A randomised controlled trial of multimodal physiotherapy versus advice for recent onset, painful cervical radiculopathy - the PACeR trial protocol.

BACKGROUND: A research gap exists for optimal management of cervical radiculopathy in the first 12 weeks and short term natural history of the condition is somewhat unclear, although thought to be favourable. The primary aim of this assessor blinded, superiority, 2 parallel group randomised controlled trial is to investigate the effects of a 4 week physiotherapy programme (6-8 sessions) of manual therapy, exercise and upper limb neural unloading tape, compared to a control of weekly phone advice; on disability, pain and selected biopsychosocial measures, in acute and sub-acute cervical radiculopathy patients. A secondary aim is to identify whether any baseline variables, symptom duration or group allocation can predict outcome. METHODS: Participants are recruited from GP referrals in an urban setting, from a neurosurgery non-urgent waiting list and from self-referral through Facebook advertising. Eligible participants (n = 64) are diagnosed with radiculopathy based on a clinical prediction rule and must have symptoms of unilateral, single level, radiculopathy for between 2 and 12 weeks, without having yet received physiotherapy. Random 1:1 group allocation (using variable block sizes), allocation concealment, blinded assessment and intention to treat analysis are being employed. Treatment is provided by clinical specialist physiotherapists in primary and secondary care settings. Outcomes are measured at baseline, 4 (primary endpoint) and 12 weeks. Participants' report of pain, disability and their rating of recovery is also recorded by telephone interview at 6 months. Statistical analysis of between group differences will be performed with ANOVAs and MANOVAs, and multivariable regression analysis will be undertaken to explore predictor variables. Ethical approval for this study has been received from the Beaumont Hospital and Irish College of General Practitioners Research Ethics Committees. The trial is registered at ClinicalTrials.gov (NCT02449200). DISCUSSION: An internal pilot study to test retention and recruitment strategies led to trial expansion and this is now a multi centre trial involving 5 clinical sites. TRIAL REGISTRATION: NCT02449200 . Registered 20/05/15.

ADvAnced PhysioTherapy in MuSculosKeletal Triage: Investigating prognostic factors, healthcare utilisation and clinical outcomes (ADAPT MSK) - a cohort study protocol.

BACKGROUND: Clinical specialist physiotherapist-led musculoskeletal triage clinics were introduced nationally in Ireland in 2011 to improve patient care and reduce waiting times for secondary care orthopaedics and rheumatology. Evidence has shown them to be effective in reducing waiting lists, however there are currently no data on longitudinal patient outcomes following clinic attendance. The primary aim of this cohort study is to identify predictors of pain and function outcomes up to one year following musculoskeletal triage review. Secondary aims include measuring self-reported use of healthcare resources over the 12-month follow-up period and to explore musculoskeletal phenotypes based on established prognostic factors for musculoskeletal pain. This is a prospective cohort study. METHODS: ADvAnced PhysioTherapy in MuSculosKeletal Triage (ADAPT MSK) will recruit a cohort of 252 adults through musculoskeletal triage clinics across five secondary care sites in Ireland. The STrengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines will be adhered to for future reporting. Adults (≥ 18 years old) attending physiotherapist-led musculoskeletal triage clinics with musculoskeletal pain, who do not require surgical or consultant-led medical care will be considered for participation. Participant demographics, health literacy, healthcare utilisation, and self-report questionnaires on pain, function, musculoskeletal health, musculoskeletal risk stratification, fear of movement, and psychological distress will be obtained at baseline, with follow-ups at three, six, and 12 months. Primary outcomes are pain intensity and function. Secondary outcomes include musculoskeletal risk stratification status, musculoskeletal health, healthcare utilisation, and work-related factors. Descriptive statistics will be used to profile the participants and predictors of outcome will be assessed using multivariable linear regression. Musculoskeletal phenotypes will be explored using latent class analysis. RESULTS: Results will be disseminated via peer-reviewed journal publication and presentation at national and international conferences. Engagement with a public patient involvement (PPI) panel will explore dissemination strategies for public and service user engagement.

Idiopathic toe walking-A follow-up survey of gait analysis assessment.

BACKGROUND: Toe-walking is a normal variant in children up to 3 years of age but beyond this a diagnosis of idiopathic toe-walking (ITW) must be considered. ITW is an umbrella term that covers all cases of toe-walking without any diagnosed underlying medical condition and before assigning these diagnosis potential differential diagnoses such as cerebral palsy, peripheral neuropathy, spinal dysraphism and myopathy must be ruled out. Gait laboratory assessment (GLA) is thought to be useful in the evaluation of ITW, and kinematic, kinetic and electromyography features associated with ITW have been described. However, the longer term robustness of a diagnosis based on GLA has not been investigated. The primary aim of this study was to examine if a diagnosis of ITW based on GLA features persisted. METHODS: All patients referred to a national gait laboratory service over a ten year period with queried ITW were sent a postal survey to establish if a diagnosis of ITW which had been offered following GLA persisted over time. The gait and clinical parameters differentiating those reported as typical ITW and not-typical-ITW following GLA were examined in the survey respondents. RESULTS: Of 102 referrals to the laboratory with queried ITW, a response rate of 40.2% (n = 41) was achieved. Of the respondents, 78% (n = 32) were found to be typical of ITW following GLA and this diagnosis persisted in the entire group at an average of 7 years post GLA. The other nine subjects were reported as not typical of ITW following GLA and 44.4% (n = 4) received a subsequent differential diagnosis. The clinical examination and gait analysis features differentiating these groups were consistent with previous literature. CONCLUSION: GLA appears to be a useful objective tool in the assessment of ITW and a diagnosis based on described features persists in the long-term.

Reliability of three-dimensional gait analysis in cervical spondylotic myelopathy.

BACKGROUND: Gait impairment is one of the primary symptoms of cervical spondylotic myelopathy (CSM). Detailed assessment is possible using three-dimensional gait analysis (3DGA), however the reliability of 3DGA for this population has not been established. The aim of this study was to evaluate the test-retest reliability of temporal-spatial, kinematic and kinetic parameters in a CSM population. METHODS: Twelve patients with CSM (mean age 54 years) were consecutively recruited from a neurosurgery clinic. 3DGA was conducted on 2 separate days, less than 1 week apart, using the VICON(®) 250 Motion Analysis. The average of 10 gait cycles was analysed. Reliability was assessed using the one-way random intraclass correlation coefficient (ICC), the standard error of measurement (SEM), and Bland-Altman limits of agreement (LOA). RESULTS: Temporal-spatial parameters showed excellent reliability, with ICCs above 0.9 for speed, cadence, stride length, double support time, and step width. ICCs for kinematic parameters ranged from acceptable (0.62, peak knee flexion in stance) to excellent (0.95, total hip sagittal plane motion). The SEM for all kinematic parameters was below 4°, with the exception of peak hip internal rotation (5.8°). Peak values were less reliable than the total range of motion in a plane. The majority of kinetic parameters showed excellent reliability (ICCs>0.85), with the exception of peak medio-lateral ground reaction force (ICC 0.12). CONCLUSIONS: This information will enhance the interpretation of gait scores for CSM patients, as an estimate of the change required to exceed measurement error is now available.