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What to Read: April to June 2014

Cathedral of Learning

Blog Posts

What is the Lateral Shift & Why Does It Matter?“, by Trent Nessler, PT, DPT

Kinesio Taping looks so cool, but is it effective?“, by Leo Costa, PT, PhD

Assess, Don’t Assume“, by Mike Reinold, PT, DPT, SCS, ATC, CSCS

Is hip strength a risk factor for patellofemoral pain?“, by Christian Barton, PT, PhD

How do rest periods affect strength gains?“, by Chris Beardsley, PhD

Assessing VBI before cervical manipulation: Should we test for it?“, by Chris Fox, PT, DPT

There is no skill in manual therapy…?“, by Adam Meakins

Unstable Surface Training: The Good, Bad, and Ugly“, by Eric Cressey, MS, CSCS

Iliotibial Band Syndrome, Running, and Gender – What you should know“, by Christopher Johnson, PT, MCMT, ITCA

Common Misconceptions of the Functional Movement Screen“, by Phil Plisky, PT, DSc, OCS, ATC, CSCS

Screening for Movement Dysfunction: Are We Missing Anything?“, by Greg Lehman, BKin, MSc, DC, MScPT


Kooiker L, Van De Port IGL, Weir A, Moen MH. Effects of Physical Therapist–Guided Quadriceps-Strengthening Exercises for the Treatment of Patellofemoral Pain Syndrome: A Systematic Review. Journal of Orthopaedic & Sports Physical Therapy. 2014; 44(6): 391–B1.

Enseki K, Harris-Hayes M, White DM, et al. Nonarthritic Hip Joint Pain. Journal of Orthopaedic & Sports Physical Therapy. 2014; 44(6): A1–A32.

Cools AM, Borms D, Cottens S, Himpe M, Meersdom S, Cagnie B. Rehabilitation Exercises for Athletes With Biceps Disorders and SLAP Lesions: A Continuum of Exercises With Increasing Loads on the Biceps. American Journal of Sports Medicine. 2014; 42(6): 1315–1322.

Drew BT, Smith TO, Littlewood C, Sturrock B. Do structural changes (eg, collagen/matrix) explain the response to therapeutic exercises in tendinopathy: a systematic review. British Journal of Sports Medicine. 2014; 48(12): 966–972.

Kiesel KB, Butler RJ, Plisky PJ. Prediction of Injury by Limited and Asymmetrical Fundamental Movement Patterns in American Football Players. Journal of Sport Rehabilitation. 2014; 23(2): 88–94.

Powers CM, Ho K-Y, CHEN Y-J, Souza RB, Farrokhi S. Patellofemoral Joint Stress During Weight-Bearing and Non—Weight-Bearing Quadriceps Exercises. Journal of Orthopaedic & Sports Physical Therapy. 2014; 44(5): 320–327.

Nilstad A, Andersen TE, Kristianslund E, et al. Physiotherapists Can Identify Female Football Players With High Knee Valgus Angles During Vertical Drop Jumps Using Real-Time Observational Screening. Journal of Orthopaedic & Sports Physical Therapy. 2014; 44(5): 358–365.

Otsuki R. EFFECT OF INJURY PREVENTION TRAINING ON KNEE MECHANICS IN FEMALE ADOLESCENTS DURING PUBERTY. International Journal of Sports Physical Therapy. 2014; 9(2): 149–156.

Glaws KR. INTRA- AND INTER-RATER RELIABILITY OF THE SELECTIVE FUNCTIONAL MOVEMENT ASSESSMENT (SFMA). International Journal of Sports Physical Therapy. 2014;9(2):195–207.

Rust DA, Giveans MR, Stone RM, Samuelson KM, Larson CM. Functional Outcomes and Return to Sports After Acute Repair, Chronic Repair, and Allograft Reconstruction for Proximal Hamstring Ruptures. American Journal of Sports Medicine. 2014; 42(6): 1377–1383.


When Can I Play Again? Return to Sports Testing for the Upper Extremity.


