Cervical kinematics estimated by finite helical axis behaviour differs in patients with neck related problems as compared to healthy controls.

Purpose The present study analyses the kinematics of patients with neck problems and healthy controls by estimation of Finite Helical Axis behaviour. A cross sectional study design was used to investigate whether FHA behaviour differs due to neck problems. METHODS: 584 subjects were recruited from private and ambulatory institutional physiotherapy practices. Among these 171 patients with neck related problems were selected based on referral diagnosis by primary care general practitioners. Cervical kinematics were compared based on minimal convex hull, path length and mean angle of the Finite Helical Axis distribution as well as on the helical angle. Three active planar motions were registered: flexion-extension, axial rotation and lateral bending. RESULTS: Patients demonstrated a significantly reduced and less variable behaviour of the Finite Helical Axis during active flexion-extension and axial rotation motions as compared to healthy individuals and lateral bending. CONCLUSION: Patients with neck related problems demonstrate a more restricted motion behaviour with less variability in Finite Helical Axis distribution and orientation during active planar motions. At present it is not clear whether these kinematic differences are the result or the cause of dysfunction. These slides can be retrieved under Electronic Supplementary Material.

Association between Functional Performance and Return to Performance in High-Impact Sports after Lower Extremity Injury: A Systematic Review.

After lower extremity injury, only half of the injured athletes return to their pre-injury sports level. Even though functional performance tests are often used to make return to sport decisions, it is unknown whether functional performance is associated with return to performance after such injuries. The aim of this systematic review was to identify, critically appraise, and analyze studies that investigated the association of functional performance tests with return to performance after lower extremity injuries in athletes participating in high-impact sports. MEDLINE, Embase, Web of Science, and CINAHL were systematically searched for relevant studies. Articles were independently screened by two authors and data were obtained from each included study using a data extraction form. Two authors independently scored methodological quality using the Quality In Prognosis Studies tool. A qualitative best evidence synthesis was conducted. Eight studies reported the association of functional performance with return to performance after lower extremity injuries, involving 1,246 athletes after anterior or posterior cruciate ligament reconstruction. No studies were found on the association of functional performance with return to performance for lower extremity injuries other than after anterior or posterior cruciate ligament reconstruction. All included studies had a high risk of bias. Two studies found significant but small associations for selected hop tests after anterior cruciate ligament reconstruction. Low evidence of association between functional performance and return to performance was present after anterior cruciate ligament reconstruction for the triple hop for distance, the 6-meter timed hop, the side hop in female athletes, and for the combination of the single and crossover hop for distance. In athletes after posterior cruciate ligament reconstruction, the vertical jump showed a significant but small association with return to performance. There is no high-quality evidence that functional performance is associated with return to performance after lower extremity injuries in athletes practicing high-impact sports. Low quality evidence suggests small associations after anterior and posterior cruciate ligament reconstruction. No evidence exists for lower extremity injuries other than after anterior or posterior cruciate ligament reconstruction. Therefore, research on functional performance associated with return to performance is recommended in high-quality prospective cohort studies including athletes with any type of lower extremity injury.

Cervico-cephalalgiaphobia: a subtype of phobia in patients with cervicogenic headache and neck pain? A pilot study.

