Teaching and learning clinical reasoning skill in undergraduate medical students: A scoping review.

BACKGROUND: Clinical reasoning involves the application of knowledge and skills to collect and integrate information, typically to arrive at a diagnosis, implement appropriate interventions, solve clinical problems, and improve the quality of health care and patient outcomes. It is a vital competency that medical students must acquire, as it is considered the heart of medicine. PURPOSE: This scoping review aimed to identify and summarize the existing literature on learning and teaching strategies for improving clinical reasoning skill in undergraduate medical education. METHODS: We conducted electronic searches in Scopus, PubMed/Medline (NLM), Web of Science (WOS), and ERIC to retrieve articles published between January 1, 2010, and March 23, 2024. We also performed hand searches by scanning the reference lists of included studies and similar reviews and searching three key journals. After removing duplicates, two reviewers independently extracted data from primary articles using a standard data extraction form. The authors used Arksey and O'Malley's framework. RESULTS: Among the 46581 retrieved records, 54 full-text articles were included in the present review. We categorized the educational strategies based on their aspects, focus, and purpose. Included studies used various educational strategies for improving clinical reasoning skill in undergraduate medical education by serial cue or whole clinical cases that presented as process-oriented or knowledge-oriented. CONCLUSION: This scoping review investigated various dimensions of educational intervention for improving clinical reasoning skill in undergraduate medical education. There is a need for more precision studies with larger sample sizes, designing studies according to randomized controlled trials standards, determining MCID, or performing meta-analyses to acquire robust and conclusive results.

How Low Back Pain is Managed-A Mixed-Methods Study in 32 Countries. Part 2 of Low Back Pain in Low- and Middle-Income Countries Series.

BACKGROUND: The Lancet Low Back Pain (LBP) Series highlighted the lack of LBP data from low- and middle-income countries (LMICs). The study aimed to describe (1) what LBP care is currently delivered in LMICs and (2) how that care is delivered. DESIGN: An online mixed-methods study. METHODS: A Consortium for LBP in LMICs (n = 65) was developed with an expert panel of leading LBP researchers (>2 publications on LBP) and multidisciplinary clinicians and patient partners with 5 years of clinical/lived LBP experience in LMICs. Quantitative data were analyzed using descriptive statistics. Two researchers independently analyzed qualitative data using inductive and deductive coding and developed a thematic framework. RESULTS: Forty-seven (85%) of 55 invited panel members representing 32 LMICs completed the survey (38% women, 62% men). The panel included clinicians (34%), researchers (28%), educators (6%), and people with lived experience (4%). Pharmacotherapies and electrophysiological agents were the most used LBP treatments. The thematic framework comprised 8 themes: (1) self-management is ubiquitous, (2) medicines are the cornerstone, (3) traditional therapies have a place, (4) society plays an important role, (5) imaging use is very common, (6) reliance on passive approaches, (7) social determinants influence LBP care pathway, and (8) health systems are ill-prepared to address LBP burden. CONCLUSION: LBP care in LMICs did not consistently align with the best available evidence. Findings will help research prioritization in LMICs and guide global LBP clinical guidelines. J Orthop Sports Phys Ther 2024;54(8):560-572. Epub 11 April 2024. doi:10.2519/jospt.2024.12406.

The effectiveness of neurodynamic techniques in patients with diabetic peripheral neuropathy: Study protocol for a randomized sham-controlled trial.

Background: Diabetic peripheral neuropathy (DPN) is one of the most common complications of diabetes mellitus (DM). DPN is the primary risk factor for diabetic foot ulcers that can cause amputation. Although several observational studies have investigated the morphological and biomechanical characteristics of peripheral nerves in DPN, interventional studies regarding the effectiveness of neurodynamic techniques (NDT) in DPN patients are confined to a handful. The effects of NDT on neuropathy severity, nerve conduction parameters, quality of life (QoL), and mechanosensitivity have not been explored yet in this population. Materials and Methods: Forty type 2 DPN (T2DPN) patients, diagnosed based on an electrodiagnosis study, will be recruited into two groups. The experimental group will receive the tibial nerve's real proximal and distal slider techniques in addition to DPN standard treatment as a basic treatment, and the control group will receive the tibial nerve's sham proximal and distal slider techniques along with the basic treatment for eight sessions twice a week. Baseline and post-intervention assessments will be based on the Michigan diabetic neuropathy score (MDNS) (primary outcome), tibial nerve conduction parameters, neuropathy-specific quality of life (Neuro QoL) questionnaire, and straight leg raising range of motion (SLR ROM) (secondary outcomes). Results: This study is expected to last approximately seven months, depending on recruitment. The results of the study will be published in a peer-reviewed journal. Conclusions: The present study will evaluate the efficacy of NDT on the primary and secondary outcome measurements in DPN patients.

