Professional physical therapist education has experienced a transformation over the last few decades, moving to a doctoring profession with more autonomy and a broader scope of practice. These changes have occurred in parallel with systemic and structural changes in health care and higher education, both of which have experienced challenges with improving access and controlling costs, and have become a centerpiece of legislative and political discourse. At the same time, advances in technology have introduced new possibilities in education, with the emergence of online, blended, and "flipped" learning models that supplement or replace face-to-face instruction with distance learning. Hybrid education is a type of blended learning, utilizing both face-to-face and online instructional strategies. In a hybrid learning environment, online content may be delivered synchronously or asynchronously, replacing traditional face-to-face instructional time and reducing "seat time" for students. Recent attention has been brought to online and hybrid/blended learning in physical therapist education in the wake of the COVID-19 pandemic, as programs have been required to abruptly move from face-to-face to remote instruction. Hybrid and other forms of blended learning strategies have been described at the physical therapist education course level. However, there is no literature describing hybrid learning implementation at the physical therapist education program "levels," and there has been limited discussion on best practices for delivering hybrid, blended, and online instruction in physical therapist education. This perspective provides an overview of hybrid education, describes theoretical frameworks that guide implementation of a hybrid education curriculum, and discusses future directions for hybrid physical therapist education and educational research.

OBJECTIVE:To investigate the relationship between dry needling-induced twitch response and change in pain, disability, nociceptive sensitivity, and lumbar multifidus muscle function, in patients with low back pain (LBP).DESIGN:Quasi-experimental study.SETTING:Department of Defense Academic Institution.PARTICIPANTS:Sixty-six patients with mechanical LBP (38 men, 28 women, age: 41.3 [9.2] years).INTERVENTIONS:Dry needling treatment to the lumbar multifidus muscles between L3 and L5 bilaterally.MAIN OUTCOME MEASURES:Examination procedures included numeric pain rating, the Modified Oswestry Disability Index, pressure algometry, and real-time ultrasound imaging assessment of lumbar multifidus muscle function before and after dry needling treatment. Pain pressure threshold (PPT) was used to measure nocioceptive sensitivity. The percent change in muscle thickness from rest to contraction was calculated to represent muscle function. Participants were dichotomized and compared based on whether or not they experienced at least one twitch response on the most painful side and spinal level during dry needling.RESULTS:Participants experiencing local twitch response during dry needling exhibited greater immediate improvement in lumbar multifidus muscle function than participants who did not experience a twitch (thickness change with twitch: 12.4 [6]%, thickness change without twitch: 5.7 [11]%, mean difference adjusted for baseline value, 95%CI: 4.4 [1 to 8]%). However, this difference was not present after 1-week, and there were no between-groups differences in disability, pain intensity, or nociceptive sensitivity.CONCLUSIONS:The twitch response during dry needling might be clinically relevant, but should not be considered necessary for successful treatment.

Background: Initial reports suggest that treating myofascial trigger points in the infraspinatus with dry needling may be effective in treating patients with shoulder pain. However, to date, high quality clinical trials and thorough knowledge of the physiologic mechanisms involved is lacking.Objectives: To examine the effect of dry needling to the infraspinatus muscle on muscle function, nociceptive sensitivity, and shoulder range of motion (ROM) in the symptomatic and asymptomatic shoulders of individuals with unilateral subacromial pain syndrome.Design: Within-subjects controlled trial.Methods: Fifty-seven volunteers with unilateral subacromial pain syndrome underwent one session of dry needling to bilateral infraspinatus muscles. Outcome assessments, including ultrasonic measures of infraspinatus muscle thickness, pressure algometry, shoulder internal rotation and horizontal adduction ROM, and questionnaires regarding pain and related disability were taken at baseline, immediately after dry needling, and 3-4 days later.Results: Participants experienced statistically significant and clinically relevant changes in all self-report measures. Pressure pain threshold and ROM significantly increased 3-4 days, but not immediately after dry needling only in the symptomatic shoulder [Pressure pain threshold: 5.1 (2.2, 8.0) N/cm(2), internal rotation ROM: 9.6 (5.0, 14.1) degrees, horizontal adduction ROM: 5.9 (2.5, 9.4) degrees]. No significant changes occurred in resting or contracted infraspinatus muscle thickness in either shoulder.Conclusions: This study found changes in shoulder ROM and pain sensitivity, but not in muscle function, after dry needling to the infraspinatus muscle in participants with unilateral subacromial pain syndrome. These changes generally occurred 3-4 days after dry needling and only in the symptomatic shoulders. Published by Elsevier Ltd.

