Disparities Exist in Physical Therapy Utilization and Time to Utilization Between Black and White Patients With Musculoskeletal Pain.

OBJECTIVE: Black patients are less likely than White patients to receive physical therapy for musculoskeletal pain conditions. Current evidence, however, is limited to self-reported conditions and health services use. The purpose of this study was to use a large electronic health record database to determine whether a race disparity existed in use of physical therapy within 90 days of a new musculoskeletal diagnosis. METHODS: Eligible patients (n = 52,384) were sampled from an Optum deidentified electronic health record database of 5 million adults distributed throughout the United States. In this database, patients were designated as "Black" and "White." Patients were eligible if they had a new diagnosis for musculoskeletal neck, shoulder, back, or knee pain between January 1, 2012, and December 31, 2017. Logistic regression and Cox proportional hazard models were computed before and after adjusting for covariates to estimate the association between race and receipt of physical therapy services within 90 days of musculoskeletal pain diagnoses. RESULTS: Patients were on average 47.5 (SD = 14.9) years of age, 12.8% were Black, 87.2% were White, and 52.7% were female. Ten percent of Black patients and 15.5% of White patients received physical therapy services within 90 days of musculoskeletal pain diagnoses. After adjusting for covariates, White patients were 57% more likely (odds ratio = 1.57; 95% CI = 1.44-1.71) to receive physical therapy compared with Black patients and had significantly shorter time to physical therapy than Black patients (hazard ratio = 1.53; 95% CI = 1.42-1.66). CONCLUSIONS: In a nationally distributed cohort, Black patients were less likely than White patients to utilize physical therapy and had a longer time to utilization of physical therapy for musculoskeletal pain. IMPACT: These findings highlight the need to determine the mechanisms underlying the observed disparities and how these disparities influence health outcomes.

Analysis of Calcaneal Bone Mineral Density (cBMD) in Healthy College Students.

BACKGROUND: There is limited evidence describing the relationship between calcaneal bone mineral density (cBMD) and activity level, menstrual history, or the development of bone stress injury (BSI). HYPOTHESIS/PURPOSE: The purposes of this study were to: 1) examine the influence of physical activity on cBMD in healthy college students (HCS), 2) determine if there is an association between cBMD, body mass index (BMI), sex, menstrual history, and history of BSI in HCS, and 3) compare the cBMD of HCS to cBMD data collected on intercollegiate athletes (ICA) from a previous study. STUDY DESIGN: Cross-sectional design. METHODS: This cross-sectional study recruited a convenience sample of HCS at one institution. Subjects provided self-reported injury and menstrual history, completed a physical activity questionnaire, and cBMD and BMI measures were obtained. Descriptive statistics, statistical analyses of relationships (Chi-square and relative risk), logistic regression, and differences (t-tests) were used in the statistical analyses. RESULTS: One hundred three HCS (82 female, 21 male; age 21.9 ± 1.13) consented to participate. The composite score for work, leisure, and sport activity ranged from 5.6 to 11.1 (7.9 ± 1.1) for HCS subjects. There was no significant correlation between cBMD and physical activity in HCS, however, a significant correlation was found between reported age of onset of menstruation and left and right cBMD (r = -0.22 and r = -0.23; p < 0.05) and history of secondary amenorrhea and history of BSI (r = 0.32; p < 0.05). There was no difference in cBMD between the male ICA and male HCS, but highly significant differences in cBMD between the female ICA and female HCS groups (p < 0.000). CONCLUSIONS: Age of menarche and secondary amenorrhea are significantly associated with cBMD and history of BSI in HCS subjects, respectively. Differences in cBMD among the HCS subjects were not related to activity level. cBMD was significantly lower in female HCS as compared to female ICA. This difference in cBMD between ICA and HCS may be activity related. LEVEL OF EVIDENCE: Level 3.

Medial Tibial Stress Syndrome in Active Individuals: A Systematic Review and Meta-analysis of Risk Factors.