Beyond the obvious: A case presentation on the misdiagnosis of posterior femoral cutaneous nerve entrapment as semitendinosus muscle tear.

To underscore the importance of evaluating the entrapment of the posterior femoral cutaneous nerve (PFCN) in patients exhibiting symptoms in the posterior thigh region. A 42-year-old male dentist, initially diagnosed with a semitendinosus muscle tear and persistent pain and tingling in the posterior thigh, sought treatment at our outpatient clinic. Despite unsuccessful physiotherapy, a comprehensive evaluation revealed an unusual entrapment of the PFCN between the sacrotuberous ligament and the semitendinosus muscle stump. The patient was subjected to a series of specialized therapeutic interventions, including soft tissue release, kinesiology taping, and lifestyle modifications. The patient's symptoms, including pain and tingling, were completely resolved, enabling him to sit on a stool for extended periods without discomfort. This case presentation emphasizes the need for physical therapists to consider the possibility of PFCN entrapment in patients experiencing pain and tingling in the posterior thigh. These symptoms can be easily mistaken for conditions such as sciatica or a hamstring muscle tear.

The effects of aerobic exercises compared to conventional chest physiotherapy on pulmonary function, functional capacity, sputum culture, and quality of life in children and adolescents with cystic fibrosis: a study protocol for randomized controlled trial study.

BACKGROUND: Cystic fibrosis (CF) is an autosomal recessive disorder caused by abnormal function of the chloride ion channels and characterized by pancreatic insufficiency and chronic endobronchial airway infection. Pulmonary dysfunction is very common and could lead to a reduction in the quality of life. Airway clearance techniques (ACT) and physical exercises are introduced as one of the main components of treatment. Therefore, it will be of interest to examine the effect of aerobic exercises compared to conventional chest physiotherapy (CPT) on pulmonary function, functional capacity, sputum culture, and quality of life in patients with CF. METHODS: Thirty patients with CF will participate in a double-blind parallel controlled trial containing 18 sessions of treatment. Group A consists of CPT and placebo aerobic exercise, and group B includes aerobic exercise and placebo CPT. Pulmonary function, functional capacity, sputum culture, and quality of life will be evaluated with a spirometry test, 6-min walk test (6MWT), sputum culture test, and the Cystic Fibrosis Questionnaire-Revised (CFQ-R), respectively, before and after the intervention. DISCUSSION: We will evaluate and compare the effectiveness of aerobic exercises and conventional chest physiotherapy on pulmonary function, functional capacity, sputum culture, and quality of life. Comparing these two treatment patterns can contribute to a better understanding of the effectiveness. Therefore, if there is a significant difference between the two treatments, the superior treatment will be prioritized clinically. TRIAL REGISTRATION: https://www.irct.ir , IRCT20210505051181N5. Registered on 19 February 2023.

The effect of dual-task conditions on postural control in adults with low back pain: a systematic review and meta-analysis.

