Region-specific Exercises vs General Exercises in the Management of Spinal and Peripheral Musculoskeletal Disorders: A Systematic Review With Meta-analyses of Randomized Controlled Trials.

OBJECTIVE: To compare the efficacy of region-specific exercises to general exercises approaches for adults with spinal or peripheral musculoskeletal disorders (MSKDs). DATA SOURCES: Electronic searches were conducted up to April 2020 in Medline, Embase, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health. STUDY SELECTION: Randomized control trials (RCTs) on the efficacy of region-specific exercises compared to general exercises approaches for adults with various MSKDs. DATA EXTRACTION: Mean differences and standardized mean differences were calculated using random-effects inverse variance modeling. Eighteen RCTs (n=1719) were included. Cohorts were composed of participants with chronic neck (n=313) or low back disorders (n=1096) and knee osteoarthritis (OA) (n=310). DATA SYNTHESIS: Based on low-quality evidence in the short-term and very low-quality in the mid- and long-term, there were no statistically significant differences between region-specific and general exercises in terms of pain and disability reductions for adults with spinal disorders or knee OA. Secondary analyses for pain reduction in the short-term for neck or low back disorders did not report any statistically significant differences according to very low- to low-quality of evidence. CONCLUSIONS: The difference in treatment effect remains uncertain between region-specific and general exercises approaches. Based on very low- to low-quality evidence, there appear to have no differences between both types of exercise approaches for pain reduction or disability for adults with spinal disorders. Future trials may change the current conclusions. More evidence is needed for region-specific exercises compared to general exercises for other peripheral MSKDs including knee OA.

Advanced practice physiotherapy for adults with spinal pain: a systematic review with meta-analysis.

OBJECTIVE: To appraise the available evidence on advanced practice physiotherapy (APP) models of care (MoC) in specialized secondary care such as orthopaedic, rheumatology or neurosurgery outpatients' clinics for adults with spinal pain. METHODS: Systematic review with meta-analysis. Electronic searches were conducted up to July 2020 in Medline, Embase, Cochrane CENTRAL and CINAHL. Studies on APP MoC in specialized secondary care for adults with spinal pain were included. RESULTS: Eighteen studies (n = 9405), including two randomized controlled trials and sixteen observational studies were included. One study was considered at high quality, fourteen studies were considered of moderate quality and three were considered of low quality. Pooled results for change in disability for patients with spinal pain reported no significant difference between APP and usual medical care (UMC). Mean wait time for initial consultation was lower with APP (1-9.4 weeks) than with UMC MoC (23-65 weeks). Following the implementation of APP MoC, wait time for a consultation with a medical specialist was reduced (6-16 weeks). Physiotherapists in APP MoC managed independently 89.2% of the patients referred (n = 8393). Stakeholders and patients reported high satisfaction with APP care. CONCLUSIONS: APP MoC and UMC likely result in comparable pain, disability and quality of life improvement for adults with spinal pain. However, APP MoC have the potential to improve health care access by reducing wait time for consultation in specialized care and maintaining a high level of satisfaction among stakeholders and patients.

Economic evaluation of advanced practice physiotherapy models of care: a systematic review with meta-analyses.

