Academy Of Orthopaedic Physical Therapy Research Articles

Description of Medical and Surgical Conditions Requiring Referral by Physical Therapy Providers in Primary Contact Musculoskeletal Practice

OBJECTIVE: The Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association's clinical practice guideline recommendations provide a foundation for clinicians' musculoskeletal care. Some patients’ presenting clinical findings suggest conditions that would benefit from medical or surgical evaluation and management. Guidelines are not available that direct this referral. DESIGN: This practice description directs the development of guidelines for clinicians working as first provider musculoskeletal practitioners on the diagnostic criteria for referring clients for medical or surgical management. METHODS: The foundational step in developing these guidelines is to identify the conditions that first provider musculoskeletal practitioners are likely to encounter during clinical practice. This study used standard practice analysis methodology to identify and describe these conditions. RESULTS/CONCLUSION: The ensuing clinical practice guideline, based on systematic methods to evaluate and classify evidence, will provide graded recommendations on the criteria to identify, level of confidence with identifying, and urgency for referring patients, with the conditions described in this practice analysis, for medical and surgical evaluation and management.

Physical therapist perceptions and use of clinical pain mechanism assessment in the musculoskeletal setting: a survey analysis

BackgroundA mechanism-based approach to the evaluation and management of pain has been suggested across disciplines in contemporary research. However, the translation of pain mechanism assessment strategies in research to clinical practice is unclear. This study sought to explore perceptions and use of clinical pain mechanism assessment by physical therapists managing musculoskeletal pain.MethodsThis was an electronic cross-sectional survey. After initial development, refinement, and piloting for comprehensiveness, comprehensibility and relevance, the survey was disseminated to members of the Academy of Orthopaedic Physical Therapy via email listserv. Data was maintained anonymously using the online database REDCap. Descriptive statistics and Spearman’s correlations for non-parametric data were analyzed for frequencies and associations across variables.ResultsIn total, 148 respondents completed all aspects of the survey. Respondent age ranged from 26 to 73 years, with a mean (SD) of 43.9 (12.0). Most respondents (70.8%) reported performing clinical pain mechanism assessments at least ‘sometimes’. A majority (80.4%) believed clinical pain mechanism assessments are useful in guiding management strategies while 79.8% reported specifically choosing interventions to alter aberrant pain mechanisms. The most commonly used pain severity, physical examination testing and questionnaires were the numeric pain rating scale, pressure pain thresholds and pain diagrams, respectively. However, the vast majority of instruments to clinically assess pain mechanisms were performed by a small proportion of respondents (< 30%). There were no significant correlations between age, years of experience, highest earned degree, completion of advanced training or specialist certification and testing frequency.ConclusionThe evaluation of pain mechanisms involved in the pain experience is becoming common in research. The clinical application of pain mechanism assessment is unclear. Based on the results of this survey, physical therapists in the orthopedic setting believe pain mechanism assessment is useful, but data suggests it is infrequently performed. Additional research to uncover clinician motivation related to pain mechanism assessment is warranted.

The Prevalence and Etiologies of Transverse Myelitis in Latin America: A Systematic Review (P4-8.011)