BACKGROUND: Dual-task conditions, which involve performing two tasks simultaneously, may exacerbate pain and further impair daily functioning in individuals with low back pain (LBP). Understanding the effects of dual-task conditions on postural control in patients with LBP is crucial for the development of effective rehabilitation programs. Our objective was to investigate the impact of dual-task conditions on postural control in individuals with LBP compared to those without LBP. METHODS: We conducted a comprehensive search of Medline via PubMed, Scopus, the Cochrane Central Register of Controlled Trials, Web of Science, and EMBASE databases, with no language restrictions, from inception to January 1, 2023. The primary outcome measures of the study were velocity, area, amplitude, phase plane portrait, and path/sway length of the center of pressure (CoP). Standardized mean difference (SMD) effect sizes were calculated, and the quality of the studies was assessed using the Newcastle-Ottawa Scale (NOS). RESULTS: From 196 studies, five involving 242 adults (≥ 18 years) met the inclusion criteria. Three studies were rated as high quality, while two were deemed moderate. In the included studies, 140 participants had non-specific LBP, while 102 participants did not report any symptoms, with mean ages of 36.68 (± 14.21) and 36.35 (± 15.39) years, respectively. Three studies had both genders, one exclusively included females, and one did not specify gender. Meta-analyses of primary outcomes revealed no significant differences in postural control between patients with LBP and pain-free controls during both easy and difficult postural tasks and cognitive load for velocity (easy: SMD - 0.09, 95% CI - 0.91 to 0.74; difficult: SMD 0.12, 95% CI - 0.67 to 0.91), area (easy: SMD 0.82, 95% CI - 2.99 to 4.62; difficult: SMD 0.14, 95% CI - 2.62 to 2.89), phase plane (easy: SMD - 0.59, 95% CI - 1.19 to 0.02; difficult: SMD - 0.18, 95% CI - 0.77 to 0.42), path/sway length (easy: SMD - 0.18, 95% CI - 0.77 to 0.42; difficult: SMD - 0.14, 95% CI - 0.84 to 0.55), and amplitude (easy: SMD 0.89, 95% CI - 1.62 to 3.39; difficult: SMD 1.31, 95% CI - 1.48 to 4.10). CONCLUSIONS: The current evidence suggests that there are no significant differences in postural control parameters during dual-task conditions between individuals with non-specific LBP and pain-free subjects. However, due to the limited number of available studies, significant publication bias, and considerable statistical heterogeneity, definitive conclusions cannot be drawn. Therefore, further research comprising high-quality studies with larger sample sizes is necessary to obtain conclusive results. Trial registration PROSPERO CRD42022359263.

Dry needling in a multimodal rehabilitation protocol following rotator cuff repair surgery: study protocol for a double-blinded randomized sham-controlled trial.

BACKGROUND: Rotator cuff tear (RCT) is one of the main causes of shoulder pain and dysfunction. Rotator cuff repair (RCR) is a common surgical procedure for the management of RCTs. Presence of myofascial trigger points (MTrP) as a result of surgical procedure can aggravate postoperative shoulder pain. The purpose of this protocol is to describe a randomized controlled trial design to evaluate the effect of implementing 4 sessions of myofascial trigger point dry needling (MTrP-DN) within a multimodal rehabilitation protocol following RCR surgery. METHODS: Forty-six participants aged 40-75 will be recruited having postoperative shoulder pain after RCR and meeting the inclusion criteria. Participants will be randomly divided into 2 groups: One group will undergo MTrP-DN, manual therapy, exercise therapy and electrotherapy and the other will receive sham dry needling (S-DN), manual therapy, exercise therapy and electrotherapy. This protocol will cover 4 weeks of intervention. The primary outcome measure will be the Numeric Pain Rating Scale (NPRS) for pain. Secondary outcome measures will be Shoulder Pain and Disability Index (SPDI), range of motion (ROM), strength and adverse events. DISCUSSION: This is the first study to investigate the use of 4 sessions of MTrP-DN in combination with a multimodal rehabilitation protocol for postoperative shoulder pain, restriction, weakness and dysfunction following RCR. The results of this study may help to determine the effect of MTrP-DN on various outcomes after RCR surgery. TRIAL REGISTRATION: This trial was registered at the ( https://www.irct.ir ), (IRCT20211005052677N1) on 19/2/2022.

Altered muscle strength and flexibility among a subgroup of women with chronic nonspecific low back pain: Cross-sectional case-control study.

OBJECTIVE: To compare muscle strength and flexibility among a subgroup of women with extension-related chronic nonspecific low back pain (CNLBP) with healthy controls. METHODS: In this case-control study, 32 subjects with and without extension-related CNLBP were tested (n = 16 in each group). Gluteal, abdominal, paravertebral, and hamstring strength, along with hip flexor flexibility and hamstring flexibility were compared between groups. Data were analyzed using the Mann-Whitney test (p < .007). RESULTS: The CNLBP subgroup displayed significantly lower strength of all muscles analyzed (p < .007), with the exception of gluteus medius. The flexibility of the hip flexors and hamstrings were not significantly reduced among the women with CNLBP (p > .007). DISCUSSION: The present study showed that alterations in muscle strength, but not flexibility, partly consistent with those previously hypothesized but not objectively reported, were present among a subgroup of women with extension-related CNLBP. These results may have implications for the selection of therapeutic exercises among this subgroup of people with CNLBP.