BACKGROUND: The objective of this systematic review is to appraise evidence on the economic evaluations of advanced practice physiotherapy (APP) care compared to usual medical care. METHODS: Systematic searches were conducted up to September 2021 in selected electronic bibliographical databases. Economic evaluation studies on an APP model of care were included. Economic data such as health care costs, patient costs, productivity losses were extracted. Methodological quality of included studies was assessed with the Effective Public Health Practice Project tool and the Critical Appraisal Skills Programme checklist. Meta-analyses were performed and mean differences (MD) in costs per patient were calculated using random-effect inverse variance models. Certainty of the evidence was assessed with the GRADE Approach. RESULTS: Twelve studies (n = 14,649 participants) including four randomized controlled trials, seven analytical cohort studies and one economic modeling study were included. The clinical settings of APP models of care included primary, emergency and specialized secondary care such as orthopaedics, paediatrics and gynaecology. The majority of the included participants were adults with musculoskeletal disorders (n = 12,915). Based on low quality evidence, health system costs including salaries, diagnostic tests, medications, and follow-up visits were significantly lower with APP care than with usual medical care, at 2 to 12-month follow-up (MD: - 145.02 €/patient; 95%CI: - 251.89 to - 38.14; n = 7648). Based on low quality evidence, patient costs including travel and paid medication prescriptions, or treatments were significantly higher with APP care compared to usual medical care, at 2 to 6-month follow-up (MD: 22.18 €/patient; 95%CI: 0.40 to 43.96; n = 1485). Based on very low quality evidence, no significant differences in productivity losses per patient were reported between both types of care (MD: 450 €/patient; 95%CI: - 80 to 970; n = 819). CONCLUSIONS: This is the first systematic review and meta-analysis on the economic evaluation of APP models of care. Low quality evidence suggests that APP care might result in lower health care costs, but higher patient costs compared to usual medical care. Costs differences may vary depending on various factors such as the cost methodology used and on the clinical setting. More evidence is needed to evaluate cost benefits of APP models of care.

Shoulder Rotator Cuff Disorders: A Systematic Review of Clinical Practice Guidelines and Semantic Analyses of Recommendations.

OBJECTIVES: To perform a systematic review of clinical practice guidelines (CPGs) and semantic analysis of specific clinical recommendations for the management of rotator cuff disorders in adults. DATA SOURCES: A systematic bibliographic search was conducted up until May 2018 in Medline, Embase, and Physiotherapy Evidence Database, or PEDro, databases, in addition to 12 clinical guidelines search engines listed on the Appraisal of Guidelines for Research and Evaluation (AGREE) website. STUDY SELECTION: Nine CPGs on the management of rotator cuff disorders in adults or workers, available in English or French, and published from January 2008 onward, were included and screened by 2 independent reviewers. DATA EXTRACTION: CPG methodology was assessed with the AGREE II checklist. A semantic analysis was performed to compare the strength of similar recommendations based on their formulation. The recommendations were categorized in a standardized manner considering the following 4 levels: "essential," "recommended," "may be recommended," and "not recommended." DATA SYNTHESIS: Methodological quality was considered high for 3 CPGs and low for 6. All CPGs recommended active treatment modalities, such as an exercise program in the management of rotator cuff disorders. Acetaminophen or nonsteroidal anti-inflammatory drug prescriptions and corticosteroid injections were presented as modalities that may be recommended to decrease pain. Recommendations related to medical imagery and surgical opinion varied among the guidelines. The most commonly recommended return-to-work strategies included intervening early, use of a multidisciplinary approach, and adaptation of work organization. CONCLUSIONS: Only 3 CPGs were of high quality. The development of more rigorous CPGs is warranted.

Advanced practice physiotherapy surgical triage and management of adults with spinal disorders referred to specialized spine medical care: a retrospective observational study.