The following is another article written for the online, video-based physical therapy continuing education company MedBridge

A lot has been written and researched with regards to return to sport criteria and testing for injuries of the lower extremity, and more specifically following anterior cruciate ligament reconstruction (ACL-R), however little attention has been given to injuries of the upper extremity. As with ACL-R, return to sport following surgical intervention in the upper extremity is less than stellar. Harris et al conducted a systematic review that found amongst elite pitchers undergoing shoulder surgery (rotator cuff, biceps/labrum, instability, internal impingement, ect.), only 68% returned to play 12 months following surgery. Additionally, they found that 22% of major league baseball pitchers included in their review never returned to sport. In agreement with these findings, Cohen et al evaluated the return to sport of professional baseball players following shoulder and/or elbow surgery and found only 48%  of participants returned to the same or higher level of professional baseball following surgery. Why are these numbers so low and what can we do as rehabilitation specialists to improve the rate of return to sport following surgery?

Sometimes, it simply takes correctly identifying those who are at risk of re-injury or those simply not ready to rerun to their chosen sport. When devising an appropriate return to sport test, Phil Plisky, PT, DSc, OCS, ATC, CSCS says in his course, “Return to Sport and Discharge Testing“, that each test should be reliable, predictive of injury, have discriminate validity, and the test must be modifiable with training/rehabilitation. With regards to the upper extremity, there is a significant gap in knowledge/research in comparison to the lower extremity. That being said, the Y-Balance Test has recently been adapted to help fill this gap. Gorman et al investigated to reliability of the Upper Quarter Y Balance Test (UQ-YBT) and found that the test-retest reliability (0.80-0.99) and inter-rater reliability (1.00) ranged from good to excellent. Along with this information, normative data was determined amongst active adults with males generally performing the test superiorly to females and a minimally detectable difference of 8.1 cm in the medial direction, 6.4 cm in the superolateral direction, and 6.1 cm in the inferolateral direction. In addition to these findings, Westrick et al found that there was no significant difference between the dominant and non-dominant limb when young females or males perform the UQ-YBT. This shows that, generally speaking, any significantly asymmetrical findings should be investigated further prior to returning the athlete to his/her sport. While, currently, there are no studies investigating this test’s capacity to predict injury or its ability to be modified with training, the excellent reliability and discriminate validity make this a solid return to sport test.

Similarly, the Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST) offers an additional way to assess upper extremity dynamic stability, albeit in a singular plane. Once again, this test demonstrates excellent reliability with a Test-Retest Reliability of 0.92 (Goldbeck et al), an intersession reliability ranging between 0.87 to 0.96 (Tucci et al), and an intrasession reliability ranging between 0.86 and o.97. Furthermore, Tucci et al also found the CKCUEST to have discriminate validity as those performing the test with diagnosed subacromial impingement performed significantly inferiorly in comparison to asymptomatic participants. Along with this excellent reliability and obvious display of closed kinetic chain dynamic stability, the CKCUEST also has recently been shown to have the capacity to predict injury. Pontillo et al performed a prospective cohort study attempting to identify potentially factors that would be predictive of upper extremity injury in collegiate football players. The only significant factor in predicting future injury in this population of athletes was a CKCUEST in which the athlete completed < 21 touches (Sn= 79%, Sp= 83%, + LR= 4.74, – LR= 0.25, Odds Ratio= 18.75). This is a significant finding and shows the benefit for utilizing this test not only for return to sport, but also in pre-season testing to identify individuals who are at risk for injury.

For a more demanding task, similar to the single-leg hop testing utilized for patients following ACL reconstruction, the One-Arm Hop Test was created to test the athlete’s plyometric, power, and dynamic closed kinetic chain stability. Unfortunately, to this date, there has only been one study investigating this specific return to sport test. Falsone et al found the test to have good Test-Retest Reliability (0.78-0.81) and also found only a 4.4% difference between non-dominant and dominant limbs when performing the test. This once again shows the ability to assess post-operative function based upon the symmetry between limbs. While this may not be a perfect solution, it allows the ability to utilize the test with evidence-based backing until further research is conducted investigating its ability to predict injury and/or be modified with training.