Background: Little is known about the physiologic mechanism of dry needling. While some evidence suggests that dry needling may decrease nocioceptive sensitivity and facilitate muscle function, no studies to date have examined these physiologic changes compared to clinical outcomes.Objective: To examine changes in lumbar multifidus (LM) muscle function and nociceptive sensitivity after dry needling in patients with LBP and to determine if such changes differ in patients that exhibit improved disability (responders) and those that do not (non-responders).Design: Quasi-experimental study.Methods: Sixty-six volunteers with mechanical LBP (38 men, age = 41.3 +/- 9.2 years) completed the study. Ultrasound measurements and pain algometry of the LM were taken at baseline and repeated immediately following dry needling treatment to the LM muscles and after one week. The percent change in muscle thickness from rest to contraction was calculated for each time point to represent muscle function. Pressure pain threshold (PPT) was used to measure nociceptive sensitivity. Participants were dichotomized as responders and non-responders based on whether or not they experienced clinical improvement using the modified Oswestry Disability Index after one week. 2 x 3 mixed-model ANOVA were conducted for group (responders vs. non-responders) by time.Results: Patient responders exhibited larger improvements in LM muscle contraction and nociceptive sensitivity 1 week, but not immediately, after dry needling than non-responders.Conclusions: Our results suggest that there may be lasting and clinically relevant sensorimotor changes that occur in LBP patients that improve with dry needling treatment that partially explain the physiologic mechanism of action. Published by Elsevier Ltd.

BACKGROUNDRehabilitative ultrasound Imaging (RUSI) is increasingly used in the management of musculoskeletal conditions as it provides an objective measure of muscle function while being less invasive than needle electromyography. While research has documented the ability to reliably measure trunk muscles in patients with back pain, no study to date has used RUSI to quantify infraspinatus muscle function in patients with shoulder impingement syndrome (SIS).HYPOTHESIS/PURPOSEThe purpose of this study was to examine the intra-rater and inter-rater reliability of measuring infraspinatus muscle thickness with RUSI and to compare such measures during resting versus contracted muscle states and in the symptomatic versus asymptomatic shoulders in patients with SIS.STUDY DESIGNCross-sectional, measurement study.METHODSFifty-two participants with unilateral SIS underwent a standard baseline examination to include RUSI of the infraspinatus muscle bilaterally. Images were acquired at rest and during a submaximal isometric contraction, by two novice examiners. The isometric contraction was elicited by having prone participants externally rotate their shoulder from a position of 90° abduction into a dynamometer and hold a static force of 20 mmHg (approximately 20-30% maximal voluntary contraction). Images were captured using a standardized placement of the transducer placed just inferior to the spine of the scapula along the medial scapular border and measured off-line using Image J software (V1.38t, National Institutes of Health, Bethesda, Maryland).RESULTSEstimates (ICCs) for thickness measurements ranged between 0.96 and 0.98 for intra-rater reliability and between 0.87 and 0.92 for inter-rater reliability. Reliability was substantially lower (ICC = 0.43 to 0.79) for calculations of percent thickness change. The infraspinatus muscle was significantly thicker when contracted (19.1mm) than during rest (16.2mm) in both shoulders (p < 0.001). There was also a statistically significant interaction between contraction state and shoulder (p = 0.026), indicating that the change in thickness that occurred during contraction was significantly smaller in the symptomatic shoulder than in the asymptomatic shoulder.CONCLUSIONRUSI measurements of infraspinatus muscle thickness appear to be highly reliable, both within the same examiner and between different examiners, in patients with SIS. Moreover, such measurements were different in rested and contracted states of the infraspinatus, as well as, between the symptomatic and asymptomatic shoulders of patients with unilateral SIS.LEVEL OF EVIDENCELevel 2.