INTRODUCTION: In this novel advanced practice physiotherapy (APP) model of care, advanced practice physiotherapists (APPTs) assess, triage, and manage adults with spinal disorders to alleviate the growing demands in specialized spine medical care. OBJECTIVES: To describe this APP model of care, to assess change in disability 3 months after rehabilitation care and to assess surgical triage and diagnostic concordance between APPTs and spine surgeons. METHODS: In this retrospective observational study, consecutive patients who completed the 3-month follow-up data were analyzed. Sociodemographic, clinical characteristics, and self-reported disabilities including the Oswestry Disability Index (ODI) and Neck Disability Index (NDI) at baseline and 3 months were extracted. Paired t-tests were used to assess changes in disability. Surgical triage and diagnostic concordance between APPTs and surgeons were measured with raw agreement, Cohen's Kappa, and PABAK. RESULTS: In this model, trained APPTs triaged surgical candidates and provided rehabilitation care including education and exercises to patients with spinal disorders. The APPTs referred only 18/46 participants to spine surgeons. Surgical triage and diagnostic concordance were high with raw agreement of 94% and 89%. At the 3-month follow-up, significant improvements in disability were observed among nonsurgical candidates with back (mean difference (MD): -13.0/100 [95%CI: -19.8 to -6.3], n = 23) or neck disorders (MD: -16.0/100 [95%CI: -29.6 to -2.4], n = 5), but not among surgical candidates referred by APPTs to spine surgeons. CONCLUSION: In this limited sample, adults with spinal disorders that were initially referred to a spine surgeon by family physicians were effectively assessed, triaged, and managed by an APPT.

The efficacy of exercise therapy for rotator cuff related shoulder pain according to the FITT principle: a systematic review with meta-analyses.

OBJECTIVE: To evaluate the efficacy of exercise interventions with differing frequency, intensity, type and time (FITT) on shoulder pain and disability in people with rotator cuff related shoulder pain (RCRSP). DESIGN: Intervention systematic review with meta-analyses. LITERATURE SEARCH: Electronic searches were conducted up to May 2023. STUDY SELECTION CRITERIA: Randomized controlled trials (RCTs) comparing the effects of exercise interventions differing in prescription according to the FITT principle, in people with RCRSP. DATA SYNTHESIS: Separate meta-analyses comparing exercise type (specific versus non-specific exercise) and intensity (high versus low) were conducted. GRADE was used to evaluate the certainty of evidence. RESULTS: Twenty-two RCTs (n=1281) were included. There was moderate certainty evidence that motor control exercise programs, when compared to non-specific exercise programs, significantly reduced disability in the short- (SMD: -0.29; 95%CI: -0.51 to -0.07; n=323; 7 RCTs) and medium-term (SMD: -0.33; 95%CI: -0.57 to -0.09; n=286; 5 RCTs), but not pain in the short-term (SMD: -0.19; 95%CI: -0.41 to 0.03; n=323; 7 RCTs). Uncertainties remained regarding other exercise types (eccentric and scapula-focused exercise programs) versus non-specific exercise programs, and exercise intensity due to low to very low certainty evidence. No trials were identified that compared different frequencies or times. CONCLUSION: For adults with RCRSP, motor control exercise programs were probably slightly superior to non-specific exercise programs. However, it is unclear if the effects were due to motor control exercise or to other program characteristics such as progression and tailoring.

FITT Odyssey: A Scoping Review of Exercise Programs for Managing Rotator Cuff Related Shoulder Pain.

OBJECTIVE: To summarize the FITT (frequency, intensity, time, type) components of exercise programs included in randomized controlled trials (RCTs) that compared 2 or more programs for managing rotator cuff related shoulder pain (RCRSP). DESIGN: Scoping review. LITERATURE SEARCH: Electronic searches were conducted up to May 2023. STUDY SELECTION CRITERIA: RCTs comparing the effects of 2 or more types of exercise programs, differing in prescription according to the FITT principle, in people with RCRSP. DATA SYNTHESIS: We extracted data from each trial report so that we could answer items 1-10 and 13-15 from the Consensus on Exercise Reporting Template (CERT). Descriptive analysis of the exercise programs was performed by summarising and presenting the FITT characteristics, and other relevant CERT characteristics (material, provider, delivery, tailoring). RESULTS: FITT characteristics from 46 exercise programs included in 22 trials were extracted. The exercise programs were divided into 4 categories (defined in accordance to the original authors' description and proposed rationale): motor control (n=8), scapula-focused (n=7), eccentric (n=8), and non-specific exercise programs (n=28). Five programs were allocated to 2 different categories. The different program types had similar parameters. Exercise programs frequency ranged from 2 to 7 times per week, dose ranged from 1 to 3 sets and 4 to 30 repetitions per sets and exercise program duration ranged from 4 to 16 weeks. CONCLUSION: There was considerable variability in the parameters used to prescribe exercises for RCRSP. Clinicians seeking guidance on FITT parameters derived from trials should do so cautiously because there was no one size-fits-all approach.