CONTEXT: Medial tibial stress syndrome (MTSS) is a common condition in active individuals and presents as diffuse pain along the posteromedial border of the tibia. OBJECTIVE: To use cross-sectional, case-control, and cohort studies to identify significant MTSS risk factors. DATA SOURCES: Bibliographic databases (PubMed, Scopus, CINAHL, SPORTDiscus, EMBASE, EBM Reviews, PEDRo), grey literature, electronic search of full text of journals, manual review of reference lists, and automatically executed PubMed MTSS searches were utilized. All searches were conducted between 2011 and 2015. STUDY SELECTION: Inclusion criteria were determined a priori and included original research with participants' pain diffuse, located in the posterior medial tibial region, and activity related. STUDY DESIGN: Systematic review with meta-analysis. LEVEL OF EVIDENCE: Level 4. DATA EXTRACTION: Titles and abstracts were reviewed to eliminate citations that did not meet the criteria for inclusion. Study characteristics identified a priori were extracted for data analysis. Statistical heterogeneity was examined using the I2 index and Cochran Q test, and a random-effects model was used to calculate the meta-analysis when 2 or more studies examined a risk factor. Two authors independently assessed study quality. RESULTS: Eighty-three articles met the inclusion criteria, and 22 articles included risk factor data. Of the 27 risk factors that were in 2 or more studies, 5 risk factors showed a significant pooled effect and low statistical heterogeneity, including female sex (odds ratio [OR], 2.35; CI, 1.58-3.50), increased weight (standardized mean difference [SMD], 0.24; CI, 0.03-0.45), higher navicular drop (SMD, 0.44; CI, 0.21-0.67), previous running injury (OR, 2.18; CI, 1.00-4.72), and greater hip external rotation with the hip in flexion (SMD, 0.44; CI, 0.23-0.65). The remaining risk factors had a nonsignificant pooled effect or significant pooled effect with high statistical heterogeneity. CONCLUSION: Female sex, increased weight, higher navicular drop, previous running injury, and greater hip external rotation with the hip in flexion are risk factors for the development of MTSS.

The Quality of Reporting of Abstracts in Physical Therapy Literature is Suboptimal: Cross-Sectional, Bibliographic Analysis.

OBJECTIVE: The quality of abstract reporting in physical therapy literature is unknown. The purpose of this study was to provide baseline data for judging the future impact of the 2010 Consolidated Standards of Reporting Trials statement specifically referencing the 2008 Consolidated Standards of Reporting Trials statement for reporting of abstracts of randomized controlled trials across and between a broad sample and a core sample of physical therapy literature. DESIGN: A cross-sectional, bibliographic analysis was conducted. Abstracts of randomized controlled trials from 2009 were retrieved from PubMed, PEDro, and CENTRAL. Eligibility was determined using PEDro criteria. For outcomes measures, items from the Consolidated Standards of Reporting Trials statement for abstract reporting were used for assessment. Raters were not blinded to citation details. RESULTS: Using a computer-generated set of random numbers, 150 abstracts from 112 journals comprised the broad sample. A total of 53 abstracts comprised the core sample. Fourteen of 20 Consolidated Standards of Reporting Trials items for both samples were reported in less than 50% of the abstracts. Significantly more abstracts in the core sample reported (% difference core - broad; 95% confidence interval) title (28.4%; 12.9%-41.2%), blinding (15.2%; 1.6%-29.8%), setting (47.6%; 32.4%-59.4%), and confidence intervals (13.1%; 5.0%-25.1%). CONCLUSIONS: These findings provide baseline data for determining if continuing efforts to improve abstract reporting are heeded.

Lower extremity overuse bone injury risk factors in collegiate athletes: a pilot study.