<h3>Objective:</h3> To investigate the prevalence of transverse myelitis (TM) in Latin America (LA) and identify common etiologies and preferred diagnostic tools. <h3>Background:</h3> TM is a rare neuroinflammatory condition of the spinal cord that can cause chronic and debilitating symptoms. TM is understudied in developing regions of the world, including in LA, leading to inequities in access to care. There is a need to investigate the disease’s prevalence in LA. <h3>Design/Methods:</h3> We searched PubMed and Cochrane Library for articles published in English, Spanish or Portuguese from 2010 to 2022 related to TM in LA. After excluding articles that did not meet eligibility criteria, we extracted data on population characteristics, TM frequency, etiologies, and diagnostics from each included article for descriptive analysis. <h3>Results:</h3> No studies were found that examined TM prevalence in LA or within a specific LA country. A total of 42 studies were included that investigated TM among LA populations with various primary diseases and 1 study on TM among a community population. A wide range of TM frequency data was found spanning 20 different LA countries. Demyelinating disease was the most commonly investigated TM etiology <i>(n=25 studies)</i> with the highest prevalence rates of TM. Infectious <i>(n=15)</i>, idiopathic <i>(n=3)</i>, vascular <i>(n=1)</i>, and post-vaccinal <i>(n=1)</i> etiologies were also examined in included studies. The most frequently utilized diagnostic tools for identifying TM were MRI, CSF cytology and CSF or serum antibodies specific to demyelinating or infectious diseases. <h3>Conclusions:</h3> This review highlights important gaps in identifying TM among general community populations and diseased subpopulations of non-demyelinating etiologies in LA. There may also be diagnostic access barriers to identifying TM outside of tertiary referral centers and specialized outpatient clinics. By improving our understanding of TM epidemiology in LA and diagnostic barriers, we may improve disability and health outcomes for patients with TM in LA. <b>Disclosure:</b> Mr. Almubaslat has nothing to disclose. Mr. Underwood has nothing to disclose. Ms. Torian has nothing to disclose. Miss Salvatierra has nothing to disclose. Miss Aponte Castro has nothing to disclose. Ms. Baldwin-SoRelle has nothing to disclose. Ms. Carlson has received personal compensation in the range of $500-$4,999 for serving as a Independent Consultant with Academy of Orthopaedic Physical Therapy, APTA, Inc.. Dr. Diaz has nothing to disclose.

Tennis Elbow: What Is It? How Do I Get Back to My Regular Activities?

You do not have to play tennis to get tennis elbow-a very common problem for people who do lots of repetitive movements of the wrist, forearm and elbow, such as carpentry, painting or racquet sports. Most people with tennis elbow feel pain on the outside of their elbow and upper forearm. Experts in managing elbow pain developed a guideline for rehabilitation clinicians to use to help you understand more about tennis elbow. Here, we explain what the guidelines say about how to diagnose tennis elbow (sometimes called lateral elbow pain or lateral elbow tendinopathy), the specific treatments your physical therapist might offer you to help manage pain and improve the mobility of your elbow, and the types of exercises you could do to strengthen the muscles in your wrist and forearm.

Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention.

The Academy of Orthopaedic Physical Therapy and the American Academy of Sports Physical Therapy have an ongoing effort to create evidence-based clinical practice guidelines (CPGs) for orthopaedic and sports physical therapy management and prevention of musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability and Health (ICF). This guideline focuses on the exercise-based prevention of knee injuries and provides an update on the 2018 guideline, J Orthop Sports Phys Ther. 2018;48(9):A1-A42. doi:10.2519/jospt.2018.0303 J Orthop Sports Phys Ther. 2023;53(1):CPG1-CPG34. doi:10.2519/jospt.2023.0301.

Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021.

Low back pain (LBP) remains a musculoskeletal condition with an adverse societal impact. Globally, LBP is highly prevalent and a leading cause of disability. This is an update to the 2012 Academy of Orthopaedic Physical Therapy (AOPT), formerly the Orthopaedic Section of the American Physical Therapy Association (APTA), clinical practice guideline (CPG) for LBP. The overall objective of this update was to provide recommendations on interventions delivered by physical therapists or studied in care settings that included physical therapy providers. It also focused on synthesizing new evidence, with the purpose of making recommendations for specific nonpharmacologic treatments. J Orthop Sports Phys Ther 2021;51(11):CPG1-CPG60. doi:10.2519/jospt.2021.0304.

Returning to Work After an Injury or Illness.

When we experience an injury or illness, it can affect our ability to work. Work rehabilitation helps people return to work after an illness or injury. When possible, work rehabilitation can also help people stay at work as they manage their illness or injury. To understand how physical therapists can best support people as they return to work, experts in work rehabilitation reviewed all the available research and discussed what the research means. These experts shared their findings and recommendations in "Clinical Guidance to Optimize Work Participation After Injury or Illness: The Role of Physical Therapists," published in JOSPT in August 2021. J Orthop Sports Phys Ther 2021;51(8):382. doi:10.2519/jospt.2021.0506.

Physical Therapy After Hip Fracture in Older Adults: What New Guidelines Mean for You.