Core competencies for first contact physiotherapists in a direct access model of care for adults with musculoskeletal disorders: A scoping review.

INTRODUCTION: To optimise the management of Musculoskeletal disorders (MSKDs), many countries have implemented direct access to physiotherapy; however, the core competencies required for first contact physiotherapists (PTs) have not been precisely defined. The aim of this scoping review is to identify and describe the core competencies required for first contact PTs treating adults with MSKDs. METHODS: We conducted a scoping review of the literature by searching eight databases and grey literature up to July 2023. We performed a thematic analysis of the competencies identified based on predefined themes relevant to first contact physiotherapy in direct access models in primary or emergency care settings. RESULTS: Sixty-five articles were included. Seventeen core competencies were identified and grouped into 5 themes: (1) Assessment and examination; (2) Management and interventions; (3) Communication; (4) Cooperation and collaboration; and (5) Professionalism and leadership. CONCLUSIONS: Our findings provide an international perspective on the core competencies required for first contact PTs.

Efficacy of physiotherapy interventions for the management of adults with cervicogenic headache: A systematic review and meta-analyses.

OBJECTIVE: To update and appraise the efficacy of physiotherapy for adults with cervicogenic headache. LITERATURE SURVEY: Bibliographic searches were conducted up to October 2021 for randomized controlled trials (RCTs), assessing the efficacy of physiotherapy interventions for adults with cervicogenic headache, in five databases: CINAHL, Physiotherapy Evidence Database (PEDro), PubMed, Sage Journals, and Wiley Online Library. METHODOLOGY: Data extraction of included trials was conducted by two reviewers according to a standardized extraction form. The PEDro tool and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach were used for grading evidence. Results from trials with similar interventions and with similar outcome measures were pooled into separate meta-analyses. A qualitative synthesis was performed for studies that were not pooled into meta-analyses. SYNTHESIS: Fourteen trials were included. Moderate-certainty evidence indicates that manual therapy significantly reduces headache frequency (mean difference [MD]: -0.93 episodes/week; 95% confidence interval [CI]: -1.40 to -0.46; 2 RCTs; n = 265) compared to sham manual therapy, and headache frequency (MD: -1.23 episodes/week; 95% CI: -1.55 to -0.91; 3 RCTs; n = 126) and intensity (MD: -1.63/10; 95% CI: -2.15 to -1.10; 4 RCTs; n = 208) compared to no treatment in the short term. At 12-month follow-up, moderate-certainty evidence indicates that manual therapy did not lead to greater reduction in headache intensity (MD Visual Analog Scale 0-10: -0.12; 95% CI: -0.49 to 0.26; 2 RCTs; n = 265) or frequency (MD: -0.32 episodes/week; 95% CI: -0.91 to 0.28; 2 RCTs; n = 265) when compared to a sham manual therapy. In the long-term, in one high quality trial, neck exercise significantly reduced headache intensity compared to no treatment (MD: -1.51/10; 95% CI: -2.52 to -0.50; n = 100) or to aerobic exercises in another trial of moderate quality (MD: -1.15/10; 95% CI: -2.1 to -0.20; n = 180). CONCLUSIONS: Manual therapy in the short term and neck exercise in the long term may be efficacious to treat adults with cervicogenic headache. More high-quality evidence is needed and future results may change the current conclusions. Trial Registration Prospero: #CRD42019135858.

Advanced practice physiotherapists can diagnose and triage patients with musculoskeletal disorders while providing effective care: a systematic review.