OBJECTIVES: The term 'cephalalgiaphobia' was introduced in the mid-1980s and defined as fear of migraine (attacks). We hypothesized that a specific subtype of cephalalgiaphobia affects patients with cervicogenic headache (CEH). This study aimed to: (1) define the term 'cervico-cephalalgiaphobia'; (2) develop a set of indicators for phobia relevant to patients with CEH; and (3) apply this set to a practice test in order to estimate the frequency of cervico-cephalalgiaphobia in the Dutch primary care practice of manual physical therapy. METHODS: A systematic approach was used to develop a definition and potential indicators for cervico-cephalalgiaphobia. An expert group appraised the definition and the set of indicators (score per indicator: never; sometimes; often/always). An invitation to participate in the practice test was sent to Dutch manual physical therapy practices (n = 56) representing 134 manual physical therapists (MPTs). The cut-off point for percentages of scores for coverage of the indicators was set at ≥ 60%. RESULTS: The expert group agreed with the proposed definition of cervico-cephalalgiaphobia. A set of eight indicators for cervico-cephalalgiaphobia was selected from 10 initial indicators. Thirty-six MPTs provided data from 46 patients diagnosed with CEH. The coverage of 'often/always' was substantial for the indicators, 'Short-term positive results in previous manual physical therapeutic treatment', 'Shorter interval between treatment sessions', 'Fear of "locked facet joints" of the neck', 'More frequent manipulation', and 'Fear of increase in headaches'. Coverage was also substantial for 'never' regarding 'Long-term positive results in previous manual physical therapeutic treatment'. 'Confirmation of "locked facet joints" of the cervical spine by MPT as a cause for increase of CEH' scored 'often/always' in all patients. Coverage for 'Increased use of medication with insufficient effect' was substantial, scoring as 'sometimes' in 39 (84.8%) patients. DISCUSSION: Cervico-cephalalgiaphobia was defined and a set of eight indicators formulated based on the literature and clinical expertise. The practice test provides valuable information on the frequency of indicators for cervico-cephalalgiaphobia in the Dutch manual physical therapy practice, suggesting that cervico-cephalalgiaphobia is common in patients with CEH.

Manual physical therapists' use of biopsychosocial history taking in the management of patients with back or neck pain in clinical practice.

OBJECTIVE: To develop and evaluate process indicators relevant to biopsychosocial history taking in patients with chronic back and neck pain. METHODS: The SCEBS method, covering the Somatic, Psychological (Cognition, Emotion, and Behavior), and Social dimensions of chronic pain, was used to evaluate biopsychosocial history taking by manual physical therapists (MPTs). In Phase I, process indicators were developed while in Phase II indicators were tested in practice. RESULTS: Literature-based recommendations were transformed into 51 process indicators. Twenty MTPs contributed 108 patient audio recordings. History taking was excellent (98.3%) for the Somatic dimension, very inadequate for Cognition (43.1%) and Behavior (38.3%), weak (27.8%) for Emotion, and low (18.2%) for the Social dimension. MTPs estimated their coverage of the Somatic dimension as excellent (100%), as adequate for Cognition, Emotion, and Behavior (60.1%), and as very inadequate for the Social dimension (39.8%). CONCLUSION: MTPs perform screening for musculoskeletal pain mainly through the use of somatic dimension of (chronic) pain. Psychological and social dimensions of chronic pain were inadequately covered by MPTs. Furthermore, a substantial discrepancy between actual and self-estimated use of biopsychosocial history taking was noted. We strongly recommend full implementation of the SCEBS method in educational programs in manual physical therapy.

Intraexaminer reliability of hand-held dynamometry in the upper extremity: a systematic review.

OBJECTIVE: To summarize and appraise the literature on the intraexaminer reliability of hand-held dynamometry (HHD) in the upper extremity. DATA SOURCES: MEDLINE, CINAHL, and EMBASE were searched for relevant studies published up to December 2011. In addition, experts were contacted, and journals and reference lists were hand searched. STUDY SELECTION: To be included in the review, articles needed to (1) use a repeated-measures, within-examiner(s) design; (2) include symptomatic or asymptomatic individuals, or both; (3) use HHD to measure muscle strength in any of the joints of the shoulder, elbow, or wrist with the "make" or the "break" technique; (4) report measurements in kilogram, pound, or torque; (5) use a device that is placed between the examiner's hand and the subject's body; and (6) present estimates of intraexaminer reliability. DATA EXTRACTION: Quality assessment and data extraction were performed by 2 reviewers independently. DATA SYNTHESIS: Fifty-four studies were included, of which 26 (48%) demonstrated acceptable intraexaminer reliability. Seven high-quality studies showed acceptable reliability for flexion and extension of the elbow in healthy subjects. Conflicting results were found for shoulder external rotation and abduction. Reliability for all other movements was unacceptable. Higher estimates were reached for within-sessions reliability and if means of trials were used. CONCLUSIONS: Intraexaminer reliability of HHD in upper extremity muscle strength was acceptable only for elbow measurements in healthy subjects. We provide specific recommendations for future research. Physical therapists should not rely on HHD measurements for evaluation of treatment effects in patients with upper extremity disorders.