Hip fractures become more common as people age. If they occur when someone is 65 years of age or older, there are a number of things that can ensure a good outcome. Once hip fractures are treated, usually by surgery, rehabilitation begins. This should include physical therapy. The JOSPT published a clinical practice guideline titled "Physical Therapy Management of Older Adults With Hip Fracture" in the February 2021 issue. In this Perspectives for Patients article, we share what the experts found and what it means for you or someone for whom you may be caring. J Orthop Sports Phys Ther 2021;51(2):62. doi:10.2519/jospt.2021.0502.

Physical Activity Promotion Attitudes and Practices Among Outpatient Physical Therapists: Results of a National Survey.

Physical activity (PA) promotion delivered by physical therapists is effective. However, little is known about how much PA promotion is integrated into outpatient US physical therapist practice. The purpose of this study was to determine the current PA promotion practices and factors that influence those practices among outpatient US physical therapists. A sample of outpatient US physical therapists from the Academy of Orthopaedic Physical Therapy and American Physical Therapy Association (APTA) Geriatrics completed an adaptive online survey that included questions related to PA promotion practices and factors that influence those practices. We dichotomized levels of PA promotion as regular and irregular. Multivariable logistic regression was used to determine what factors predicted regular PA promotion. A total of 522 individuals participated and 393 surveys were included in the analyses (75.3%). Most participants (58.5%) irregularly promoted PA and few reported always screening for patients' PA levels (12.7%). The strongest predictor of regularly promoting PA was screening for baseline PA (odds ratio = 5.07, 95% confidence interval = 2.23, 11.57). Physical therapists' own PA levels compared favorably to the US adult population and other health professionals and predicted PA promotion. Other factors related to capability, opportunity, and environment were predictors of PA promotion. Perceived lack of financial support from insurance companies, lack of support from clinical employers, and a perception of competing priorities were barriers to PA promotion. Despite being a public health priority, the majority of physical therapists surveyed infrequently screen for baseline PA and irregularly promote PA. Perceived financial barriers, lack of organizational support, and prioritizing other patient problems hinder PA promotion in the outpatient setting. Despite guidance from national and international governing bodies, US outpatient physical therapists do not regularly promote PA to patients and perceive financial constraints and competing priorities as key barriers. Professional and patient stakeholders should be involved in designing pathways to improve PA promotion practices among outpatient US physical therapists.

Video-Based Motion Analysis Use: A National Survey of Orthopedic Physical Therapists.

Motion analysis is performed by physical therapists to assess and improve movement. Two-dimensional video-based motion analysis (VBMA) is available for smartphones/tablets and requires little to no equipment or cost. Research on VBMA use in clinical practice is limited. The purpose of this study was to examine the current use of VBMA in orthopedic physical therapist practice. Members of the Academy of Orthopaedic Physical Therapy completed an online survey. Questions examined frequency of VBMA use, reasons for use, facilitators/barriers, device/apps used, practice patterns, other certificates/degrees, and demographic information. Among the final analysis sample of 477 respondents, 228 (47.8%) use VBMA. Of 228 VBMA users, 91.2% reported using it for ≤25% of their caseload, and 57.9% reported using their personal device to capture movement. Reasons for using VBMA included visual feedback for patient education (91.7%), analysis of movement (91.2%), and assessment of progress (51.8%). Barriers to use included lack of device/equipment (48.8%), lack of space (48.6%), and time restraint (32.1%). Those with ≤20years of clinical experience (odds ratio [OR]=1.83, 95% CI=1.21-2.76), residency training (OR=2.49, 95% CI=1.14-5.43), and fellowship training (OR=2.97, 95% CI=1.32-6.66), and those from the West region of the United States (OR=1.66, 95% CI=1.07-2.56) were more likely to use VBMA. More than 50% of surveyed orthopedic physical therapists do not use VBMA in clinical practice. Future research should be directed toward assessing reliability and validity of VBMA use by smartphones, tablets, and apps and examining whether VBMA use enhances treatment outcomes. Data security, patient confidentiality, and integration into the electronic medical record should be addressed. This study is the first to our knowledge to describe the use of VBMA in orthopedic physical therapist practice in the United States. It is the first step in understanding how VBMA is used and might be used to enhance clinical assessment and treatment outcomes.

