collaborative internship model supports the mission of each internship site, providing them a critical mass of labor via economies of scale in exchange for an enriched investment into their clinical education.

Median and ulnar neuropathies in U.S. Army Medical Command Band members.

PURPOSE: Musicians have been reported as having a high prevalence of upper-extremity musculoskeletal disorders, including carpal tunnel syndrome. The purpose of this study was to determine the presence of median and ulnar neuropathies in U.S. Army Medical Command (MEDCOM) Band members at Fort Sam Houston, Texas. METHODS: Thirty-five MEDCOM Band members (30 males, 5 females) volunteered to participate. There were 33 right-handed musicians, and the mean length of time in the MEDCOM Band was 12.2 yrs (range, 1-30 yrs). Subjects completed a history form, were interviewed, and underwent a physical examination of the cervical spine and bilateral upper extremities. Nerve conduction studies of the bilateral median and ulnar nerves were performed. Electrophysiological variables served as the reference standard for median and ulnar neuropathy and included distal sensory latencies, distal motor latencies, amplitudes, conduction velocities, and comparison study latencies. RESULTS: Ten of the 35 subjects (29%) presented with abnormal electrophysiologic values suggestive of an upper extremity mononeuropathy. Nine of the subjects had abnormal median nerve electrophysiologic values at or distal to the wrist; 2 had bilateral abnormal values. One had an abnormal ulnar nerve electrophysiologic assessment at the elbow. Nine of these 10 subjects had clinical examination findings consistent with the electrophysiological findings. CONCLUSIONS: The prevalence of mononeuropathies in this sample of band members is similar to that found in previous research involving civilian musicians (20-36%) and far exceeds that reported in the general population. Prospective research investigating screening, examination items, and injury prevention measures in musicians appears to be warranted.

The role of U.S. military physical therapists during recent combat campaigns.

U.S. military physical therapists have a proud history of providing medical care during operational deployments ranging from war to complex humanitarian emergencies. Regardless of austerity of environment or intensity of hostility, U.S. military physical therapists serve as autonomous providers, evaluating and treating service members with and without physician referral. This perspective article suggests that the versatility of U.S. military physical therapist practice enables them not only to diagnose musculoskeletal injuries but also to provide a wide range of definitive care and rehabilitation, reducing the need for costly evacuation. War is not sport, but the delivery of skilled musculoskeletal physical therapy services as close to the point of injury as possible parallels the sports medicine model for on- or near-field practice. This model that mixes direct access with near-immediate access enhances outcomes, reduces costs, and allows other health care team members to work at the highest levels of their licensure.

Undetected pectoralis major tendon rupture in a patient referred to a physical therapist in a combat environment: a case report.

BACKGROUND AND PURPOSE: This case report describes a patient who was referred to a physical therapist for treatment of a shoulder strain and was eventually diagnosed with a rupture of the pectoralis major tendon that required surgical repair. The purpose of this case report is to highlight the management of this injury within the unique constraints of a combat environment. CASE DESCRIPTION: A 29-year-old man, currently serving as an active duty soldier in the U.S. Army in Iraq, had a sudden onset of right shoulder pain during the concentric portion of a bench press. He was seen by a physician immediately after the injury, diagnosed with a shoulder strain, and referred to a physical therapist for a sling and exercise instruction. On the basis of the history and physical examination findings, which were consistent with a pectoralis major tendon rupture, the physical therapist placed a consult to an orthopedic surgeon in the United States through teleconsultation because orthopedic surgeons were not easily accessible in Iraq for nonemergency musculoskeletal referrals. Subsequently, the orthopedic surgeon advised evacuating the patient out of Iraq for surgical treatment. OUTCOMES: By means of magnetic resonance imaging, the patient was diagnosed as having a rupture of the pectoralis major tendon at the musculotendinous junction near its insertion into the greater tubercle of the humerus that required surgical repair. At 3 months after surgery, the patient had full pain-free shoulder active range of motion and had progressed well through his strengthening program in a manner that allowed return to full duty. At 6 months after surgery, the patient maintained full duty status, was performing a routine of strength training 3 times per week, and had met all of his rehabilitation and personal goals. DISCUSSION: Successful treatment of this patient depended on analysis of the history and physical examination findings by the physical therapist to form an accurate diagnosis. In addition, timely medical evacuation and referral to an orthopedic surgeon for surgical treatment were coordinated in a combat environment. Completion of a progressive rehabilitation program after pectoralis major tendon repair also contributed to this patient's full recovery and return to duty. Had the physical therapist only followed the initial referral request, given this patient's military duties and sports and recreational activities, this case probably would have resulted in suboptimal outcomes.