Sensory profiles and their role in the persistence of central sensitization symptoms in low back pain. A prospective cohort study.

INTRODUCTION: Acute lower back pain can lead to neuroplastic changes in the central nervous system, and symptoms of central sensitization after 12 weeks. While sensory sensitivity has been shown to predict symptoms of central sensitization, trait sensory profiles may be prognostic in the persistence of central sensitization symptoms in low back pain over time. OBJECTIVE: To examine sensory profiles as prognostic symptoms of central sensitization in people with acute low back pain. METHODS: A longitudinal type 2 prognostic factor research study was performed according to the PROGRESS framework. Baseline and 12-week follow-up measures were taken using the Adolescent/Adult Sensory Profile and the Central Sensitization Inventory measures. Study participants were consecutively included from primary care physiotherapy practices. Univariable, and multivariable regression analyses were performed to adjust sensory profiles based on previous history of low back pain, baseline Central Sensitization Inventory scores, level of pain, disability, age, and duration of low back pain. RESULTS: After adjustment, the sensory profiles of Low Registration B = 0.44, 95%CI (0.18, 0.70), Sensation Seeking B = 0.38, 95%CI (0.19, 0.57), Sensory Sensitive B = 0.49, 95%CI (0.25, 0.74), Sensation Avoiding B = 0.40, 95% CI (0.15, 0.65) was significantly associated with the persistence of central sensitization symptoms (N = 103). CONCLUSION: Sensory profiles may predict symptoms of central sensitization after 12 weeks in people with acute low back pain.

Impact of direct access on the quality of primary care musculoskeletal physiotherapy: a scoping review from a patient, provider, and societal perspective.

Introduction: Worldwide many countries provide direct access in physiotherapy. The aim of this scoping review was to synthesize the available evidence on the quality of primary care musculoskeletal physiotherapy from different perspectives. Methods: Systematic searches were conducted in three databases up to September 2022. Studies were included when regarding assessment of at least one of the following perspectives: patient (quality of Life, patient satisfaction, pain, functioning, adverse events), provider (treatment compliance, responsibility, liability, status, prestige, job satisfaction), and society (number of referrals, amount of medical imaging, medication use, number of sessions needed for rehabilitation, and overall costs and cost-effectiveness). Selection and methodological quality assessment of systematic reviews were performed. Data extraction and analysis were performed separately for systematic reviews and individual primary studies. Results: Five systematic reviews as well as 17 primary studies were included. From a patient perspective, no significant effect of direct access was found for pain and a tendency in favour of direct access was found for quality of life, functioning, and well-being. Concerning providers, higher treatment compliance was found in direct access to physiotherapy and decision-making was more accurate. From a societal perspective, significant differences in favour of direct access physiotherapy were found for waiting time, prescribed medication, and medical imaging. In addition, there was a tendency towards lower health care costs. Conclusions: Emerging evidence suggests that direct access physiotherapy could provide at least equal quality of care for patients and better opportunities for providers and the society on selected outcomes.

Mydriatic visual acuity in diabetic patients: a randomized controlled trial.