Work-related musculoskeletal disorders in physical therapists attributable to manual therapy

ABSTRACT Background: Use of manual therapy (MT) is a risk factor for the development of work-related musculoskeletal disorders (WRMDs) in physical therapists (PTs) although the current evidence is limited on this topic. Objectives: The purpose of this study was to understand the type, association, and prevalence of WRMDs among practitioners of MT, explore relationships between MT and WRMD, and determine impacts of WRMDs on PTs. Design: Cross-sectional survey design. Methods: A web-based survey was distributed through the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association. The survey gathered information on the respondents’ professional profiles, any WRMDs sustained, and how those injuries affected their professional and personal lives. Results: Overall, 38.5% of PT respondents using MT reported having sustained an MT attributable WRMD. Female respondents reported a greater rate of MT attributable injuries. Although exposure risk is cumulative, novice practitioners are also injured. Limitations: Generalizability of these results may be limited because of the sample size and specific population responding. Conclusion: Over one-third of PT survey respondents reported WRMDs attributable to MT. The results indicated WRMDs may begin early in one’s career and tend to accumulate over years of practice. MT educational programming at all levels warrants emphasis on practitioner safety.

Spurling’s test – inconsistencies in clinical practice

ABSTRACT Objective: The purpose of this study was to investigate the methodology, interpretation, and perceived value of Spurling’s test toward diagnosis/classification and treatment. Methods: An anonymous web-based survey was made available to physical therapist members of the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association. Based on video demonstrations of technique and symptom distribution, questions included preferred method, criteria for test interpretation, and perceived value of Spurling’s test and other examination findings toward clinical decision-making. Professional profile data were also collected. Results: Among the 452 participants completing the survey, no method of testing was preferred by more than 37%, with ipsilateral lateral flexion, rotation, and extension with compression being most frequently preferred followed by ipsilateral lateral flexion with compression at 32%. Proximal provocation of symptoms only without distal symptoms was interpreted as a positive test by 67%. Participants rated Spurling’s test of moderate to low value toward diagnosis/classification and treatment. Discussion: Inconsistency with methodology and interpretation of Spurling’s test is suggested to be pervasive in physical therapist practice. While an optimal test methodology has yet to be identified, result interpretation does have a basis for clarification toward diagnosis/classification and reduction of unwanted variance in practice.

Comparing expert opinion within the care team regarding postoperative rehabilitation protocol following rotator cuff repair

There is no established consensus regarding the optimal rehabilitation protocol following rotator cuff repair, including duration of immobilization, timing to initiate range of motion and resistance exercises, and the importance of supervised, formal therapy. The purpose of this study was to determine agreement in opinion regarding rotator cuff rehabilitation between orthopedic surgeons and physical therapists (PTs). A 50-question survey was created on a secure data capture system and distributed via e-mail to members of professional organization affiliations. Surgeon participants were recruited from the American Shoulder and Elbow Surgeons, and PTs were recruited from the American Society of Shoulder and Elbow Therapists and the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association. Survey responses were analyzed for interprofessional differences in majority opinion and distribution of answer choices. A total of 167 surgeons and 667 PTs responded to the survey. Of the 39 questions evaluated, surgeons and PTs reached intraprofessional majority agreement in 26 (67%) and 28 (72%) statements, respectively, with agreements matching in 17 instances and differing in 4. The 2 groups had different answer preferences in 32 questions (82%). PTs were more likely to support shorter immobilization intervals (P < .001), earlier strengthening (P < .001), and more frequent home exercises (P = .002), whereas surgeons endorsed more conservative weight-bearing restrictions (P < .001), time-based phase transitions (P < .001), and web-based technological platforms for rehabilitation (P < .001). Our findings show that although significant discrepancy of opinion exists within professions, greater differences in preferences exist between surgeons and PTs regarding rotator cuff repair rehabilitation.

Is Excellence in the Cards?