BACKGROUND AND PURPOSE: There is limited evidence regarding risk factors for lower extremity overuse bone injury (LEOBI) in collegiate athletes. The purposes of the study were to: 1) determine incidence of LEOBI in selected sports and its impact on athletic participation and ADL, 2) assess risk relationships between LEOBI and selected risk factors, and 3) establish the viability of using calcaneal densitometry as a screening tool to identify risk for LEOBI. STUDY DESIGN: Prospective analytical cohort design. METHODS: Collegiate athletes in selected sports (swimming/diving, women's soccer, field hockey, cross-country/track) at one university were invited to participate. Consenting athletes completed an initial questionnaire including demographic information, history, and menstrual function. Measurements included height/weight, hip abductor strength, foot posture index, and calcaneal bone mineral density. Athletes were monitored for potential LEOBI for nine months and an algorithm was used to determine if physician referral was required. The primary outcome of interest was the occurrence of physician-diagnosed LEOBI. If LEOBI was diagnosed by the physician, the athlete completed a follow-up visit including a repeat bone mineral density scan. All athletes were invited for a repeat scan at the end of the year and completed a final questionnaire. Athlete demographics were summarized using descriptive statistics and differences in continuous risk factors were analyzed using t-tests and ANOVA. Finally, risk relationships for categorical variables were analyzed using chi-square and relative risk. RESULTS: 84 athletes (64 female, 20 male) consented to participate. Over the study period, eight athletes (one male, seven females) were diagnosed with LEOBI (LEOBI group), five with stress fractures and three with medial tibial stress syndrome. The other 76 athletes who did not have a diagnosis of LEOBI were placed in the non-LEOBI group. Five of the eight were cross-country/track athletes; no swimming/diving athletes had bone injury. Sport (cross-country/track) had a significant relative risk value of 2.26 (95% CI = 1.18-4.32) for LEOBI. There was no association between LEOBI occurrence and sex, hip abductor strength, body mass index, foot type, and menstrual function. There was no difference in bone mineral density at initial or follow-up measures between LEOBI and non-LEOBI groups (p>.05) when analyzing all athletes. When analyzing ground-based athletes only at follow-up (n=44), athletes with LEOBI had lower bone mineral density of right (p = .05) and left (p =.07) calcaneus. The relative risk for developing LEOBI based on calcaneal bone mineral density below the mean of the study participants was 2.1 (95%CI = 1.09-3.35) on the left and 1.53 (95% CI=.80- 3.06) on the right. CONCLUSION: The incidence of LEOBI in this population of athletes was approximately 10%. Risk factors were sport (cross-country/track) and decreased left calcaneal bone mineral density. This study supports the use of calcaneal bone mineral density as a screening measurement for LEOBI risk and suggests the need for further investigation into additional LEOBI risk factors. LEVEL OF EVIDENCE: 2.

Introduction to the GRADE approach for guideline development: considerations for physical therapist practice.

BACKGROUND: Practice guidelines (guidelines) have an increasing role in health care delivery and are being published more frequently. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) is an approach for guideline development. The GRADE approach has been adopted by multiple national and international organizations producing guidelines related to physical therapist care. OBJECTIVE: The purpose of this article is to introduce physical therapists to the GRADE approach for guideline development. RESULTS: GRADE provides a consistent approach for guideline development and transparency in the communication of how the guidelines were developed and how the recommendations were reached, leading to informed choices by patients, clinicians, and policy makers in health care. GRADE leads to a clear distinction between the strength of the evidence and the recommendation. Both the direction (for or against) and the strength (weak or strong) of the recommendation are considered. For determining the strength of the recommendation, GRADE takes into account the quality of evidence, the balance of benefit and harm, uncertainty about or variability in patients' values and preferences, and uncertainty about whether the intervention is a wise use of resources. LIMITATIONS: The GRADE approach has been used primarily with interventions and clinical questions and less often with questions related to diagnosis and prognosis. CONCLUSIONS: The frequency of publication of guidelines is increasing. To make informed choices in the health care system, physical therapists should understand how guidelines are developed. The GRADE approach has been adopted by national and international organizations that produce guidelines relevant to physical therapist practice. Understanding the GRADE approach will enable physical therapists to make informed clinical choices.