Returning an athlete to sport is a multi-factorial decision that must incorporate that athlete’s psychological readiness to return to play, strength, range of motion, pain level, and ultimately the ability to perform the movement patterns consistent with their sport and/or position. The aforementioned return to sport tests provides a hierarchical (i.e. increasingly demanding) system for testing the individual’s capacity to withstand the rigors of their chosen activity. This allows clinicians something outside of subjective reports, range of motion, and strength measures to assess your patient’s ability to perform dynamic upper extremity tasks prior to returning to sport and in doing so, we may be able to identify some of the deficits our athletes are hiding that are preventing them from ultimately returning to their sport.


Things are not always as they seem… The Basis for a Regional Interdependence Model


The following is another article written for the online, video-based physical therapy continuing education company MedBridge Education

Think for a minute about what you would do if the following patient walked into your clinic…

A 24-year-old female patient presents with left anterior knee pain, which was exacerbated after beginning a rigorous marathon training program. No other complaints other than pain during her runs and for 4-6 hours thereafter, but no other functional limitations when performing her ADLs. 

So, based on this scenario, where would you focus your evaluation? My guess is that the majority of clinicians would focus on the knee and more specifically, the patellofemoral joint. Active and passive range of motion would be taken, gross lower extremity strength would be screened, and special tests would be performed. But, what if the patellofemoral joint was not the issue?

While these tests and measures are often indicated, with regards to musculoskeletal injuries, a joint or muscle group proximal or distal to the involved site can actually be the cause of the patient’s complaints. This concept is known as Regional Interdependence. This can be seen with a variety of orthopedic complaints as hip involvement has been associated with low back pain (Cibulka et al) and knee osteoarthritis (Cliborne et al), and thoracic/rib involvement in neck pain (Cleland et al) and subacromial impingement (Bergman et al). Specifically speaking of patellofemoral pain syndrome (PFPS) and our marathon running patient, proximal and distal impairments have also been shown to be very common in this patient population. A recent study conducted by Khayambashi et al found that following 8 weeks of hip abductor and external rotator strengthening, reduced pain and improved function was reported in women with PFPS in comparison to a control group. Furthermore, Khayambashi et al later conducted a randomized controlled trial comparing quadriceps strengthening to posterolateral hip strengthening in patients with PFPS. This study once again favored the hip-strengthening group with improvements in VAS and WOMAC scores in the posterolateral hip exercise group being superior to those in the quadriceps exercise group post-intervention and at 6-month follow-up. Going along with these findings, a systematic review investigating the utility of proximal stability training in patients with PFPS, which included 8 RCTs and found a consistent reduction of pain and improved function in the treatment of patellofemoral pain (Peters et al). Additionally, looking distally from the knee at the foot/ankle joint, according to a case-control study performed by Barton et al, individuals who present with PFPS, possess a more pronated foot posture and increased foot mobility compared to controls.

So, as the research shows, there is a fairly significant amount of evidence supporting the premise of Regional Interdependence, but how do we evaluate how and where to address the potential proximal or distal impairments? While there are several systems available to therapists to identify and address impairments based on the regional interdependence model, one of the most well-known and widely accepted systems is that of the Selective Functional Movement Assessment (SFMA). This system consists of a series of 7 full-body movement tests designed to assess fundamental patterns of movement, such as bending and squatting, in those with known musculoskeletal pain. From this assessment, interventions can then be applied to the identified impairments. While in comparison to its brother system, the Functional Movement Screen (FMS), which was developed for movement assessment in individuals without a painful condition, the SFMA has significantly less research available. That being said, a reliability study was recently conducted by Glaws et al in the International Journal of Sports Physical Therapy. This study found intra-rater reliability that ranged from Good to Poor and inter-rater reliability ranging from slight to substantial agreement. Those raters with increased experience utilizing the system demonstrated superior performance compared to those who were less experienced. This study provides preliminary evidence with regards to the reliability of the system, but there has yet to be a study conducted to validate the system’s effectiveness. In lieu of this evidence, the system itself still provides a reliable way to assess your patient’s movement impairments and allows the clinician to apply interventions, whether manual therapy techniques or therapeutic exercise, that will improve the patient’s quality of movement. For further information regarding the SFMA and its utility, take the time to understand the intricacies of the system by taking “Movement Dysfunction: An Evidence-Based Overview” by Kyle Kiesel, PT, PhD, ATC. The research indicates that movement relies on a coordinated interaction of multiple joints, muscles, and biological systems (cardiovascular, musculoskeletal, neurological, ect.). Because of these multiple influences, the therapist must look at potential factors that may be predisposing the patient to their painful condition and many times this will take us away from the effected joint.