Thomas G. McPoil, PT, PhD, FAPTA, is Emeritus Professor of Physical Therapy at Regis University, Denver, Colorado, and Emeritus Regents' Professor of Physical Therapy at Northern Arizona University. He has served as an Adjunct Honorary Professor in the School of Physiotherapy at the University of Queensland, Brisbane, Australia, and currently serves as a consultant to the Physical Therapy Orthotics Clinic at Denver Health Medical Center, Denver, Colorado. Dr. McPoil is known nationally and internationally for his scholarly contributions that have systematically examined foot and ankle function from both scientific and clinical perspectives. Dr. McPoil is an author or coauthor of 130 publications in peer-reviewed journals, coeditor of 2 books, and coauthor of 6 book chapters. His work reaches beyond the profession of physical therapy, as he served on the editorial boards of Foot and Ankle International, the Journal of Foot and Ankle Research, and Research in Sports Medicine and is currently on the editorial boards of the Journal of the American Podiatric Medical Association and The FOOT. Dr McPoil received his PhD in kinesiology with a specialization in biomechanics from University of Illinois at Urbana-Champaign. He holds an MS in physical education with a specialization in athletic training from Louisiana State University and a BA in physical education from the California State University, Sacramento. During his career, he has held faculty appointments at the University of Illinois at Chicago, Northern Arizona University, and Regis University. Dr McPoil's clinical practice has focused on the management of chronic orthopedic foot and ankle disorders for the past 38 years. Dr McPoil is the founding president of the Foot and Ankle Special Interest Group of the Academy of Orthopaedic Physical Therapy. He has served as Vice President of the Academy of Orthopaedic Physical Therapy and as the Treasurer of the Journal of Orthopaedic and Sports Physical Therapy. He has received numerous teaching awards, including APTA's Dorothy E. Baethke & Eleanor J. Carlin Award for Excellence in Academic Teaching and the Academy of Orthopaedic Physical Therapy's James A. Gould Excellence in Teaching Orthopaedic Physical Therapy Award. He is a recipient of a Fulbright Senior Scholar Award, the William J. Stickel Award for Research in Podiatric Medicine, the Academy of Orthopaedic Physical Therapy's Stanley Paris Distinguished Service Award and was elected a Catherine Worthingham Fellow of APTA in 2007.

Physical therapist clinical reasoning and classification inconsistencies in headache disorders: a United States survey

ABSTRACTObjective: The purpose of this study was to investigate the decision-making processes of physical therapists relating to evaluation and categorization of patients with headaches, including consistency with criteria proposed by the International Headache Society (IHS).Methods: A national online survey was distributed in cooperation with the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association. Three hypothetical patient case vignettes featuring headache disorders were used as assessment instruments. Additionally, data on physical therapist education, clinical experience, manual therapy training, self-efficacy, and familiarity & consistency with IHS criteria were collected. Physical therapist identification and valuation of clinical features of headache disorders were also examined in the decision-making processes.Results: Among the 384 respondents, 32.3% classified the tension-type headache case consistent with IHS criteria. The cervicogenic and migraine headache cases were classified at 54.8% and 41.7% consistent with IHS categories, respectively. Experienced clinicians and those with formal manual training categorized patient presentations with greater consistency. Clinician familiarity with IHS classification criteria was low with 73.6% collectively somewhat and not familiar, while 26.4% of physical therapists were self-described as very or moderately familiar.Discussion: Clinicians’ headache categorization was significantly affected by symptom misattribution and weighting of individual examination findings. Weighting by practitioners of clinical features varied markedly with greatest emphasis being placed on detailed manual examination procedures, including passive intervertebral movements. Inconsistencies in valuation of clinical features in headache categorization suggest a need for further formal education in physical therapy educational curricula and in post-graduate education, including of IHS criteria and classification.Level of Evidence: 2a

Wrist and hand pain in orthopaedic physical therapists: A mixed-methods study

BackgroundOrthopaedic physical therapists (PTs) who perform manual therapy are at high risk for wrist and hand pain. Studies that examine the magnitude, scope and causes of wrist and hand pain are needed so that prevention programs can be developed. ObjectivesThe objective of this study was to determine the magnitude, scope, and impact of wrist and hand pain in orthopaedic PTs and to identify potential strategies for prevention. DesignThis was a sequential, mixed methods study including quantitative and qualitative components. MethodsThe quantitative phase consisted of an online survey sent to members of the Academy of Orthopaedic Physical Therapy. The qualitative phase consisted of focus groups with Orthopaedic PTs who had wrist and hand pain. ResultsThe survey included 962 PTs and the focus groups included 10 PTs. The one-year prevalence of wrist and hand pain was 75%. Increasing age, decreasing experience, female gender, performing more manual therapy and working more than 40 h per week were associated with an increased risk of moderate to severe wrist and hand pain. Soft-tissue mobilization was the most frequently cited causative factor. The most commonly mentioned strategy for prevention was altering body mechanics and technique. Focus group participants highlighted the importance of managing expectations for manual therapy by patients. ConclusionsFormal injury prevention programs for PT students and PTs are urgently needed. These programs should focus on improving body mechanics and technique, attention to workload, careful selection of manual techniques, and managing expectations for manual therapy.