STUDY DESIGN:Quasi-experimental.OBJECTIVES:To explore for associations between demographic, patient history, and physical examination variables and short-term improvement in self-reported disability following dry needling therapy performed on individuals with low back pain (LBP).BACKGROUND:Dry needling is an intervention used with increasing frequency in patients with LBP; however, the characteristics of patients who are most likely to respond are not known.METHODS:Seventy-two volunteers with mechanical LBP participated in the study. Potential prognostic factors were collected from baseline questionnaires, patient history, and physical examination tests. Treatment consisted of dry needling to the lumbar multifidus muscles bilaterally, administered during a single treatment session. Improvement was based on percent change on the Oswestry Disability Index at 1 week. The univariate and multivariate associations between 33 potential prognostic factors and improved disability were assessed with correlation coefficients and multivariate linear regression.RESULTS:Increased LBP with the multifidus lift test (rpb = 0.31, P = .01) or during passive hip flexion performed with the patient supine (rpb = 0.23, P = .06), as well as positive beliefs about acupuncture/dry needling (rho = 0.22, P = .07), demonstrated univariate associations with Oswestry Disability Index improvement. Aggravation of LBP with standing (rpb = -0.27, P = .03), presence of leg pain (rpb = -0.29, P = .02), and any perception of hypermobility in the lumbar spine (rpb = -0.21, P = .09) were associated with less improvement. The multivariate model identified 2 predictors of improved disability with dry needling: pain with the multifidus lift test and no aggravation with standing (R(2) = 0.16, P = .01).CONCLUSION:Increased LBP with the multifidus lift test was the strongest predictor of improved disability after dry needling, suggesting that the finding of pain during muscle contraction should be studied in future dry needling studies.LEVEL OF EVIDENCE:Prognosis, level 1b.

Objectives: Describe short-and long-term outcomes observed in individuals with hip osteoarthritis (OA) treated with a pre-selected, standardized set of best-evidence manual therapy and therapeutic exercise interventions.Methods: Fifteen consecutive subjects (9 males, 6 females; mean age: 52 +/- 7.5 years) with unilateral hip OA received an identical protocol of manual therapy and therapeutic exercise interventions. Subjects attended 10 treatment sessions over an 8-week period for manual therapy interventions and performed the therapeutic exercise as a home program.Results: Baseline to 8-week follow-up outcomes were as follows: Harris Hip Scale (HHS) scores improved from 60.3(+/- 10.4) to 80.7(+/- 10.5), Numerical Pain Rating Scale (NPRS) scores improved from 4.3(+/- 1.9) to 2.0(+/- 1.9), hip flexion range of motion (ROM) improved from 99 degrees (+/- 10.6) to 127 degrees (+/- 6.3) and hip internal rotation ROM improved from 19 degrees (+/- 9.1) to 31 degrees (+/- 11.5). Improvements in HHS, NPRS, and hip ROM measures reached statistical significance (P, 0.05) at 8-weeks and remained significant at the 29-week follow-up. Mean changes in NPRS and HHS scores exceeded the minimal clinically important difference (MCID) at 8-weeks and for the HHS scores alone at 29 weeks. The 8 and 29 week mean Global Rating of Change scores were 5.1(+/- 1.4) and 2.1(+/- 4.2), respectively.Discussion: Improved outcomes observed following a pre-selected, standardized treatment protocol were similar to those observed in previous studies involving impairment-based manual therapy and therapeutic exercise for hip OA. Future studies might directly compare the two approaches.

Background: Expression of microRNAs (miRs) has been shown to be altered in many solid tumours and is being explored in melanoma. The malignant potential of some melanocytic lesions is difficult to predict. We hypothesised that characterisation of miR expression in borderline melanocytic proliferations would lead to the identification of a molecular profile that could be used with known prognostic factors to differentiate lesions with high malignant potential. Methods: The miR expression profile of melanocytic lesions (benign naevi, malignant melanoma and borderline melanocytic tumours) was evaluated by real-time PCR. Results: PCR analysis revealed primary cutaneous melanomas had an 8.6-fold overexpression of miR-21 and a 7.5-fold overexpression of miR-155 compared with benign naevi ( P <0.0001). In situ hybridisation confirmed these results. miR-21 and miR-155 were significantly overexpressed within borderline lesions ( P =0.0011 and P =0.0048, respectively). When borderline lesions were categorised by mitotic activity and Breslow thickness, miR-21 was associated with mitotic activity and miR-155 was associated with thickness ( P <0.025). Among 14 patients with borderline lesions who underwent sentinel lymph node biopsy (SLNB), positive SLNB was associated with increased miR-21 and miR-155 in the primary lesion compared with lesions with a negative SLNB. Conclusion: MicroRNA expression profiles can be used to characterise atypical melanocytic lesions.