PURPOSE: The aim of this randomized controlled equivalence trial was to demonstrate that, in diabetic patients, dilating the pupils before as compared with after refraction and visual acuity assessment would not lead to different advice given to patients. METHODS: Three hundred sixteen adult patients with diabetes mellitus were randomized. The experimental group was administered tropicamide 0.5% before refraction and visual acuity assessment and the control group after refraction and visual acuity assessment. Study outcomes were the advised time till next visit, the advice on adjustment of refractive correction, further diagnostics, treatment, duration of the eye examination, and patient satisfaction. RESULTS: No difference was seen in advised time till next visit between the experimental group (12.39 ± 5.01 months) and the control group (12.84 ± 4.96 months) (p = 0.425). In addition, the advice concerning adjustment of refractive correction (p = 0.069), further diagnostics (p = 1.000), and therapy (p = 0.178) did not significantly differ. Waiting time was significantly shorter for the experimental group (22.25 vs. 36.18 minutes; p < 0.001). People in the experimental group were relatively more often "very satisfied" than "satisfied" in comparison with participants in the control group for "attention being paid by the optometrist" (p = 0.025) and "advice on refractive correction" (p = 0.047). CONCLUSIONS: In diabetic patients, dilating pupils before refraction and visual acuity assessment does not lead to different advice given to patients compared with dilating pupils after refraction and visual acuity assessment, whereas waiting time significantly decreases and patient satisfaction is similar or even better. Increased efficiency is beneficial to both patients and clinicians.

External validation and updating of prognostic models for predicting recovery of disability in people with (sub)acute neck pain was successful: broad external validation in a new prospective cohort.

QUESTION: Can existing post-treatment prognostic models for predicting neck pain recovery (primarily in terms of disability and secondarily in terms of pain intensity and perceived improvement) be externally validated and updated at the end of the treatment period and at 6 and 12 weeks of follow-up in a new Dutch cohort of people with neck pain treated with guideline-based usual care physiotherapy? DESIGN: External validation and model updating in a new prospective cohort of three previously developed prognostic models. PARTICIPANTS: People with (sub)acute neck pain and registered for primary care physiotherapy treatment. OUTCOME MEASURES: Recovery of disability, pain intensity, and perceived recovery at 6 and 12 weeks and at the end of the treatment period. RESULTS: Discriminative performance (c-statistic) of the disability model at 6 weeks was 0.73 (95% CI 0.69 to 0.77) and reasonably well calibrated after intercept recalibration. The disability model at 12 weeks and at the end of the treatment period showed discriminative c-statistic performance values of 0.69 (95% CI 0.64 to 0.73) and 0.68 (95% CI 0.63 to 0.72), respectively, and was well calibrated. Pain models and perceived recovery models did not reach acceptable performance. Cervical mobility added value to the disability models and pain catastrophising to the disability and pain models at 6 weeks. DISCUSSION: Broad external validation of the disability model was successful in people with (sub)acute neck pain and clinicians may use this model in clinical practice with reasonable accuracy. Further research is required to assess the disability model's clinical impact and generalisability, and to identify additional valuable model predictors. REGISTRATION: https://osf.io/a6r3k/.

Exploratory Study of Associations and Agreement between Prognostic Patient-Registered Factors, Physiotherapists' Intuitive Synthesis, and Patient-Reported Factors in Whiplash-Associated Disorders.