Clinical and electrodiagnostic abnormalities of the median nerve in US Army Dental Assistants at the onset of training.

PURPOSE/HYPOTHESIS: Dental personnel including dentists, dental hygienists, and dental assistants have been reported as having a high prevalence of upper-extremity musculoskeletal disorders, including carpal tunnel syndrome. Previous research has not involved dental assistant students at the onset of dental training. Therefore, the purpose of this study was to determine the presence of median and ulnar neuropathies in US Army dental assistants at the onset of their training. NUMBER OF SUBJECTS: Fifty-five US Army Soldiers (28 female, 27 male) enrolled in the Dental Assistant (68E) course, volunteered to participate in the study. The mean age of the dental assistant students was 24±7.2 years (range 18-41 years). There were 45 right handed dental assistant students, and the mean length of time in the Army prior to dental training was 27 months (range 3-180 months). MATERIALS/METHODS: Subjects were evaluated during the first week of their 10-week dental assistant course. Subjects completed a history form, were interviewed, and underwent a physical examination. Electrophysiological status of the median and ulnar nerves of both upper extremities was obtained by performing motor and sensory nerve conduction studies. Descriptive statistics for subject demographics and nerve conduction study variables were calculated. RESULTS: Six of the 55 subjects (11%) presented with abnormal electrophysiologic values suggestive of median mononeuropathy at or distal to the wrist. Five of the subjects had abnormal electrophysiologic values in both hands. Five of these 6 subjects had clinical examination findings consistent with the electrophysiological findings. The ulnar nerve electrophysiologic assessment was normal in all subjects sampled. CONCLUSIONS: The prevalence of median mononeuropathies in this sample of Army dental assistants at the onset of training is greater than 5% prevalence reported in previous healthy populations and is less than 26% prevalence in previous research examining Army dental assistants with dental work experience. CLINICAL RELEVANCE: Median neuropathy at or distal to the wrist has been reported in dental personnel including dentists, dental hygienists, and dental assistants, and is also prevalent in this sample of dental assistants at the onset of training. Further long-term prospective research involving the impact of dental practice and techniques for reducing upper extremity injuries in dental professionals appears to be warranted.

Clinical and electrodiagnostic abnormalities of the median nerve in dental assistants.

STUDY DESIGN: Descriptive. OBJECTIVES: To determine the presence of clinical and electrodiagnostic abnormalities of the median and ulnar nerves in both upper extremities of dental assistants. BACKGROUND: A high prevalence of median neuropathies at, or distal to, the wrist have been reported in dentists and dental hygienists. But there is a paucity of literature on the incidence of abnormalities of the median or ulnar nerves in dental assistants. METHODS: Thirty-five United States Army dental assistants (24 female, 11 male; age range, 18-41 years) volunteered for the study. Subjects completed a standardized history and physical examination. Nerve conduction status of the median and ulnar nerves of both upper extremities was obtained by performing motor, sensory, and F-wave (central) nerve conduction studies. RESULTS: All electrophysiological variables were normal for motor, sensory, and F-wave (central) values when compared to a chart of normal values. Based on comparison studies of median and ulnar motor latencies within the same hand, 9 subjects (26%) involving 14 hands (20%) were found to have electrodiagnostic abnormalities of the median nerve at, or distal to, the wrist. The other 26 dental assistants demonstrated normal comparison studies of the median and ulnar nerves in both upper extremities. CONCLUSIONS: In this descriptive study of 35 dental assistants, 9 subjects (26%) were found to have electrodiagnostic abnormalities of the median nerve at, or distal to, the wrist (when compared to the ulnar nerve of the same hand). Ulnar nerve electrophysiological function was within normal limits for all subjects examined.