2014 Therapydia Blog Awards: Best Student Blog!


Orthopedic Manual Physical Therapy was officially named ‘Best Student Blog’ in Therapydia’s PT Blog Awards for the second consecutive year! Thank you so much for the continued support and taking time out of your day to to vote for OMPT! I was honored just to be nominated along with The AAOMPT sSIG, Pitt Physical Therapy, The Student Physical Therapist, and A Cup A Day.

OMPT also came in 3rd place for ‘Best Research Blog’ and it was honestly great just to be named in the same breath as Body in Mind and Forward Thinking PT. Congratulations to Joseph Brence, DPT, FAAOMPT and all those that contribute to Forward Thinking PT!

Thanks again for all of your continued support,

John Snyder, DPT, CSCS


2014 Therapydia PT Blog Awards!

Screen Shot 2014-04-25 at 8.04.15 AM

Thanks to all your continued support, was nominated for both ‘Best PT Student Blog’ and ‘Best PT Research Blog’ in Therapydia’s 2014 PT Blog Awards. It’s an honor to be named in the same group as all of the nominees in both categories!

Please continue to support and CAST YOUR VOTE (voting ends in ~ 2 weeks)!


John Snyder, SPT, CSCS


Last Chance!


Last chance to save $225.00 on a one-year subscription to MedBridge Education’s online physical therapy continuing education resource! My affiliate discount will expire on April 30th, so if you’re interested in evidence-based continuing education that you can complete at home, don’t miss this opportunity! I do not push many products through my website for various reasons, but I honestly believe every clinician or DPT student can learn a ton from this resource. If you have any questions about my experience with MedBridge, feel free to e-mail me and I can answer any questions you have.

For the Discounted rate, CLICK HERE or feel free to check out the MedBridge website and use promo code orthomanualPT when you’re ready to buy!

Thanks and enjoy!

John Snyder, SPT, CSCS


Research Review: Validation of a Clinical Prediction Rule to Identify Patients with LBP Likely to Respond to Stabilization Exercises


In the next instalment of my Research Review Series for MedBridge Education, we discuss a recent randomized controlled study investigating the validity of a clinical prediction rule for identifying patients with low back pain likely to respond favoribly to a spinal stabilization program.

Study Design

Randomized Controlled Trial.


One hundred five patients diagnosed with LBP and referred to physical therapy at 1 of 5 outpatient clinics of Clalit Health Services in the Tel-Aviv metropolitan area, Israel, were recruited for this study. Of these 105 patients, 40 were positive on the Stabilization CPR and 65 were negative. The most evident difference between baseline differences of groups was age, with those in the stabilization group being significantly younger (one of the items of the CPR is < 40 years old).

Inclusion Criteria: 18 to 60 years of age, primary complaint of LBP with or without associated leg symptoms (pain, paresthesia), and had a minimum score of 24% on the Hebrew version of the modified Oswestry Disability Index (MODI) outcome measure.

Exclusion Criteria: History indicating any red flags (malignancy, infection, spine fracture, cauda equina syndrome), 2 or more signs suggesting lumbar nerve root compression (decreased deep tendon reflexes, myotomal weakness, decreased sensation in a dermatomal distribution, or a positive SLR, crossed SLR, or femoral nerve stretch test), history of corticosteroid use, osteoporosis, or rheumatoid arthritis. Additionally, patients were excluded if they were pregnant, received chiropractic or physical therapy care for LBP in the preceding 6 months, could not read or write in the Hebrew language, or had a pending legal proceeding associated with their LBP.


Outcome Measures: Hebrew version of the modified Oswestry Disability Index (MODI) and Numerical Pain Rating Scale (NPRS).