BACKGROUND: A large proportion of people who sustain a whiplash injury will have persistent pain, disability, and participation problems. Several prognostic factors for functional recovery have been reported in the literature but these factors are often evaluated based on differing implementations in clinical practice. Additionally, physiotherapists also rely on their clinical intuition to estimate the functional prognosis of their patients, but this is seldom measured in experimental research. Furthermore, no study to date has explored the associations between clinical intuition, clinically estimated factors, and objectively measured factors for functional recovery of patients with Whiplash-Associated Disorders (WAD). AIM: The aim of this exploratory study is to evaluate associations between prognostic factors for functional recovery, based on routinely collected data in a specialized primary care physiotherapy practice in a consecutive sample of patients (n = 523) with WAD. METHODS: Three sources of prognostic factors were selected: (1) physiotherapists' synthesis of clinical intuition in terms of high-risk, inconclusive risk, or low-risk for functional recovery, (2) patient-registered factors from history taking, and (3) patient-reported prognostic factors derived from questionnaires. Prognostic factors were selected based on the literature, recommendations in Dutch clinical practice guidelines, and consensus between experts. Spearman's rank correlation coefficients were calculated to explore the associations between sources of prognostic factors, using a cutoff ≥0.25 for acceptable association. RESULTS: Associations between physiotherapists' intuitive synthesis and patient-registered variables were substantial (rs = 0.86), between patient-registered variables and patient-reported variables fair (ranging from 0.30 to 0.41) to substantial (ranging from 0.69 to 0.73), and between physiotherapists intuitive synthesis and patient-reported variables fair (ranging from 0.30 to 0.37). CONCLUSION: When estimating prognosis for functional recovery using clinical reasoning, physiotherapists should integrate patients' registered experience of their course of recovery, as well as the timeline after an accident, with their own synthesis of clinical intuition regarding prognostic factors in patients with WAD.

Risk assessment of vascular complications following manual therapy and exercise for the cervical region: diagnostic accuracy of the International Federation of Orthopaedic Manipulative Physical Therapists framework (The Go4Safe project).

QUESTION: What is the diagnostic accuracy of the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) framework to assess the risk of vascular complications in patients seeking physiotherapy care for neck pain and/or headache? DESIGN: Cross-sectional diagnostic accuracy study. PARTICIPANTS: One hundred and fifty patients seeking physiotherapy for neck pain and/or headache in primary care. METHODS: Nineteen physiotherapists performed the index test according to the IFOMPT framework. Patients were classified as having a high, intermediate or low risk of vascular complications, following manual therapy and/or exercise, derived from the estimated risk of the presence of vascular pathology. The reference test was a consensus medical decision reached by a vascular neurologist and an interventional neurologist, with input from a neuroradiologist. The neurologists had access to clinical data and magnetic resonance imaging of the cervical spine, including an angiogram of the cervical arteries. OUTCOME MEASURES: Diagnostic accuracy measures were calculated for 'no contraindication' (ie, the low-risk category) and 'contraindication' (ie, the high-risk and intermediate-risk categories) for manual therapy and/or exercise. Sensitivity, specificity, predictive values, likelihood ratios and the area under the curve were calculated. RESULTS: Manual therapy and/or exercise were contraindicated in 54.7% of the patients. The sensitivity of the IFOMPT framework was low (0.50, 95% CI 0.39 to 0.61) and its specificity was moderate (0.63, 95% CI 0.51 to 0.75). The positive and negative likelihood ratios were weak at 1.36 (95% CI 0.93 to 1.99) and 0.79 (95% CI 0.60 to 1.05), respectively. The area under the curve was poor (0.57, 95% CI 0.49 to 0.65). CONCLUSION: The IFOMPT framework has poor diagnostic accuracy when compared with a reference standard consisting of a consensus medical decision.

Pre- and postmatch hop test outcomes in soccer players returning to performance after lower extremity injury.

BACKGROUND: Most soccer injuries concern the lower extremity with a higher injury rate during the second half of matches. In advising safe return to sport, hop tests are usually assessed at the point of return to sport under non-fatigued conditions. No studies exist investigating hop test outcomes before and after a match in soccer players returning to performance after lower extremity injury and non-injured teammates. The objective is to assess differences in hop test outcomes before and after a match in and between soccer players returning to performance after lower extremity injury and their non-injured teammates. METHODS: A repeated-measures design was used to measure outcomes on five hop tests before and after a soccer match. For analyzing differences in hop tests before and after a match, paired sample t-tests were used. Independent t-tests were used to analyze differences between soccer players after injury and non-injured teammates. Effect sizes were calculated using Cohen's d. RESULTS: Hop tests were completed by 61 amateur soccer players after injury and 121 non-injured teammates. Differences in hop tests before and after the match within both groups had negligible to small effect sizes (d=0.00-0.49), except for the figure of 8- and 30-seconds side hop in the injured leg of RTPf soccer players (d=0.56 and d=0.71 respectively). Differences between both groups were negligible to small (d=0.00-0.36). CONCLUSIONS: Soccer players returning to performance after a lower extremity injury showed similar scores on hop tests than their non-injured teammates. More demanding sport-specific performance test and measurement of quality of movement are additionally recommended for safe return to sport decision-making.