A survey of exercise-related leg pain in community runners.

PURPOSE/BACKGROUND: Exercise-related leg pain (ERLP) is a common problem in runners. The purposes of this study were to 1) report ERLP occurrence among adult community runners; 2) determine ERLP impact on daily activities; and 3) determine if there is a relationship between ERLP occurrence and selected potential risk factors including sex, age, years of running, ERLP history, body mass index (BMI), orthotic use, menstrual function, and training variables. METHODS: Community runners registered for a local race were invited to complete a questionnaire including demographics and potential risk factors. Analyses of differences (t-test) and relationships (Chi-square) were conducted and relative risk (RR) values were calculated. RESULTS: 225 registered runners (105 male, 120 female) participated; 63.6% reported ERLP history, and 35.1% reported ERLP in the 3 months preceding the race with bilateral medial ERLP as the most common presentation. Of the 79 runners who experienced ERLP during the 3 months preceding the race, ERLP caused 41.8% to reduce their running and interfered with walking or stair climbing in < 10%. Chi square analyses showed no significant association of sex, menstrual function, orthotic use, or BMI with ERLP occurrence. Significant associations were observed between ERLP history and ERLP occurrence in the previous year (RR=3.39; 2.54-4.52 95% CI), and between ERLP in the 3 months preceding the race and both years running and training mileage. Greater ERLP occurrence was observed in runners with less than 3 years experience (RR = 1.53; 1.08-2.17 95% CI) and runners who ran fewer than 15 miles/week (RR = 1.47; 1.04-2.08 95% CI). Those runners with < 3 years running experience and a race pace of 9 min/mile or > were at greater risk for ERLP when compared to other participants (RR=1.53; 1.07-2.18 95% CI). CONCLUSION: Interfering ERLP was common among this group of community runners. Risk factors included ERLP history, training mileage < 15 miles/week, and < 3 years running experience. Further investigation is warranted to identify factors which may increase a community runner's risk of developing ERLP. LEVEL OF EVIDENCE: 2b.

The effect of foot orthotic use on exercise related leg pain in cross country athletes.

OBJECTIVES: The purposes of this research were to (1) investigate the effect of foot orthotic use on exercise related leg pain (ERLP) in cross-country (XC) athletes, and (2) determine if an association between foot type and foot orthotic use exists. DESIGN: Prospective cohort design. SETTING: High schools and colleges in a Midwestern metropolitan region. PARTICIPANTS: 213 high school and college XC athletes (107 male, 106 female). MATERIALS/METHODS: Participants were seen before the fall XC season for classification of foot type, visual orthotic inspection, and questionnaire completion regarding foot orthotic use and ERLP. Statistical analysis of relationships (chi-square) was conducted. RESULTS: 37 of the 213 XC athletes (17.4%) used foot orthotics; 31 of the 37 athletes using foot orthotics (83.8%) reported a history of ERLP. Of these 31 athletes, 17 (54.8%) were using orthotics for ERLP and 15 reported a decrease in ERLP with orthotic use. Fourteen athletes were using orthotics for a reason other than ERLP and only 2 reported a decrease in ERLP with orthotic use. Athletes using orthotics included all three foot types (pronated, neutral, supinated) with no relationship between orthotic use and foot type. CONCLUSION: One-sixth of the XC athletes used foot orthotics and most using orthotics for ERLP reported a decrease in ERLP symptoms. The majority of athletes using orthotics for reasons other than ERLP reported no change in ERLP symptoms. There was no association between foot type and orthotic use.

Using MeSH (medical subject headings) to enhance PubMed search strategies for evidence-based practice in physical therapy.