QUESTIONS: What is the diagnostic and surgical triage concordance between advanced practice physiotherapists (APPTs) and physicians? What is the clinical efficacy of advanced practice physiotherapy care compared with usual medical care? DESIGN: Systematic review with meta-analyses. LITERATURE SEARCH: Medline, Embase, Cochrane CENTRAL and CINAHL were searched up to March 2022. STUDY SELECTION CRITERIA: Concordance studies on diagnostic or surgical triage between APPTs and physicians and randomised controlled trials comparing the clinical efficacy of an advanced practice physiotherapy (APP) model of care compared with usual medical care for participants with musculoskeletal disorders. DATA SYNTHESIS: Meta-analyses were performed for concordance and clinical outcomes. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) was used to evaluate the certainty of evidence. RESULTS: Nineteen concordance studies (n = 1,745) and six randomised trials (n = 1,960) were included. Based on moderate-certainty evidence, the pooled Kappa for diagnostic concordance between APPTs and physicians was 0.76 (95% CI 0.68 to 0.85, n = 1,108). Based on high-certainty evidence, the pooled Kappa for surgical triage concordance was 0.71 (95% CI 0.63 to 0.78, n = 1,128). Based on moderate-certainty evidence, APP care resulted in a comparable or greater reduction in pain (MD -0.92 out of 10, 95% CI -1.75 to -0.10, n = 494) when compared with usual medical care at medium-term follow-up. Based on low-certainty evidence, APP care resulted in a comparable or greater reduction in disability (SMD -0.31, 95% CI -0.67 to 0.04, n = 535) when compared with usual medical care at medium-term follow-up. CONCLUSION: Concordance between APPTs and physicians is probably good to very good for diagnosis and good to very good for surgical triage of musculoskeletal disorders. Patients with musculoskeletal disorders managed in an APP model of care probably report comparable or greater pain and disability reductions when compared with usual medical care. REGISTRATION: CRD42022320950.

Cervicogenic headache, an easy diagnosis? A systematic review and meta-analysis of diagnostic studies.

BACKGROUND: The diagnosis of cervicogenic headache (CGH) remains a challenge for clinicians as the diagnostic value of detailed history and clinical findings remains unclear. OBJECTIVES: To update and evaluate available evidence of the prevalence and the diagnostic accuracy of the detailed history and clinical findings for CGH in adults with headache. DESIGN: Systematic review with meta-analysis. METHODS: CINAHL, Cochrane Central, Embase, PEDro and PubMed were searched for studies before March 2022 that reported detailed history and/or clinical findings related to the diagnosis of cervicogenic headache. Study selection, risk of bias assessment (QUADAS-2 and PROBAST), and data extraction were performed. Meta-analyses for the cervical flexion-rotation test (CFRT) was performed. Certainty of the evidence was assessed with the GRADE approach. RESULTS: Eleven studies were included. Moderate certainty evidence indicated that the CFRT differentiated CGH from lower cervical facet-induced headache, migraine, concomitant headaches or asymptomatic subjects (Se 83.0% [95%CI:70.0%-92.0%]; Sp 83.0% [95%CI:71.0%-91.0%]; positive LR 5.0 [95%CI:2.6-9.5]; negative LR 0.2 [95%CI:0.1-0.4]; n = 4 studies; n = 182 participants). Several diagnostic classifications and test clusters based on headache history and clinical findings can be useful, despite uncertain accuracy, in formulating the diagnosis of CGH. CONCLUSION: Evidence support to undertake an evaluation of headache history and signs and symptoms and a physical examination of the patient neck to diagnose CGH. During the physical examination, a positive or negative CFRT probably has a small to moderate effect on the probability of a patient having a CGH. The diagnostic value of the other findings remains unclear. TRIAL REGISTRATION: #CRD42020201772.

Diagnosing, Managing, and Supporting Return to Work of Adults With Rotator Cuff Disorders: Clinical Practice Guideline Methods.