The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome.

The study was an exploratory, one group pretest/post-test study, with the objective of investigating the short-term effects of thoracic spine thrust manipulations (TSTMs) on patients with shoulder impingement syndrome (SIS). There is evidence that manual physical therapy that includes TSTM and non-thrust manipulation and exercise is effective for the treatment of patients with SIS. However, the relative contributions of specific manual therapy interventions are not known. To date, no published studies address the short-term effects of TSTM in the treatment of SIS. Fifty-six patients (40 males, 16 females; mean age 31.2+/-8.9) with SIS underwent a standardized shoulder examination, immediately followed by TSTM techniques. Outcomes measured were the Numeric Pain and Rating Scale (NPRS) and the Shoulder Pain and Disability Index (SPADI), all collected at baseline and at a 48-h follow-up period. Additionally, the Global Rating of Change Scale (GRCS) was collected at 48-h follow-up to measure patient perceived change. At 48-h follow-up, the NPRS change scores for Neer impingement sign, Hawkins impingement sign, resisted empty can, resisted external rotation, resisted internal rotation, and active abduction were all statistically significant (p<0.01). The reduction in the SPADI score was also statistically significant (p<0.001) and the mean GRCS score=1.4+/-2.5. In conclusion, TSTM provided a statistically significant decrease in self reported pain measures and disability in patients with SIS at 48-h follow-up.

Lumbopelvic manipulation for the treatment of patients with patellofemoral pain syndrome: development of a clinical prediction rule.

STUDY DESIGN: Prospective cohort/predictive validity study. OBJECTIVE: To determine the predictive validity of selected clinical exam items and to develop a clinical prediction rule (CPR) to determine which patients with patellofemoral pain syndrome (PFPS) have a positive immediate response to lumbopelvic manipulation. BACKGROUND: Quadriceps muscle function in patients with PFPS was recently shown to improve following treatment with lumbopelvic manipulation. No previous study has determined if individuals with PFPS experience symptomatic relief of activity-related pain immediately following this manipulation technique. METHODS AND MEASURES: Fifty subjects (26 male, 24 female; age range, 18-45 years) with PFPS underwent a standardized history and physical examination. After the evaluation, each subject performed 3 typically pain-producing functional activities (squatting, stepping up a 20-cm step, and stepping down a 20-cm step). The pain level perceived during each activity was rated on a numerical pain scale (0 representing no pain and 10 the worst possible pain). Following the assessment, all subjects were treated with a lumbopelvic manipulation, which was immediately followed by retesting the 3 functional activities to determine if there was any change in pain ratings. An immediate overall 50% or greater reduction in pain, or moderate or greater improvement on a global rating of change questionnaire, was considered a treatment success. Likelihood ratios (LRs) were calculated to determine which examination items were most predictive of treatment outcome. RESULTS: Data for 49 subjects were included in the data analysis, of which 22 (45%) had a successful outcome. Five predictor variables were identified. The most powerful predictor of treatment success was a side-to-side difference in hip internal rotation range of motion greater than 14 masculine (+LR, 4.9). If this variable was present, the chance of experiencing a successful outcome improved from 45% to 80%. CONCLUSION: A CPR was developed to predict an immediate successful response to lumbopelvic manipulation in patients with PFPS. However, in light of a limited sample size and omission of potentially meaningful predictor variables, future studies are necessary to validate the CPR.

Diagnosis of medial knee pain: atypical stress fracture about the knee joint.