Randomization: Based on a computer-generated list of random numbers, which was then stratified by CPR status to ensure that adequate numbers of patients with a positive and a negative CPR status would be included in each intervention group.

Evaluation: A physical examination was conducted that included a neurological screen to rule out lumbar nerve root compression. Next, lumbar active motion was evaluated, during which the presence of aberrant movement, as defined by Hicks et al, was determined. Bilateral SLR range of motion, segmental mobility of the lumbar spine, and the prone instability testing was then also conducted. The patients’ status on the CPR (positive or negative) was established based on the findings of the physical examination.

Interventions: Patients in both the Lumbar Stabilization Exercise group (LSE Group) and Manual Therapy group (MT) received 11 treatments over an 8 week period and a 12 visit, which consisted of solely a re-evaluation. The LSE group was first educated on the function and common impairments related to the lumbar stabilizing musculature, they were then taught to perform an isolated contraction of the transversus abdominis and lumbar multifidus through an abdominal drawing-in maneuver (ADIM) in the quadruped, standing, and supine positions. Once the patient could successfully perform these actions, the demands on the musculature were increased by the addition of various upper and lower extremity movements. Finally, during the seventh session, functional movements were added to their program. Those patients randomized to the MT group received several thrust and non-thrust mobilization techniques to their lumbar spine in addition to manual stretching of several hip and thigh muscle groups. Each treatment session included up to three manual techniques (one of which had to be a thrust technique). With regards to exercise, those in the MT group performed active range of motion and self-stretching exercises, but did not perform isolated spinal stabilization exercises. All variations and progressions of exercises and manual therapy techniques can be seen in the appendix of the research report.


With regards to MODI, clinical significance could not be determined after 2-way interaction between treatment group and CPR status was calculated (p = 0.17). That being said, individuals who were positive on the CPR did demonstrate less disability at the end of the study compared to those who were negative (p = 0.02). Furthermore, amongst patients who were positive on the CPR, those who received LSE also demonstrated less disability following treatment compared to those who received MT. When the authors introduced a modified CPR, which consisted of positive prone instability test and presence aberrant movement, they did find a significant interaction with treatment for final MODI. Those positive on the modified CPR demonstrated superior outcomes compared to the group as a whole and also showed improved outcomes when receiving LSE compared to MT (p = 0.005).


The most prevalent limitations include an inadequate sample size, which resulted in a limited overall power of the findings as well as the retrospective nature of some of the findings (i.e. modified CPR). Additionally, this study had a high drop-out rate for a study of its size with an overall drop-out rate of 22.8% (33% in the LSE group and 14% in the MT group). The lower dropout rate in the MT group could potentially be due to an attention affect due to the manual contact required for the interventions within this group compared to the LSE group. Additionally, while short-term results are important, understanding the long-term implications of either MT or LSE is of greater importance. This study only included an 8 week follow-up and it would be beneficial to see the long-term implications with a 6 or 12 month follow-up to gauge the overall effectiveness of the CPR and associated interventions. Finally, it should be noted that status on CPR was determined prior to group determination, which introduces an additional level of bias. Future studies should look at results with CPR determination post priori or following allocation to groups.

Clinical Implications

Manual therapy and spinal stabilization are two very common interventions utilized by physical therapists when treating low back pain. As manual therapy is common amongst clinicians and generally considered an effective treatment option, it provides an excellent reference value in the validation of the stabilization CPR. Unfortunately, the utility of the CPR as it was constructed could not be validated based on the findings of this study. Several factors could have played into this discrepancy including attention effect by those in the MT group, small sample size, and large dropout percentage. While the original CPR could not be validated, retrospectively an abbreviated CPR was identified and ‘validated’ based on the findings of the 2-way interaction between treatment group and modified CPR status. So, while this study seems like a knock to the current lumbar stabilization CPR, the study design and execution of the study cannot allow the CPR to be disregarded as all of the aforementioned limitations may have played a significant role in the study’s results. Additionally, the creation of an abridged CPR may have more value to clinicians long-term as it provided superior results and requires less factors to be evaluated by the clinician. However, the results must be taken with a grain of salt as a prospective evaluation of the modified CPR must be conducted in order to determine its utility. Clinical prediction rules and the effectiveness of spinal stabilization are polarizing issues within the physical therapy community and this study debatably provides support to the use of spinal stabilization and indicates that future research is needed to clear up the murkiness of the current stabilization CPR. When treating the lumbar spine, no treatment should be provided with every patient and Chad Cook, PT, PhD, FAAOMPT goes into great detail in his course, “Evidence-Based Treatment of the Lumbar Spine”, with regards to the use of spinal stabilization within the Treatment-Based Classification system.