OBJECTIVES: To present the methods used to develop a clinical practice guideline (CPG) with recommendations endorsed by key stakeholders for assessing, managing, and supporting return to work for adults with rotator cuff disorders. DESIGN: Clinical practice guideline development. METHODS: A steering committee composed of the research team of this project led the development of this CPG in 5 phases, which followed the standards of the NICE and AGREE II collaborations. During the preparation phase (I), a multidisciplinary working committee of experts in managing rotator cuff disorders (n = 20) determined the scope and objectives of the CPG. The recommendations development phase (II) included initial knowledge synthesis, development of preliminary recommendations, systematic consultations with a multidisciplinary panel of key stakeholders (n = 51) using a modified three-round Delphi approach and drafting of the original CPG. In the external evaluation phase (III), an external committee of experts evaluated the original CPG using the AGREE II tool. In the dissemination phase (IV), the strategy for disseminating the CPG was developed and implemented. During the update phase (V), the CPG was revised based on an update of the initial knowledge synthesis. RESULTS: Seventy-three preliminary recommendations were developed from the initial knowledge synthesis. During the Delphi consultation, all of these recommendations were endorsed, and one new recommendation was proposed by panelists. The original CPG received an overall AGREE II score of 83% from the external evaluators. In 2021, an update of the initial 2017 knowledge synthesis was conducted and 13 recommendations were revised. CONCLUSION: The 5-phase consensus methods approach guided the development of a high-quality CPG on assessing, managing, and supporting return to work for adults with rotator cuff disorders. J Orthop Sports Phys Ther 2022;52(10):665-674. Epub: 27 July 2022. doi:10.2519/jospt.2022.11307.

Multimodal Interventions Including Rehabilitation Exercise for Older Adults With Chronic Musculoskeletal Pain: A Systematic Review and Meta-analyses of Randomized Controlled Trials.

BACKGROUND AND PURPOSE: Musculoskeletal disorders (MSKDs) are the most common causes of disabilities for older adults. The aim of this systematic review and meta-analysis is to assess the effectiveness of multimodal interventions including exercise rehabilitation for older adults with chronic MSKDs. METHODS: A literature search was conducted up to February 2019 in 5 bibliographical databases to identify randomized controlled trials (RCTs) that compared multimodal interventions including exercise rehabilitation with usual medical care or no intervention. Randomized controlled trials were assessed with the Cochrane risk-of-bias tool. Meta-analyses were performed and pooled mean differences (MDs) or standardized mean differences (SMDs) were calculated. RESULTS: Sixteen RCTs (n = 2322 participants) were included. One RCT was considered at low risk of bias, 8 had some concerns of bias, and 7 had a high risk of bias. Participants suffered from hip or knee osteoarthritis (OA) (n = 12 RCTs), low back pain (LBP) (n = 2 RCTs) and generalized chronic pain (GCP) (n = 2 RCTs). Multimodal interventions were significantly more effective than usual care to decrease pain (visual analog scale, out of 10 points) in the short term, MD: -0.71 (95% confidence interval [CI] -1.08 to -0.34, n = 900), and in the long term: MD: -0.52 (95% CI -0.98 to -0.05, n = 575), but these differences are not considered clinically important. In terms of disabilities, multimodal interventions were also significantly more effective than usual care. The SMDs were -0.47 (95% CI -0.61 to -0.34, n = 903) and -0.29 (95% CI -0.46 to -0.13, n = 568) for OA trials in the short and long terms, respectively, and -0.47 (95% CI -0.81 to -0.12, n = 211) for LBP and GCP trials in the short term. The magnitude of these effects may be considered as small to moderate. CONCLUSION: Multimodal intervention including exercise rehabilitation combined with usual medical care is an efficacious therapeutic option to reduce disabilities in older adults with chronic MSKDs. A significant but not clinically important effect was observed for pain. The most beneficial component of the multimodal interventions in terms of education, exercises, or medication remains to be determined.