BACKGROUND: Evidence-based practice (EBP) is an important paradigm in health care. Physical therapists report lack of knowledge and time constraints as barriers to EBP. OBJECTIVE: The purpose of this technical report is to illustrate how Medical Subject Headings (MeSH), a controlled vocabulary thesaurus of indexing terms, is used to efficiently search MEDLINE, the largest component of PubMed. Using clinical questions, this report illustrates how search terms common to physical therapist practice do or do not map to appropriate MeSH terms. A PubMed search strategy that takes advantage of text words and MeSH terms is provided. RESULTS: A search of 139 terms and 13 acronyms was conducted to determine whether they appropriately mapped to a MeSH term. The search results were categorized into 1 of 5 outcomes. Nearly half (66/139) of the search terms mapped to an appropriate MeSH term (outcome 1). When a search term did not appropriately map to a MeSH term, it was entered into the MeSH database to search for an appropriate MeSH term. Twenty-one appropriate MeSH terms were found (outcomes 2 and 4), and there were 52 search terms for which an appropriate MeSH term was not found (outcomes 3 and 5). Nearly half of the acronyms did not map to an appropriate MeSH term, and an appropriate MeSH term was not found in the database. LIMITATIONS: The results are based on a limited number of search terms and acronyms. CONCLUSIONS: Understanding how search terms map to MeSH terms and using the PubMed search strategy can enable physical therapists to take full advantage of available MeSH terms and should result in more-efficient and better-informed searches.

Foot orthoses in lower limb overuse conditions: a systematic review and meta-analysis--critical appraisal and commentary.

REFERENCE/CITATION: Collins N, Bisset L, McPoil T, Vicenzino B. Foot orthoses in lower limb overuse conditions: a systematic review and meta-analysis. Foot Ankle Int. 2007;28(3):396-412. CLINICAL QUESTION: Among patients with or at risk for musculoskeletal overuse conditions, (1) do foot orthoses provide clinically meaningful improvements, and (2) are foot orthoses cost-effective? DATA SOURCES: Studies published through September 28, 2005, were identified by using MEDLINE, EMBASE, CINAHL and Pre-CINAHL, Physiotherapy Evidence Database (PEDro), PubMed, SPORTDiscus, Biological Abstracts, Web of Science, Allied Health and Complementary Medicine Database, and the full Cochrane Library. The authors did not provide the search strategy used. Reference lists of included randomized controlled trials (RCTs) and identified systematic reviews were searched by hand. STUDY SELECTION: Studies were included if (1) they were RCTs that included the use of foot orthoses (either custom or prefabricated) in 1 of the intervention groups, (2) the clinical problem was an overuse condition as defined by the American College of Foot and Ankle Orthopedics and Medicine guidelines for which foot orthoses were recommended, and (3) at least 1 clinically relevant outcome was measured for a minimum of 1 week. Limits were not placed on year of publication, status of publication, or language. DATA EXTRACTION: The journal, authors, and author affiliations of included RCTs were masked from 2 of the reviewers who independently assessed the included RCTs for methodologic quality using a modified PEDro scale plus 3 additional items (justification of sample size, use of outcome measures with known validity and reliability, and reporting of adverse or side effects). Disagreements on methodologic quality were resolved with consensus or by a third reviewer. The effect sizes for the included RCTs were represented by relative risk (RR) for dichotomous outcomes and standardized mean difference (SMD) for continuous data. Confidence intervals (CIs) were reported for RR and SMD. Study data were extracted directly from each of the included studies. If provided, data from intention-to-treat analysis were extracted. Study authors were contacted when insufficient data were reported. A meta-analysis (random-effects model) was conducted using Review Manager (version 4.2; The Nordic Cochrane Centre, Copenhagen, Denmark). MAIN RESULTS: The search identified 3192 potentially relevant studies. Full articles were retrieved for 327 studies. Twenty-two of the 327 studies met the inclusion criteria. Because the authors of 1 study used the same methods to report on 2 populations, a total of 23 RCTs were included in the systematic review. Prevention of lower limb overuse conditions with the use of foot orthoses was reported in 8 RCTs (7 studies). The effect of foot orthoses in the treatment of lower limb overuse conditions was reported in 15 RCTs. Of the 23 RCTs, the cost-effectiveness of foot orthoses was reported in 2 and the adverse effects of foot orthoses were reported in 8. Across the prevention RCTs, data were available for analysis for a range of 47 to 417 participants with 8 to 16 weeks of follow-up. Based on 4 RCTs in which the researchers examined prevention of lower limb overuse conditions with foot orthoses versus control in military personnel, the RR was 1.49 (95% CI  =  1.07, 2.08). A clinically beneficial effect size was set a priori at 1.5 or greater for the foot-orthoses group or at 0.7 or less for the comparison group. Based on 2 RCTs reported in 1 study of the use of custom versus prefabricated foot orthoses for prevention of lower limb overuse conditions, no significant difference in risk was found (RR  =  1.14, 95% CI  =  0.90, 1.44). In their calculating and reporting of RR, the authors do not appear to have followed convention. Across the treatment RCTs, data were available for analysis for a range of 18 to 133 participants with 8 to 52 weeks of follow-up. The authors of the treatment RCTs reported a variety of outcome measures. Two of these, patient-perceived treatment effect (PPE) and pain on the visual analog scale (VAS), were used to calculate an overall treatment effect (PPE as RR and VAS as SMD). Based on 2 RCTs examining foot orthoses versus control, no significant difference in PPE was found (RR  =  1.01, 95% CI  =  0.61, 1.68). Based on 2 RCTs in which custom versus prefabricated foot orthoses were examined, no significant difference in PPE was found (RR  =  0.88, 95% CI  =  0.42, 1.81). The VAS data reported in the text appear to contradict the VAS data reported in Figure 2 for foot orthoses versus control for the treatment of lower limb overuse conditions. Specifically, the lower limit of the CI in the text was negative (-0.28) and in Figure 2 was positive. Because of this apparent contradiction, we did not interpret these data. Authors of 2 RCTs reported cost-effectiveness, but the data could not be pooled. Adverse events were reported in 8 of the 22 studies. The most common adverse effect reported was discomfort, which was the main reason for discontinuing foot-orthoses use in 2 studies. CONCLUSIONS: The evidence supports the use of foot orthoses to prevent a first occurrence of lower limb overuse conditions and shows no difference between custom and prefabricated foot orthoses. The evidence was insufficient to recommend foot orthoses (custom or prefabricated) for the treatment of lower limb overuse conditions.