10597 Background: The considerable morbidity, mortality and relative rarity of retroperitoneal sarcoma demands an experienced institution to achieve better clinical outcomes. Methods: From the surgical oncology sarcoma database, the charts of 44 patients (pts) with primary retroperitoneal sarcoma from 1989 to 2005 were retrospectively reviewed. Those pts with primary surgery performed at The James Cancer Hospital of The Ohio State University (CHRI) were compared to those who underwent initial surgery at a non-tertiary care center and subsequently were referred for intra-abdominal recurrences. Data were compared with Fisher’s exact test and Student’s t-test where appropriate. Results: Thirty-three pts underwent initial resection of a retroperitoneal sarcoma at CHRI whereas 11 pts underwent initial surgery elsewhere. On univariate analysis, there were no significant differences between the two groups with regard to age, gender, histologic type, grade or disease free interval. Initial surgery at CHRI was more likely to produce an R0 resection (79% vs. 36%, p<0.05) with subsequent negative margins. Preoperative chemoradiation and postoperative chemotherapy were more prevalent for pts treated initially at CHRI than at the outside (36% vs.18%, p>0.05). There was no significant difference in disease-free interval between the two groups from initial surgery to first recurrence (14 mo.s vs. 18 mo.s, p>0.05). Intra-operative radiation (IORT) was utilized in 21 of the 44 pts and had a significant impact on decreasing intra-abdominal recurrence (28% vs. 74% p<0.05). Seven of the 11 pts reoperated on at CHRI underwent IORT with a median follow-up of 30 months. On subgroup analysis, the survival of Grade 1 retroperitoneal sarcomas was significantly better for patients initially operated at CHRI, 61 mo.s vs. 43 mo.s, p<0.05. Hovever, there was no difference in cancer mortality between the two groups (39% vs. 45%, p>0.05). Conclusions: The utilization of multimodality therapy in the initial treatment of retroperitoneal sarcoma was significantly greater in pts treated at CHRI. The surgical therapy resulted in increased R0 resection and decreased intra-abdominal recurrence which led to a greater survival in the subgroup of grade 1 patients. No significant financial relationships to disclose.

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Purpose To evaluate the safety of sequentially administered recombinant (r) human (h) interleukin-12 (IL-12) and interferon alfa-2b (IFN-alpha-2b) in patients with advanced cancer and to determine the effects of endogenously produced IFN-gamma on Janus kinase-signal transducer and activator of transcription (Jak-STAT) signal transduction in patient peripheral-blood mononuclear cells (PBMCs).Patients and Methods Forty-nine patients with metastatic cancer received rhIL-12 on day 1 and IFN-a-2b on days 2 to 6 of either a 14-day (n = 43) or a 7-day treatment cycle (n = 6). rhIL-12 was initially administered subcutaneously at a dose of 100 ng/kg, whereas IFN-alpha-2b was escalated from 1 to 10 million units (MU) in cohorts of three patients (1, 3, 5, 7, or 10 MU). rhIL-12 was subsequently administered intravenously (IV) in escalating doses (100 to 500 ng/kg) to achieve greater IFN-gamma production. Peripheral blood was drawn for measurement of plasma IFN-gamma and the induction of Jak-STAT signal transduction in PBMCs.Results No IL-12- or IFN-alpha-related dose-limiting toxicities were observed. There were no responses in 41 assessable patients. Five patients exhibited stable disease lasting 6 months or longer while on therapy. Optimal induction of IFN-gamma by IL-12 occurred after an IV dose of 250 ng/kg. Patient PBMCs exhibited increased levels of STAT1 after IL-12 administration. The peak level of IFN-gamma achieved with IL-12 therapy correlated with the peak level of intracellular STAT1 in patient PBMCs (r = 0.38, P = .021).Conclusion The combination of rhIL-12 and IFN-a-2b can be administered sequentially with minimal toxicity. IV administration of rhIL-12 modulates IFN-alpha-induced Jak-STAT signal transduction in patient PBMCs.

The spectrum of melanocytic proliferations ranges from banal to overtly malignant. Borderline melanocytic lesions which bridge these two extremes pose a challenge, as their biological nature remains undefined. We set out to evaluate the utility of the sentinel lymph node biopsy in such lesions. Our compendium was defined by 11 cases of borderline melanocytic proliferations whereby sentinel node sampling was conducted. There were three severely atypical dermal‐epidermal melanocytic proliferations manifesting borderline features with nevoid melanoma (calf, shoulder, knee), three arising in association with a deep penetrating nevus (chest, shoulder, and arm), three atypical Spitz’s tumors (helix, calf, arm, back), and two atypical pigment‐synthesizing melanocytic tumors, resembling equine melanotic disease in one and cellular blue nevus in another (buttock, calf, arm). The patient population comprised seven males and five females ranging in age from age 9–36 (mean: 25 years). At least one positive sentinel lymph node was uncovered in seven of the cases with a positive sentinel lymph observed in all but one case of deep penetrating nevus and atypical Spitz’s tumor. The identification of sentinel lymph node positivity in seven of the twelve cases (58%) validates the role of sentinel lymph node biopsy in the setting of borderline melanocytic proliferations.