STUDY DESIGN: Resident's case problem. BACKGROUND: A 19-year-old female, currently enrolled in a military training program, sought medical care for a twisting injury to her right knee. The patient reported her symptoms as similar to an injury she incurred 1 year previously while enrolled in the same military program. The patient's past medical history included a nondepressed fracture of the medial tibial plateau and complete tear of the deep fibers of the medial collateral ligament. DIAGNOSIS: Physical exam revealed nonlocalized anterior and medial knee pain without evidence of internal derangement. Initial knee and tibia radiographs were unremarkable. Referral for orthopedic physician evaluation resulted in concurrence with the therapist's diagnosis and plan of care, and the patient was allowed to continue with limited physical training demands. Despite periods of rest, the patient's symptoms progressively worsened upon attempts to resume running. The examining therapist referred the patient for magnetic resonance imaging (MRI) due to the patient's worsening symptoms, normal radiographs, and concern for a proximal tibia stress fracture. MRI revealed a severe proximal tibial metaphysis stress fracture. DISCUSSION: Stress fractures are commonly encountered injuries in individuals subjected to increased physical training demands. Early evaluation may not yield well-localized findings and may mimic other conditions. Nonmusculoskeletal conditions should be considered in the management of patients with stress fractures. This resident's case problem illustrates the importance of serial physical examinations and collaboration with other healthcare practitioners in the comprehensive assessment and management of a patient with a severe stress fracture.

Dynamic vs. static-stretching warm up: the effect on power and agility performance.

The purpose of this study was to compare the effect of a dynamic warm up (DWU) with a static-stretching warm up (SWU) on selected measures of power and agility. Thirty cadets at the United States Military Academy completed the study (14 women and 16 men, ages 18-24 years). On 3 consecutive days, subjects performed 1 of the 2 warm up routines (DWU or SWU) or performed no warm up (NWU). The 3 warm up protocols lasted 10 minutes each and were counterbalanced to avoid carryover effects. After 1-2 minutes of recovery, subjects performed 3 tests of power or agility. The order of the performance tests (T-shuttle run, underhand medicine ball throw for distance, and 5-step jump) also was counterbalanced. Repeated measures analysis of variance revealed better performance scores after the DWU for all 3 performance tests (p < 0.01), relative to the SWU and NWU. There were no significant differences between the SWU and NWU for the medicine ball throw and the T-shuttle run, but the SWU was associated with better scores on the 5-step jump (p < 0.01). Because the results of this study indicate a relative performance enhancement with the DWU, the utility of warm up routines that use static stretching as a stand-alone activity should be reassessed.

Comparison of injury rates between cadets with limb length inequalities and matched control subjects over 1 year of military training and athletic participation.

OBJECTIVES: To compare lower-limb overuse injury and low back pain incidence among cadets with and without limb length inequality (LLI) over 1 year of military training and athletic participation. METHODS: A total of 1,100 cadets were screened for LLIs; 126 of 1,100 were identified to have a LLI of > 0.5 cm and were assigned a matched control cadet. Injury rates, numbers of visits to sick call, and numbers of days spent on medical excusal during a 1-year period were then compared for the 252 cadets. RESULTS: There was no difference in prevalence of injury between the groups and no significant differences (p > 0.05) between the groups in injury rates, visits to sick call, or number of days spent on medical excusal. CONCLUSIONS: These findings do not support any increased incidence of injuries in a young, healthy, athletic, military population with mild LLIs, compared with matched control subjects without LLIs, over 1 year.

Arthroscopic versus open shoulder stabilization for recurrent anterior instability: a prospective randomized clinical trial.

BACKGROUND: Arthroscopic stabilization for anterior shoulder instability has been reported to result in a higher rate of recurrent instability compared to traditional open techniques. PURPOSE: To test the null hypothesis that there is no difference in the clinical outcomes in patients with recurrent anterior shoulder instability treated with open or arthroscopic stabilization. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A consecutive series of 64 patients with recurrent anterior shoulder instability were randomized to receive either arthroscopic or open stabilization by a single surgeon. Magnetic resonance arthrogram studies were obtained preoperatively. These findings were compared to arthroscopic findings. Postoperative evaluations included range of motion, stability, and subjective assessments including Single Assessment Numeric Evaluation, Simple Shoulder Test, Western Ontario Instability Index, and University of California, Los Angeles evaluation. Failure was defined as a second dislocation, recurrent subluxation, or symptoms precluding return to previous work or unrestricted active military duty. RESULTS: Sixty-one patients, 29 who received open stabilization and 32 who received arthroscopic stabilization, were evaluated at a mean of 32 months postoperatively (range, 24-48 months). Patient demographics were equivalent. Preoperative magnetic resonance arthrogram findings were confirmed at arthroscopic examination. The mean operative time was significantly shorter for the arthroscopic repairs (59 vs 149 minutes; P < .001). There were 3 clinical failures (2 open stabilizations, 1 arthroscopic stabilization) by the established criteria. There was a statistically significant improvement from preoperative to postoperative Single Assessment Numeric Evaluation scores in both groups (P < .001). The mean loss of motion (compared to the contralateral shoulder) was greater in the open shoulders. Subjective evaluations were equal in both groups. CONCLUSION: Clinical outcomes after arthroscopic and open stabilization were comparable. Preoperative magnetic resonance arthrograms in shoulders with anterior instability allow an accurate diagnosis of intra-articular abnormality that correlates well with operative findings. Arthroscopic stabilization for recurrent anterior shoulder instability can be performed safely; the clinical outcomes are comparable to those after traditional open stabilization.