Diagnosing, Managing, and Supporting Return to Work of Adults With Rotator Cuff Disorders: A Clinical Practice Guideline.

OBJECTIVE: To develop a clinical practice guideline covering the assessment, management, and return to work of adults with rotator cuff disorders. DESIGN: Clinical practice guideline. METHODS: Using systematic reviews, appraisal of the literature, and an iterative approach to obtain consensus from key stakeholders, clinical recommendations and algorithms were developed in the context of the health care system and work environment of the province of Quebec (Canada). RESULTS: Recommendations (n = 73) and clinical decision algorithms (n = 3) were developed to match the objectives. The initial assessment should include the patient's history, a subjective assessment, and a physical examination. Diagnostic imaging is only necessary in select circumstances. Acetaminophen, nonsteroidal anti-inflammatory drugs, and injection therapies may be useful to reduce pain in the short term. Clinicians should prescribe an active and task-oriented rehabilitation program (exercises and education) to reduce pain and disability in adults with rotator cuff disorders. Subacromial decompression is not recommended to treat rotator cuff tendinopathy. Surgery is appropriate for selected patients with a full-thickness rotator cuff tear. A return-to-work plan should be developed early, in collaboration with the worker and other stakeholders, and must combine multiple strategies to promote return to work. CONCLUSION: This clinical practice guideline was developed to assist the multidisciplinary team of clinicians who provide health care for adults with a rotator cuff disorder. The CPG guides clinical decisionmaking for diagnosis and treatment, and planning for successful return to work. J Orthop Sports Phys Ther 2022;52(10):647-664. Epub: 27 July 2022. doi:10.2519/jospt.2022.11306.

Single session compared with multiple sessions of education and exercise for older adults with spinal pain in an advanced practice physiotherapy model of care: protocol for a randomised controlled trial.

OBJECTIVES: To assess the effectiveness and cost-effectiveness of a single session compared with multiple sessions of education and exercise for older adults with spinal pain treated conservatively in an advanced practice physiotherapy model of care. METHODS AND ANALYSIS: In this pragmatic randomised controlled trial, 152 older adults (≥65 years old) with neck or back pain initially referred for a consultation in neurosurgery, but treated conservatively, will be recruited through the advanced practice physiotherapy neurosurgery CareAxis programme in the Montreal region (Quebec, Canada). In the CareAxis programme, older patients with spinal pain are triaged by an advance practice physiotherapist and are offered conservative care and only potential surgical candidates are referred to a neurosurgeon. Participants will be randomised into one of two arms: 1-a single session or 2-multiple sessions (6 sessions over 12 weeks) of education and exercise with the advance practice physiotherapist (1:1 ratio). The primary outcome measure will be the Brief Pain Inventory (pain severity and interference subscales). Secondary measures will include self-reported disability (the Neck Disability Index or Oswestry Disability Index), the Pain Catastrophizing Scale, satisfaction with care questionnaires (9-item Visit-specific Satisfaction Questionnaire and MedRisk), and the EQ-5D-5L. Participants' healthcare resources use and related costs will be measured. Outcomes will be collected at baseline and at 6, 12 and 26 weeks after enrolment. Intention-to-treat analyses will be performed, and repeated mixed-model analysis of variance will assess differences between treatment arms. Cost-utility analyses will be conducted from the perspective of the healthcare system. ETHICS AND DISSEMINATION: Ethics approval has been obtained from the Comité d'éthique de la recherche du CIUSS de l'Est-de-l'Île-de-Montréal (FWA00001935 and IRB00002087). Results of this study will be presented to different stakeholders, published in peer-reviewed journals and presented at international conferences. PROTOCOL VERSION: V.4 August 2021. TRIAL REGISTRATION NUMBER: NCT04868591; Pre-results.