Clinical characteristics differ between patients with non-traumatic neck pain, patients with whiplash-associated disorders, and pain-free individuals.

BACKGROUND: Evidence is lacking to what extent patients with Whiplash-Associated Disorders (WAD), those with non-traumatic neck pain (NTNP), and pain-free individuals differ regarding type and severity of impairments, disability, and psychological factors. OBJECTIVE: To compare clinical characteristics between patients with WAD, with NTNP, and pain-free individuals in primary care physiotherapy. Additionally, differences between patient groups for both acute and chronic symptoms were assessed. METHOD: A cross-sectional study was conducted including 168 patients with WAD, 336 matched patients with NTNP, and 336 pain-free individuals. Differences and prevalence rates were calculated for pain intensity, pain distribution, cervical range of motion, neck flexor muscle endurance, self-reported disability, and psychological factors. RESULTS: Patients with WAD had higher pain intensity (median 6/10 vs. 5/10 p<.01), had a wider distribution of their neck pain (p=.02), more restricted cervical flexion-extension (-11.9°) and rotation (-12.4°), less muscle endurance (-5.5 seconds), and more disability (+14.0%), compared to patients with NTNP. More patients with WAD reported low back pain (+9.5%) and headache (+12.2%) as musculoskeletal comorbidities. Regarding anxiety, depression, and stress, most patients (>83%) scored in the normal range. No significant differences between the patient groups were observed (p>.16). Both patient groups scored significantly worse than pain-free individuals on all characteristics. Patients with WAD and NTNP experienced different types of activity limitations and participation restrictions. CONCLUSION: WAD is a more severe condition than NTNP and should be considered a separate subgroup. A different approach in clinical practice and research is required for WAD and NTNP.

Improved quality of physiotherapy care in patients with Whiplash-Associated Disorders: Results based on 16 years of routinely collected data.

Quality improvement is now a central tenet in physiotherapy care, and quality indicators (QIs), as measurable elements of care, have been applied to analyze and evaluate the quality of physiotherapy care over the past two decades. QIs, based on Donabedian's model of quality of care, provide a foundation for measuring (improvements in) quality of physiotherapy care, providing insight into the many remaining evidentiary gaps concerning diagnostics, prognostics and treatment, as well as patient-related outcome measures. In this overview we provide a synthesis of four recently published articles from our project group on the topic of quantitative measures of quality improvement in physiotherapy care, in this context specifically focused on patients with WAD in primary care physiotherapy. A set of process and outcome QIs (n = 28) was developed for patients with WAD and linked to a database consisting of routinely collected data (RCD) on patients with WAD collected over a 16-year period. The QIs were then embedded per step of the clinical reasoning process: (a) administration (n = 2); (b) history taking (n = 7); (c) objectives of examination (n = 1); (d) clinical examination (n = 5); (e) analysis and conclusion (n = 1); (f) treatment plan (n = 3); (g) treatment (n = 2); (h) evaluation (n = 5); and (i) discharge (n = 2). QIs were expressed as percentages, allowing target performance levels to be defined ≥70% or ≤30%, depending on whether the desired performance required an initially high or low QI score. Using RCD data on primary care patients with WAD (N = 810) and a set of QIs, we found that the quality of physiotherapy care has improved substantially over a 16-year period. This conclusion was based on QIs meeting predetermined performance targets of ≥70% or ≤30%. Twenty-three indicators met the target criterium of ≥70% and three indicators ≤30%. Our recommended set of QIs, embedded in a clinical reasoning process for patients with WAD, can now be used as a basis for the development of a validated QI set that effectively measures quality (improvement) of primary care physiotherapy in patients with WAD.