Identification and management of 2 femoral shaft stress injuries.

STUDY DESIGN: Resident's case problem. BACKGROUND: Although femoral shaft stress fractures in the general population are rare, they are more common among endurance athletes and military recruits. Such individuals presenting with a complaint of hip, thigh, or knee pain should raise suspicion for femoral shaft stress injury. A United States Military Academy cadet presented to West Point's Physical Therapy-Sports Medicine clinic with a complaint of thigh pain related to training with the local marathon team. A second cadet presented to the same clinic during Cadet Basic Training with a complaint of vague but increasing hip, thigh, and knee pain. DIAGNOSIS: Both cadets were suspected of having femoral stress injuries, based on clinical exams, and both diagnoses were confirmed with diagnostic imaging. The 2 cadets were both treated conservatively with progressive rehabilitation once healing was confirmed with radiographs. They both responded favorably to conservative management and returned to full athletic activity at approximately 12 weeks. DISCUSSION: Symptoms from a femoral shaft stress fracture can be vague and mimic those of other etiologies. Providers should consider a broad differential diagnosis, to include femoral shaft stress fracture, when treating endurance athletes and military recruits with anterior hip, thigh, or knee pain. Proper imaging confirms the diagnosis and sequential radiographs assist in rehabilitation planning.

Risk determination for patients with direct access to physical therapy in military health care facilities.

STUDY DESIGN: Nonexperimental, retrospective, descriptive design. OBJECTIVES: This study was designed to ascertain whether direct access to physical therapy placed military health care beneficiaries at risk for adverse events related to their management. BACKGROUND: Military health care beneficiaries have the option at most US military hospitals and clinics to first enter the health care system through physical therapy by direct access, without referral from another privileged health care provider. This level of autonomous practice incurs broad responsibilities and raises concern regarding the delivery of safe, competent, and appropriate patient care administered by physical therapists (PTs) when patients are not first examined and then referred by a physician or other privileged health care provider. While military PTs practice autonomously in a variety of health care settings, they do not work independently within any facility. Military PTs and physicians rely on one another for sharing and collaboration of information regarding patient care and clinical research as warranted. Additionally, military PTs are indirectly supervised by physicians. METHODS AND MEASURES: To reduce provider bias, a retrospective analysis was performed at 25 military health care sites (6 Army, 11 Navy, and 8 Air Force) on patients seen in physical therapy from October 1999 through January 2003. During this 40-month period, 95 PTs (88 military and 7 civilian) were credentialed to provide care throughout the various medical sites. Descriptive statistics were analyzed for total workload, number of new patients seen with and without referral, documented patient adverse events reported to each facility's Risk Management Office, and any disciplinary or legal action against a physical therapist. RESULTS: During the 40-month observation period, 472 013 patient visits were recorded. Of these, 112 653 (23.9%) were new patients, with 50 799 (45.1%) of the new patients seen through direct access without physician referral. Throughout the 40-month data collection period, there were no reported adverse events resulting from the PTs' diagnoses or management, regardless of how patients accessed physical therapy services. Additionally, none of the PTs had their credentials or state licenses modified or revoked for disciplinary action. There also had been no litigation cases filed against the US Government involving PTs during the same period. CONCLUSIONS: The findings from this preliminary study clearly demonstrate that patients seen in military health care facilities are at minimal risk for gross negligent care when evaluated and managed by PTs, with or without physician referral. The significance of these findings with respect to direct access is important for not only our beneficiaries but also our profession and the facilities in which we practice.