Risk factors for self-reported exercise-related leg pain in high school cross-country athletes.

CONTEXT: Prevention of exercise-related leg pain (ERLP) has not been successful because ERLP risk factors are not well known. OBJECTIVE: To determine the percentage of high school cross-country (XC) athletes who reported a history of ERLP in their running careers, to identify the percentage of athletes who reported an occurrence of ERLP during 1 XC season, and to investigate the association of selected factors (age, high school year, years of high school running, sex, ERLP history, body mass index [BMI], foot type, and training distance) and the occurrence of ERLP. DESIGN: Prospective cohort study. SETTING: Six local high schools. PATIENTS OR OTHER PARTICIPANTS: One hundred twenty-five high school XC athletes (62 females, 63 males). MAIN OUTCOME MEASURE(S): All athletes completed an initial ERLP questionnaire, and foot type was visually assessed. After the season, athletes were asked to complete a Web-based questionnaire regarding the seasonal occurrence of ERLP. Statistical analyses of differences (t tests) and associations (chi(2), relative risk) were conducted. RESULTS: A total of 103 of the 125 athletes (82.4%) reported a history of ERLP, with 81 athletes reporting ERLP occurrence within the month preceding completion of the initial questionnaire. Bilateral medial leg pain was the most common ERLP presentation. More than half of the athletes (58.4%) with an ERLP history reported that the pain had interfered with XC participation. Ninety-three athletes responded to the postseason questionnaire, and 45 (48.0%) reported ERLP seasonal occurrence. Most athletes (97.8%) who experienced the seasonal occurrence of ERLP had a history of ERLP. No associations were noted between ERLP history or seasonal occurrence and age, high school year, years of high school running, sex, BMI, foot type, or training distance. CONCLUSIONS: Both a history of ERLP and the seasonal occurrence of ERLP were common among these XC athletes. The only risk factor identified for ERLP season occurrence was ERLP history.