Challenges and solutions in prognostic prediction models in spinal disorders.

Methodological shortcomings in prognostic modeling for patients with spinal disorders are highly common. This general commentary discusses methodological challenges related to the specific nature of this field. Five specific methodological challenges in prognostic modeling for patients with spinal disorders are presented with their potential solutions, as related to the choice of study participants, purpose of studies, limitations in measurements of outcomes and predictors, complexity of recovery predictions, and confusion of prognosis and treatment response. Large studies specifically designed for prognostic model research are needed, using standard baseline measurement sets, clearly describing participants' recruitment and accounting and correcting for measurement limitations.

Illness perceptions as an independent predictor of chronic low back pain and pain-related disability: a prospective cohort study.

OBJECTIVES: To investigate whether illness perceptions, measured with the Brief Illness Perception Questionnaire, are an independent predictor of chronic low back pain and pain-related disability at 12 weeks. DESIGN: A prospective, observational cohort study. SETTING: 26 outpatient primary care physiotherapy practices throughout the Netherlands. PARTICIPANTS: Acute nonspecific low back pain patients between the age of 18 and 60 years, with or without radiating pain, and a pain-free episode of at least three months before onset. INTERVENTIONS: Standard physiotherapy care according to Dutch clinical practice guidelines. OUTCOME MEASURE: Chronic low back pain defined as pain ≥3/10 on the Numeric Pain Rating Scale and as pain-related disability ≥19/70 on the Pain Disability Index measured after 12 weeks. RESULTS: Two hundred and four people with acute nonspecific low back pain completed both assessments. In the multivariable analyses, adjusted for pain intensity, disability, duration, radiating pain, depressed mood, associations of illness perceptions were OR 1.04 (95% CI: 1.01 to 1.08) for pain and 1.04 (95% CI: 0.99 to 1.09) for pain-related disability. CONCLUSIONS: Illness perceptions independently predicted chronic low back pain but not pain-related disability at 12 weeks. The added predictive value of illness perceptions was relatively low.

The Non-injured Leg Can Be Used as a Reference for the Injured Leg in Single-legged Hop Tests.

BACKGROUND: Single-legged hop tests are frequently used in substantiating return to sport decisions following lower extremity injury. Evidence for using the non-injured leg as a reference for the injured leg in the return to sport decision-making at the criterion-based point of return to sport following lower extremity injury is lacking. PURPOSE: To compare absolute values in single-legged hop tests between the non-injured leg of athletes returning to high-impact sports after lower extremity injury and the matched leg of healthy athletes. STUDY DESIGN: Cross-sectional study. METHODS: One hundred and sixty-nine athletes returning to high-impact sports after lower extremity injury and 169 matched healthy athletes executed five single-legged hop tests. Differences between athletes returning to high-impact sports after lower extremity injury and matched healthy athletes on five single-legged hop tests were analyzed using paired t-tests. RESULTS: There were no statistically significant differences between the non-injured leg of athletes returning to sport and the matched leg of healthy athletes. Effect sizes ranged from 0.05 to 0.14 indicating negligible effects. CONCLUSION: Clinicians can use the non-injured leg as a reference for the injured leg in single-legged hop tests for deciding on return to high-impact sports after lower extremity injuries. LEVEL OF EVIDENCE: 3b.

Psychological assessments by manual physiotherapists in the Netherlands in patients with nonspecific low back pain.