Rabin A, Shashua A, Pizem K, Dickstein R, Dar G. A Clinical Prediction Rule to Identify Patients With Low Back Pain Who Are Likely to Experience Short-Term Success Following Lumbar Stabilization Exercises: A Randomized Controlled Validation Study. Journal of Orthopaedic & Sports Physical Therapy. 2014; 44(1): 6–18, B1–13. 


Did you enjoy this blog post? If so, please take the time to nominate Orthopedic Manual PT as ‘Best Student Blog’ in Therapydia’s 2014 PT Blog Awards!


Nominate OMPT for Therapydia’s 2014 Blog Awards!

Therapydia 2014

It’s time for the 2014 Therapydia PT Blog Awards! Please take the time to nominate OMPT ( as Best Student Blog or whatever else you want!


Thank you for your continued support,

John Snyder, SPT, CSCS


Effectiveness of Manual Therapy for Knee Pain

proximal tib-fib

The following is another article written for the online, video-based physical therapy continuing education company MedBridge Education

Knee osteoarthritis (Knee OA) is one of the most prevalent and debilitating orthopedic complaints for 28% of adults over 45 years old and 37% of those over 65 years old in the United States. In addition, 1.6% of adults over the age of 60 have undergone total knee arthroplasty (Dillon et al). Improving the underlying mobility, strength, pain, and functional limitations associated with this pathology is a critical component of patient care. There are a number of interventions employed by physical therapists for individuals suffering from knee pain – some more effective than others. Amongst one of the more common, albeit controversial, is the use of manual therapy, or more specifically, joint mobilization.

In 2000, Deyle et al published an initial investigation into the potential effectiveness of manual therapy techniques in combination with exercise in the treatment of knee OA. In this randomized controlled trial, patients in the intervention group received manual therapy techniques based on their specific impairments, which potentially included passive physiologic and accessory joint movements, muscle stretching, and soft-tissue mobilization, applied primarily to the knee. However, if any additional deficits were found in other regions (i.e. hip, foot/ankle, lumbar spine), manual therapy techniques were directed at these areas. At the completion of the study, the intervention group achieved significant improvements in 6-minute walk distance and WOMAC score at 4 weeks and 8 weeks. Additionally, only 5% of those in the intervention group underwent total knee arthroplasty (TKA) in comparison to 20% in the control group. This study was a great first step, however as the control group only received subtherapeutic ultrasound for 10 minutes to the area of knee symptoms, further investigation was warranted.

Later in 2005, Deyle et al conducted a similar study with a control group, which included a standardized home exercise program. In this study, patients in the intervention group received 8 sessions of manual therapy treatment, which consisted of passive physiological and accessory movements, manual muscle stretching, and soft-tissue mobilization. These techniques were primarily applied to structures in the knee region opposed to the holistic approach previously used in the 2000 study. At the 4 week follow-up, WOMAC scores had improved by 52% in the clinic treatment group compared to 26% in the home exercise group, whereas both groups improved by approximately 10% in their 6-minute walk distances. Additionally, at the one-year follow-up, there was no significant difference between groups in either measure. This study gives credence to short-term functional improvements for manual therapy techniques, but not necessarily walking speed or capacity. While this does offer some evidence to support the inclusion of manual therapy, it also puts into question whether a home exercise program is an adequate comparison group.