Carpal Tunnel Syndrome: A Summary of Clinical Practice Guideline Recommendations-Using the Evidence to Guide Physical Therapist Practice.

Carpal tunnel syndrome (CTS) is the most common upper extremity nerve compression syndrome. Patients with CTS experience reduced sensation, dexterity, and function. Irreversible changes in nerve structure and function due to demyelination and axonal damage can occur in long-standing cases. Published in the May 2019 issue of JOSPT, clinical practice guidelines for CTS summarize the best available evidence on incidence and prevalence, pathophysiology, classification, risk factors, examination techniques, and interventions. These guidelines provide practical recommendations for physical therapy examination, diagnosis, and treatment. J Orthop Sports Phys Ther 2019;49(5):359-360. doi:10.2519/jospt.2019.0501.

Hand Pain and Sensory Deficits: Carpal Tunnel Syndrome.

The Academy of Orthopaedic Physical Therapy and the Academy of Hand and Upper Extremity Physical Therapy have an ongoing effort to create evidence-based clinical practice guidelines (CPGs) for orthopaedic and sports physical therapy management and prevention of musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability and Health (ICF). This particular guideline focuses on hand pain and sensory deficits in carpal tunnel syndrome. J Orthop Sports Phys Ther 2019;49(5):CPG1-CPG85. doi:10.2519/jospt.2019.0301.

Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention.

The Academy of Orthopaedic Physical Therapy and the American Academy of Sports Physical Therapy have an ongoing effort to create evidence-based clinical practice guidelines (CPGs) for orthopaedic and sports physical therapy management and prevention of musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability and Health (ICF). This particular guideline focuses on the exercise-based prevention of knee injuries. J Orthop Sports Phys Ther. 2018;48(9):A1-A42. doi:10.2519/jospt.2018.0303.

Rehabilitation Practice Patterns Following Anterior Cruciate Ligament Reconstruction: A Survey of Physical Therapists.

Recovery from anterior cruciate ligament reconstruction (ACLR) requires an intensive course of postoperative rehabilitation. Although guidelines outlining evidence-based rehabilitation recommendations have been published, actual practice patterns of physical therapists are unknown. To analyze the current landscape of clinical practice as it pertains to rehabilitation progression and the use of time and objective criteria in rehabilitation following ACLR. In this cross-sectional study, an online survey was distributed to members of the Academy of Orthopaedic Physical Therapy, the American Academy of Sports Physical Therapy, and the Private Practice Section of the American Physical Therapy Association between January and March 2017. The study analyzed a sample of 1074 responses. Supervised physical therapy was reported to last 5 months or less by 56% of survey respondents. The most frequent time frames for activity progression were 3 to 4 months (58%) for jogging, 4 to 5 months (50%) for modified sports activity, and 9 to 12 months (40%) for unrestricted sports participation. More than 80% of respondents reported using strength and functional measures during rehabilitation. Of those physical therapists who assessed strength, 56% used manual muscle testing as their only means of strength testing. Single-limb hop testing (89%) was the most frequently reported measure used to allow patients to begin modified sports activity following ACLR. Performance criteria for strength and functional tests varied significantly across all phases of rehabilitation. The 45% of respondents who reported using patient-reported outcome measures indicated that just under 10% of those measures involved fear or athletic confidence scales. Considerable variation in practice exists among American Physical Therapy Association members regarding rehabilitation following ACLR. This variability in practice may contribute to suboptimal outcomes and confusion among practitioners and patients. J Orthop Sports Phys Ther 2018;48(10):801-811. Epub 22 May 2018. doi:10.2519/jospt.2018.8264.