Using a partnership between academic faculty and a physical therapist liaison to develop a framework for an evidence-based journal club: a discussion.

Evidence-based practice (EBP) in rehabilitation is increasingly recognized as important. Despite the importance of EBP, physical therapists' knowledge of EBP varies. Journal clubs have been used to educate clinicians about EBP. This discussion paper describes the partnership between academic faculty members and a physical therapist at a community hospital, and the process used to develop a framework to implement an evidence-based journal club. The partnership blended the expertise of academic faculty members and a physical therapist with knowledge of EBP who served as the liaison between members of the partnership team and the clinicians at the community hospital. The three-step framework developed enabled the clinicians to learn about critical appraisal, participate in guided practice of critical appraisal with the liaison, and lead critical appraisal of a paper with the assistance of the liaison as needed. This process could be easily replicated by other partnerships between academic faculty members and clinicians. Developing partnerships like the one described enables academicians to provide service to the profession, may enhance physical therapists' knowledge of the principles of EBP and may encourage EBP.

Menstrual function in female high school cross-country athletes.

UNLABELLED: Menstrual function in adolescent athletes has received limited investigation. OBJECTIVE: In a sample of female high school cross-country (XC) athletes, the purposes of the investigation were to (1) describe menstrual function (history and inseason), (2) describe the relationship between menstrual function and variables including body mass index (BMI), high school year, current year of running, total years running, training distance, racing pace, additional organized sport participation other than XC, and participation in XC practices and races, (3) determine the relationship between menstrual function and self-reported interfering exercise related leg pain (ERLP), and (4) determine the relationship between menstrual function history and menstrual function during a XC season. STUDY GROUP: 62 female high school XC athletes. METHODS: A prospective cohort design was used. Athletes were asked to complete an initial questionnaire querying several variables including menstrual function and ERLP history. At the end of the XC season, athletes were asked to complete a postseason questionnaire regarding menstrual function and ERLP during the XC season. RESULTS: Of the athletes, 25.8% (16/62) reported abnormal menstrual function history and 34.9% reported abnormal menstrual function inseason. Abnormal menstrual function history was a risk for previous interfering ERLP (RR = 3.00, CI: 1.09, 8.29), and abnormal menstrual function history was a risk for abnormal menstrual function inseason (RR = 4.11, CI: 1.75, 9.62). CONCLUSIONS: Abnormal menstrual function was present in this sample of athletes and was a risk for previous interfering ERLP and future episodes of abnormal menstrual function.

An exploratory analysis of PubMed's free full-text limit on citation retrieval for clinical questions.

OBJECTIVE: The research sought to determine (1) how use of the PubMed free full-text (FFT) limit affects citation retrieval and (2) how use of the FFT limit impacts the types of articles and levels of evidence retrieved. METHODS: Four clinical questions based on a research agenda for physical therapy were searched in PubMed both with and without the use of the FFT limit. Retrieved citations were examined for relevancy to each question. Abstracts of relevant citations were reviewed to determine the types of articles and levels of evidence. Descriptive analysis was used to compare the total number of citations, number of relevant citations, types of articles, and levels of evidence both with and without the use of the FFT limit. RESULTS: Across all 4 questions, the FFT limit reduced the number of citations to 11.1% of the total number of citations retrieved without the FFT limit. Additionally, high-quality evidence such as systematic reviews and randomized controlled trials were missed when the FFT limit was used. CONCLUSIONS: Health sciences librarians play a key role in educating users about the potential impact the FFT limit has on the number of citations, types of articles, and levels of evidence retrieved.

A primer on web surveys.