More recently, Abbott et al conducted a randomized controlled trial comparing manual therapy, exercise, and combined manual therapy and exercise, and a usual care group in the treatment of hip and knee OA. The findings of this study were interesting, at the one year follow-up, both the manual therapy and exercise groups achieved statistically significant improvements with regards to reduction in WOMAC scores. Whereas, combined manual therapy and exercise did not meet this same significant improvement. Along with these findings, following the intention to treat analysis, all intervention groups improved but only usual care plus manual therapy and usual care plus exercise therapy achieved clinically significant reductions of >28 WOMAC points from baseline. Once again, manual therapy and exercise plus usual care improved, but did not meet the 28-point improvement threshold. In a secondary analysis of this trial by Pinto et al, it was determined that within the New Zealand healthcare system, both manual therapy and exercise offer a significant cost savings over usual care for OA treatment.

With this recent research, there does seem to be a fairly significant benefit to the utilization of manual therapy, however a multi-modal program consisting of manual therapy and exercise seems to be less effective than manual therapy in isolation. It should be taken into consideration that this conclusion was derived from one study and may not be a true representation of the patient population as a whole. In agreement with the benefits of manual therapy found by Abbott et al, a systematic review published by Jansen et al found a greater effect size with manual therapy and exercise (0.69) in comparison to either exercise therapy (0.38) or strength training (0.34) in isolation. Additionally, recent works by Rhon et al and Ko et al found significant increases in proprioception and functional performance when manual therapy was combined with exercise and perturbation exercises, respectively.

In addition to the varying degrees of effectiveness found in the aforementioned studies, it must be considered that not every patient with knee OA will respond similarly to any given therapeutic intervention. In order to help delineate those patients with knee OA who will respond favorably to hip mobilization, Currier et al proposed a Clinical Prediction Rule (CPR) to make this distinction. This particular study found that of those individuals who 2+ of the 5 variables present, following hip mobilization, the positive likelihood ratio was 12.9 and probability of success was 97% (success defined as a decrease of at least 30% on composite Numerical Pain Rating Scale score obtained during functional tests or a Global Rating of Change Scale score of at least 3). This CPR should be used with caution, however, as no validation study has been conducted to this date. While this CPR provides some idea as to which patients will respond favorably to manual therapy interventions, it should be understood that this decision must be made in conjunction with sound clinical reasoning following a thorough patient history and physical examination.

Alexis Wright, PT, PhD, DPT, FAAOMPT goes into great detail with regards to evidence-based decision making when deciding whether joint mobilization or manipulation will benefit your patient in her course, “Evidence-Based Examination of the Hip“. So, while the research is far from definitive regarding this specific intervention, manual techniques do appear to provide significant improvements in proprioceptive capacity, perceived physical disability, and pain levels for patients presenting with knee osteoarthritis.


Research Review: Manual Physical Therapy and Perturbation Exercises in Knee Osteoarthritis

Rhon et al, 2013

Study Design

Prospective, observational cohort study.


Fifteen participants (7 male, 8 female) with a mean age of 55 years old were recruited from a convenience sample of consecutive patients evaluated for knee osteoarthritis (OA) at the Physical Therapy Clinic, Brooke Army Medical Center, San Antonio, Texas. With regards to severity, ten patients had bilateral symptoms, all 15 patients had radiographic signs of knee OA, and 10 had visible boney enlargement of the knee joint. Additionally, four of the included patients were active duty military personnel.

Inclusion Criteria: Utilizing criteria proposed by Altman (1991) and Altman et al (1986), the participants were included if they met at least one of the following three clinical clusters.

1. Knee pain for most days of the prior month: AND Crepitus with active motion and Morning stiffness in knee 38 years
2. Knee pain for most days of the prior month: AND Crepitus with active motion and Morning stiffness in knee > 30 minutes and Bony enlargement
3. Knee pain for most days of the prior month: AND No crepitus and Bony enlargement

Additional inclusion criteria include being eligible for care in a military medical treatment facility, minimum age 38 years old, and the ability to read, write, and speak sufficient English to complete the outcome tools.