Operative stabilization of posterior shoulder instability.

BACKGROUND: Symptomatic, traumatic posterior shoulder instability is often the result of a posteriorly directed blow to an adducted, internally rotated, and forward-flexed upper extremity. Operative repair has been shown to provide favorable results. Current arthroscopic techniques with suture anchors and the ability to plicate the capsule using a nonabsorbable suture may provide favorable outcomes with reduced morbidity. PURPOSE: To evaluate the results of operative shoulder stabilization in patients with traumatic posterior shoulder instability. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A consecutive series of patients who underwent arthroscopic or open posterior stabilization for traumatic posterior shoulder instability were evaluated using subjective assessments, physical examinations, the Single Assessment Numeric Evaluation, Rowe score, Simple Shoulder Test, and the Western Ontario Shoulder Instability Index. RESULTS: Between May 1996 and February 2002, 31 shoulders (30 patients) underwent posterior stabilization (19 arthroscopically, 12 open). There were 29 men and 1 woman (mean age, 23 years). Preoperatively, all patients had a distinct traumatic cause for the instability. On physical examination, all patients had posterior apprehension and increased (2+, 3+) posterior load-shift testing. Preoperative radiographs and/or magnetic resonance imaging revealed posterior rim calcification or reverse Bankart lesions in 29 cases (94%). At arthroscopy, posterior labral injuries, reverse Bankart lesions, or humeral head defects were identified. Follow-up averaged 40 months, and the mean duration between injury and surgery was 21 months. The mean Single Assessment Numeric Evaluation, Rowe score, Simple Shoulder Test, and Western Ontario Shoulder Instability Index scores, respectively, for the entire group were 89, 87, 11, and 346; for the open group, they were 81, 80, 10.5, and 594; for the arthroscopic group, they were 92, 92, 11.4, and 190. The Western Ontario Shoulder Instability Index (P < .03) and Rowe score (P < .04) outcomes scores for the arthroscopic group were statistically better than those of the open group. Twenty-nine of 31 shoulders were rated as excellent or good. CONCLUSION: In the case of traumatic posterior shoulder subluxation, posterior lesions of the labrum ("reverse Bankart"), articular edge, and capsule are observed. Surgical treatment addressing these lesions led to satisfactory results for both the open and arthroscopic treated groups. In this study, an arthroscopic technique utilizing suture anchor repair with capsular placation provided the most favorable outcomes.

Clinical diagnostic accuracy and magnetic resonance imaging of patients referred by physical therapists, orthopaedic surgeons, and nonorthopaedic providers.

STUDY DESIGN: Nonexperimental, retrospective design. OBJECTIVES: This study was designed to compare clinical diagnostic accuracy (CDA) between physical therapists (PTs), orthopaedic surgeons (OSs), and nonorthopaedic providers (NOPs) at Keller Army Community Hospital on patients with musculoskeletal injuries (MSI) referred for magnetic resonance imaging (MRI). BACKGROUND: US Army PTs are frequently the first credentialed providers privileged to examine and diagnose patients with musculoskeletal injuries. Physical therapists assigned at Keller Army Community Hospital have also been credentialed with privileges to order MRI studies for several years. METHODS AND MEASURES: To reduce provider bias, a retrospective analysis was performed on 560 patients referred for MRI over an 18-month period. An electronic review of each patient's radiological profile was performed to assess agreement between clinical diagnosis and MRI findings. Data analyses were performed through descriptive statistics and contingency tables. RESULTS: Analysis on agreement between clinical diagnosis and MRI findings produced a CDA of 74.5% (108/145) for PTs, 80.8% (139/172) for OSs, and 35.4% (86/243) for NOPs. There was a significant difference in CDA between PTs and NOPs (P<.001), and between OSs and NOPs (P<.001). There was no difference in CDA between PTs and OSs (P>.05). CONCLUSIONS: Clinical diagnostic accuracy by PTs and OSs on patients with musculoskeletal injuries was significantly greater than for NOPs, with no difference noted between PTs and OSs.