With the advancement of computers and access to the Internet, surveys using the web are becoming increasingly popular. Such surveys save money by eliminating postage costs and save time by providing immediate access to returned surveys and improved data processing. This primer describes some considerations and suggestions related to the use of web surveys. In addition to issues of sampling error, question writing, and question sequencing, successful use of web surveys requires determining if a web survey is appropriate, determining the desired level of security and confidentiality, selecting design options that enhance the survey, conducting rigorous pilot testing, and implementing strategies to maximize response rate.

Exercise-related leg pain in collegiate cross-country athletes: extrinsic and intrinsic risk factors.

STUDY DESIGN: Prospective cohort design. OBJECTIVES: To determine in a sample of collegiate cross-country athletes (1) the percentage of athletes with history of exercise-related leg pain (ERLP) associated with running, (2) the incidence of ERLP during 1 season, (3) if factors including years of collegiate running, training distance, and gender are associated with ERLP, and (4) if there is a relationship between foot type and ERLP. BACKGROUND: ERLP is a common overuse pain syndrome, but little evidence exists regarding the prevalence, incidence, and risk factors. METHODS AND MEASURES: Eighty-eight collegiate cross-country athletes (44 male, 44 female) from 5 Midwest universities consented to participate, Prior to the season, athletes completed a questionnaire and 3 measures of foot type were performed: navicular drop, medial longitudinal arch angle, and visual assessment of foot type. Athletes completed a postseason questionnaire regarding the season incidence of ERLP Statistical analyses of differences (t test, proportion test) and relationships (chi-square, relative risk) were conducted. RESULTS: Prior to the season, 60 of the 88 athletes (68%) reported a history of ERLP with bilateral medial leg pain the most common ERLP presentation. Over 50% of the athletes with a history of ERLP reported that the pain had interfered with cross-country participation. Of the 67 postseason respondents, 38.8% reported ERLP incidence during the season. Most athletes (80.8%) who reported season incidence of ERLP had a previous history of ERLP There were no differences between athletes with and without a history of ERLP or season incidence of ERLP regarding years of collegiate running, training distance, gender, and foot measures. CONCLUSION: ERLP history and season incidence was common among these cross-country athletes. The only risk factor identified for season incidence of ERLP was a history of ERLP.

Variables influencing physical therapists' perceptions of continuing education.

BACKGROUND AND PURPOSE: As of October 1, 2002, physical therapy continuing education (CE) in Illinois was mandated. Research examining the recent mandate for physical therapists to engage in CE is limited. The purposes of this study were to examine the perceptions of physical therapist clinicians and managers concerning the barriers to and facilitators of CE and to identify how physical therapists perceive the role of their department in the CE process. SUBJECTS: Participants were 23 physical therapists at 6 hospitals. METHODS: Qualitative methodology was used to analyze data. RESULTS: Four themes were identified: negotiating and managing the variables associated with CE, providing and promoting opportunities that meet physical therapists' CE needs, identifying the elements of employment environments that foster CE, and perceived implications of mandating CE. DISCUSSION AND CONCLUSION: This investigation highlights the need to identify the core set of variables associated with engaging in CE and to promote the elements of employment environments that foster CE.

Physical therapists' perspectives on the role and effectiveness of continuing education.

Research addressing the perspectives of physical therapists recently mandated to engage in continuing education (CE) is limited. The purpose of this investigation, therefore, was to identify physical therapy clinicians' and managers' views on its role and effectiveness. Participants were 23 physical therapists practicing at six different hospitals in Illinois. Qualitative methodology included participant interviews, document analysis, and field journals. Three major themes were identified: (1) attitudes toward CE and mandatory CE, (2) variables contributing to effective CE experiences, and (3) cautious optimism regarding the role of mandatory CE in the promotion of professional competence. This investigation details the need for evidence-based, clinically relevant, interactive CE presentations; ongoing discussion regarding the plausibility of increased national involvement in CE; and focused attention on overcoming obstacles associated with ineffective CE.