Background: Clinical Practice Guidelines for low back pain emphasize implementing assessment and addressing of psychosocial context. It is unknown to what extent manual physiotherapists incorporate psychological factors in their diagnostic management of patients with nonspecific low back pain.Methods: An online survey among Dutch manual physiotherapists was conducted exploring the use of 10 psychological constructs. Frequencies of attention to psychological factors during history-taking and use of questionnaires were calculated. Associations between therapists characteristics and use of psychological questionnaires were analyzed using Spearmans rank correlation coefficient (r s) and logistic regression. In addition, a retrospective patient record review was conducted.Results: One hundred and twelve manual physiotherapists returned completed surveys. Although respondents indicated psychological factors were assessed, they rarely used psychological questionnaires. Significant but negligible associations were found for age and working hours and the use of specific questionnaires. From 95 patient records reviewed, seven were identified that mentioned one psychological factor each during history taking.Conclusions: Dutch MPTs, regardless of their age and work characteristics, rarely use psychological questionnaires in patients with LBP, although they report addressing these constructs implicitly during history taking. Educational and implementation strategies are needed to warrant the use of psychological constructs and validated psychological questionnaires at all phases of the clinical reasoning process.

Development and internal validation of prognostic models for recovery in patients with non-specific neck pain presenting in primary care.

OBJECTIVES: Development and internal validation of prognostic models for post-treatment and 1-year recovery in patients with neck pain in primary care. DESIGN: Prospective cohort study. SETTING: Primary care manual therapy practices. PARTICIPANTS: Patients with non-specific neck pain of any duration (n=1193). INTERVENTION: Usual care manual therapy. OUTCOME MEASURES: Recovery defined in terms of pain intensity, disability, and global perceived improvement directly post-treatment and at 1-year follow-up. RESULTS: All post-treatment models exhibited acceptable discriminative performance after derivation (AUC≥0.7). The developed post-treatment disability model exhibited the best overall performance (R2=0.24; IQR, 0.22-0.26), discrimination (AUC=0.75; 95% CI, 0.63-0.84), and calibration (slope 0.92; IQR, 0.91-0.93). After internal validation and penalization, this model retained acceptable discriminative performance (AUC=0.74). The five other models, including those predicting 1-year recovery, did not reach acceptable discriminative performance after internal validation. Baseline pain duration, disability, and pain intensity were consistent predictors across models. CONCLUSION: A post-treatment prognostic model for disability was successfully developed and internally validated. This model has potential to inform primary care clinicians about a patient's individual prognosis after treatment, but external validation is required before clinical use can be recommended.

External validation of prognostic models for recovery in patients with neck pain.

BACKGROUND: Neck pain is one of the leading causes of disability in most countries and it is likely to increase further. Numerous prognostic models for people with neck pain have been developed, few have been validated. In a recent systematic review, external validation of three promising models was advised before they can be used in clinical practice. OBJECTIVE: The purpose of this study was to externally validate three promising models that predict neck pain recovery in primary care. METHODS: This validation cohort consisted of 1311 patients with neck pain of any duration who were prospectively recruited and treated by 345 manual therapists in the Netherlands. Outcome measures were disability (Neck Disability Index) and recovery (Global Perceived Effect Scale) post-treatment and at 1-year follow-up. The assessed models were an Australian Whiplash-Associated Disorders (WAD) model (Amodel), a multicenter WAD model (Mmodel), and a Dutch non-specific neck pain model (Dmodel). Models' discrimination and calibration were evaluated. RESULTS: The Dmodel and Amodel discriminative performance (AUC < 0.70) and calibration measures (slope largely different from 1) were poor. The Mmodel could not be evaluated since several variables nor their proxies were available. CONCLUSIONS: External validation of promising prognostic models for neck pain recovery was not successful and their clinical use cannot be recommended. We advise clinicians to underpin their current clinical reasoning process with evidence-based individual prognostic factors for recovery. Further research on finding new prognostic factors and developing and validating models with up-to-date methodology is needed for recovery in patients with neck pain in primary care.