Motor Control Exercises Compared to Strengthening Exercises for Upper- and Lower-Extremity Musculoskeletal Disorders: A Systematic Review With Meta-Analyses of Randomized Controlled Trials.

OBJECTIVE: The purpose of this review was to compare the efficacy of motor control exercises (MCEs) to strengthening exercises for adults with upper- or lower-extremity musculoskeletal disorders (MSKDs). METHODS: Electronic searches were conducted up to April 2020 in Medline, Embase, Cochrane CENTRAL, and CINAHL. Randomized controlled trials were identified on the efficacy of MCEs compared to strengthening exercises for adults with upper- or lower-extremity MSKDs. Data were extracted with a standardized form that documented the study characteristics and results. For pain and disability outcomes, pooled mean differences (MDs) and standardized mean differences (SMDs) were calculated using random-effects inverse variance models. RESULTS: Twenty-one randomized controlled trials (n = 1244 participants) were included. Based on moderate-quality evidence, MCEs lead to greater pain (MD = -0.41 out of 10 points; 95% CI = -0.72 to -0.10; n = 626) and disability reductions (SMD = -0.28; 95% CI = -0.43 to -0.13; n = 713) when compared to strengthening exercises in the short term; these differences are not clinically important. When excluding trials on osteoarthritis (OA) participants and evaluating only the trials involving participants with rotator cuff-related shoulder pain, shoulder instability, hip-related groin pain, or patellofemoral pain syndrome, there is moderate quality evidence that MCEs lead to greater pain (MD = -0.74 out of 10 points; 95% CI = -1.22 to -0.26; n = 293) and disability reductions (SMD = -0.40; 95% CI = -0.61 to -0.19; n = 354) than strengthening exercises in the short term; these differences might be clinically important. CONCLUSIONS: MCEs lead to statistically greater pain and disability reductions when compared to strengthening exercises among adults with MSKDs in the short term, but these effects might be clinically important only in conditions that do not involve OA. Inclusion of new trials might modify these conclusions. IMPACT: These results suggest that MCEs could be prioritized over strengthening exercises for adults with the included non-OA MSKDs; however, results are unclear for OA disorders.

Is ultrasound-guided lavage an effective intervention for rotator cuff calcific tendinopathy? A systematic review with a meta-analysis of randomised controlled trials.

BACKGROUND: Rotator cuff calcific tendinopathy is characterised by the deposition of hydroxyapatite crystals in one of the rotator cuff tendons and can be managed by ultrasound-guided lavage. However, evidence regarding the efficacy of ultrasound-guided lavage for rotator cuff calcific tendinopathy remains inconclusive. The aim of this systematic review and meta-analysis is to update the available evidence on the efficacy of ultrasound-guided lavage in adults with rotator cuff calcific tendinopathy. METHODS: A literature search was conducted up to April 2018 in four bibliographic databases to identify randomised control trials that compared ultrasound-guided lavage alone with other interventions to treat rotator cuff calcific tendinopathy. Randomised control trials were assessed with the Cochrane Risk of Bias Tool. Meta-analyses and/or qualitative synthesis of the evidence were performed. RESULTS: Three randomised control trials were included. Pooled results for pain (n=226) indicated that ultrasound-guided lavage may significantly decrease pain when compared with shockwave therapy, with a mean difference of -1.98 out of 10 points (95% CI -2.52 to -1.45) in the short term and of -1.84 (95% CI -2.63 to -1.04) in the long term. Based on one trial (n=25), ultrasound-guided lavage significantly improved function when compared with shockwave therapy (p<0.05). Based on another trial (n=48), the addition of ultrasound-guided lavage to a corticosteroid injection significantly improves function in the long term (p<0.05). CONCLUSION: For individuals with rotator cuff calcific tendinopathy, low-quality evidence suggests that ultrasound-guided lavage is more effective than shockwave therapy or a corticosteroid injection alone. Future trials could modify the present conclusions. TRIAL REGISTRATION NUMBER: CRD42018095858.