Exclusion Criteria: Only periarticular pain or pain referred from another region (no joint pain), injections to the knee within the last 30 days, history of knee joint replacement surgery on involved limb, evidence of other systemic rheumatic condition (lupus, rheumatoid arthritis, psoriasis, or gout), and balance deficits from other non-musculoskeletal conditions (neurologic impairments, diabetic neuropathy, cerebellar disorders, or Parkinson disease)


Outcome Measures: The Western Ontario and McMaster Universities arthritis index (WOMAC), Global Rating of Change (GROC), Functional Squat Test (FST) evaluated with numerical pain rating scale (NPRS) and range of motion (ROM), and the Step-Up Test (SUT). Additionally, tolerance to treatment was determined by asking the participants a series of questions regarding whether their symptoms had gotten significantly worse at five different time points since their last visit. Time points included were immediately following treatment, several hours following treatment, that evening prior to bed, the following morning, and from the following morning until the follow-up (approximately 72 hours later).

Evaluation: The initial evaluation included a detailed history, review of systems, and physical examination. The history included questions regarding the duration, severity, location, and distribution of symptoms. The physical examination included functional tests, palpation of bony landmarks, ROM measurement, muscle length tests, and manual assessment of the joints and soft tissues of the lower extremity.

Interventions: Each patient was treated two times per week for four weeks and received both manual therapy and perturbation interventions. Visits included joint and soft-tissue mobilization, which was supplemented with stretching, ROM, and strengthening exercises. Additionally, each patient was provided with a home exercise program targeting their specific functional limitations. The manual therapy techniques were tailored to the impairments of each individual patient, however these interventions included varying grades of knee flexion, knee extension, and patella mobilizations. With regards to perturbation training, each patient was progressed based upon clinical reasoning and as tolerated by the individual patient. Each program generally started with more emphasis on manual therapy interventions and towards the end of the program, the focus switched to perturbation exercises.


WOMAC: The mean WOMAC score demonstrated a statistically significant improvement from baseline to 6 months with a 46% improvement, which was well above the minimal clinically important difference (MCID) of 12%. Additionally, the total WOMAC score was significantly improved at the end of the 4 week intervention period and remained improved at the 6 month follow-up. Finally, the only WOMAC sub-scale that did not remain improved at the 6 month follow-up was the ‘Stiffness’ sub-scale.

GROC: At the one month follow-up, 87% of patients reached the 3 point change in GROC to identify a clinically important change. Changes decreased over time with 80% of patients still maintaining this threshold of change at 3 months and only 60% at the final 6 month follow-up. Additionally, and probably more importantly, 47% of patients met the threshold for ‘dramatic change’ (GROC > 6) at all time points.

FST: Following the 4 week intervention period, statistically significant improvements in NPRS and ROM during the FST were documented. An average decrease from 5 to 3 on the NPRS and an improvement from 29° to 35° with regards to ROM.

SUT: The Step-Up Test values also significantly improved at the 4 week evaluation with a mean improvement of 4-5 steps during the 15 second test. This translated to an average increase from 9 to 14 steps completed during the test.


Due to the prospective cohort design of this study, no comparison group was included, thus no cause and effect relationship can be identified. Additionally, some of the improvements seen in this study could be attributed to other medical treatment many of the patients received. By 6 months five patients had received knee joint injections of either corticosteroid or viscosupplementation and two of those same patients received arthroscopic surgery. Of these patients receiving either injection or arthroscopic surgery, none reported improvement in symptoms immediately following the aforementioned procedures. Pain medication was used by 12 patients initially (10 patients daily; 2 patients as needed), including non-steroidal anti-inflammatory drugs and/or acetaminophen. However, it should be pointed out that at each of the follow-up points, fewer patients were taking medications than at baseline.

Clinical Implications

While no cause and effect relationship can be determined, this study does demonstrate theoretical effectiveness of a combined manual therapy and perturbation training approach to the treatment of knee osteoarthritis. This approach was associated with significant improvements in pain, function, and balance measures. There were several limitations evident within the study, however the potential positive impact of the interventions provided add to the current literature supporting perturbation and manual therapy techniques for patients suffering from knee osteoarthritis.

Rhon D, et al. Manual physical therapy and perturbation exercises in knee osteoarthritis. Journal of Manual & Manipulative Therapy. 2013; 21(4): 220–228.


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