To the Editor: In very rare cases, breast cancer may present as an autoimmune-mediated, paraneoplastic, neurologic syndrome (1). Various specific syndromes have been reported, including cerebellar degeneration, opsoclonus-myoclonus syndrome, and stiff-person syndrome (SPS) (2,3). We herein report an atypical presentation of breast cancer in the form of a deteriorating neurologic syndrome and discuss the ramifications of diagnosing and treating such disorders. Our patient is a 71-year-old woman who initially presented with a 2-week history of left lower extremity pain and severe muscle spasms that progressed to involve the entire left lower extremity and the proximal right lower extremity. Physical examination revealed marked weakness, rigidity, stiffness, and extensor spasm of both lower extremities. Electromyography (EMG) showed continuous motor activity with motor unit potentials (MUPs) of normal amplitude and duration firing at a frequency of 15 to 20 Hz. A paraneoplastic laboratory panel of the serum was positive for antiamphiphysin antibodies only. Initial medical therapy included high-dose intravenous steroids, intravenous immune globulin (IVIG), and multiple rounds of plasmapheresis, but yielded only slight clinical improvement. Further evaluation with mammography revealed abnormal calcifications in the left breast with a normal-appearing right breast. Physical examination revealed a diffusely firm right breast with no palpable mass of the left breast. Surgical biopsies showed invasive ductal carcinoma in the right breast and only fibrocystic changes with mild ductal epithelial hyperplasia and benign microcalcifications in the left breast. Subsequent modified radical mastectomy on the right side revealed multifocal carcinoma involving the entire breast with accompanying ductal carcinoma in situ (DCIS) and extensive lymphatic invasion. Adjuvant therapy included Adriamycin, cyclophosphamide, and radiation to the chest wall and axilla. The patient’s symptoms significantly improved within 4 to 6 months after surgical resection and adjuvant treatment of the cancerous tissues, corroborating the paraneoplastic nature of her clinical syndrome. At the 2-year follow-up, the patient is without evidence of recurrence of her cancer, with minimal residual weakness and stiffness of her bilateral lower extremities. She does have some persistent spasticity which is controlled with intrathecal baclofen and phenol blocks. In an attempt to further investigate the paraneoplastic nature of the patient’s clinical symptoms, the right breast tissue was subjected to immunohistochemical staining with antiamphiphysin antibodies (BD Biosciences, catalog no. 610714). Our protocol has been previously published (4,5). The photomicrographs confirm the presence of amphiphysin in the malignant cells (Fig. 1). Our patient, combined with five previously reported cases, demonstrates the relationship of amphiphysin, SPS, and breast cancer (6–8). Five of these six patients were found to have significant clinical improvement in their neurologic symptoms after resection and adjuvant treatment of their cancerous tissues. Interestingly, our patient differs from these previous reports by demonstrating mainly lower extremity involvement with sparing of the upper limbs. We herein report an unusual presentation of breast cancer in the form of a rare neurologic syndrome. The detection of amphiphysin from cancerous breast tissue using immunohistochemical techniques is, to our knowledge,

STUDY DESIGN:Case series.OBJECTIVE:To describe an impairment-based physical therapy treatment approach for 4 patients with plantar heel pain.BACKGROUND:There is limited evidence from clinical trials on which to base treatment decision making for plantar heel pain.METHODS AND MEASURES:Four patients completed a course of physical therapy based on an impairment-based model. All patients received manual physical therapy and stretching. Two patients were also treated with custom orthoses, and 1 patient received an additional strengthening program. Outcome measures included a numeric pain rating scale (NPRS) and self-reported functional status.RESULTS:Symptom duration ranged from 6 to 52 weeks (mean duration+/-SD, 33+/-19 weeks). Treatment duration ranged from 8 to 49 days (mean duration+/-SD, 23+/-18 days), with number of treatment sessions ranging from 2 to 7 (mode, 3). All 4 patients reported a decrease in NPRS scores from an average (+/-SD) of 5.8+/-2.2 to 0 (out of 10) during previously painful activities. Additionally, all patients returned to prior activity levels.CONCLUSION:In this case series, patients with plantar heel pain treated with an impairment-based physical therapy approach emphasizing manual therapy demonstrated complete pain relief and full return to activities. Further research is necessary to determine the effectiveness of impairment-based physical therapy interventions for patients with plantar heel pain/plantar fasciitis.