Relationship of Impaired Lumbar Spine-Hip Coordination During Sit To Stand and Stand To Sit with Functional Disability in Chronic Nonspecific Low Back Pain Patients.

Background: This study aimed to investigate the relationships of lumbar spine-hip discoordination during sit-to-stand (STD) and stand-to-sit (SIT) with pain and functional disability in chronic nonspecific low back pain (CNLBP) patients. Methods: A cross-sectional observational study was conducted in a biomechanics laboratory of the physical therapy department located at the School of Rehabilitation Sciences, Iran University of Medical Sciences (Tehran-Iran). A total of 16 CNLBP patients (men 9, female 7) aged 18-40 years (mean 31.48) were selected according to our eligibility criteria. Furthermore, ten reflective markers were placed on the spinous processes of T12 and S2, posterior and anterior superior iliac spines, greater trochanters, and lateral epicondyles. The patients were instructed to perform STD and SIT tasks at a preferred speed without using their hands. Relative phase angle was used as an indicator of coordination and was identified as the inverse tangent of angular displacement/angular velocity. Moreover, the relative phase angle between the lumbar spine and right and left hip joints was measured by subtracting the phase angle of the hip joint from the lumbar spine joint. The ratios of the total movements of the lumbar spine to the total movements of the right and left hip joints were also calculated in the sagittal plane. Finally, Pearson correlation coefficients (r) were utilized to assess the association between variables. Results: The results of this study indicated that kinematic parameters of the pain had statistically significant direct relationships with functional disability in CNLBP participants during STD and SIT with r values ranging from 0.57 (Pvalue = 0.021) to 0.85 (Pvalue<0.001) and 0.54 (Pvalue=0.053) to 0.82 (Pvalue<0.001), respectively. Conclusion: Out of the results of this study, it could be stated that pain and functional disability play a major role in lumber spine-hip discoordination, and it altered the movement ratio in CNLBP patients during STD and SIT. In clinical practice, clinicians should improve lumber spine-hip discoordination in patients with CNLBP since there is a linear relationship between kinematic parameters of the pain and functional disability in patients with CNLBP.

Effects of External Focus and Motor Control Training in Comparison with Motor Control Training Alone on Pain, Thickness of Trunk Muscles and Function of Patients with Recurrent Low Back Pain: A Single Blinded, Randomized Controlled Trial.

Background: Recurrent low back pain (RLBP) affects different structures in the lumbar spine. Exercise therapy is highly recommended as one of the first-line treatments. One crucial variable introduced to enhance RLBP is the external focus. The present study aimed to investigate the effects of external focus training on pain, the thickness of transverse abdominis (TrA), internal oblique (IO), external oblique (EO), and lumbar multifidus (LM) muscles, kinesiophobia, fear-avoidance beliefs, and disability of people with RLBP. Methods: This randomized-controlled trial consisted of 38 RLBP patients. Patients were randomly divided into two groups the treatment group (n=19) that received external focus training in addition to motor control training and the control group (n=19) that received motor control training alone. The primary outcome was pain intensity, and secondary outcomes were the thickness of TrA, IO, EO, LM muscles, kinesiophobia, fear-avoidance beliefs, and disability that were measured at the baseline and after 16 sessions of interventions. The interventions were performed three sessions weekly. Results: Reduction in pain intensity was more significant in the intervention group than in the control group (P<0.001, Cohen's d=-1.47). The thickness of TrA muscle in the contraction condition of the intervention group was significantly more on the left side (P<0.001, Cohen's d=1.05) than on the right side (P=0.03, Cohen's d=0.44). Other outcomes showed no significant differences. However, the Cohen's d effect size for the left IO (Cohen's d=0.57) and TKS (Cohen's d=-0.53) were moderate. Conclusion: In RLBP patients, external focus and motor control training could effectively reduce the pain. Although this intervention could increase the thickness of the TrA muscle of RLBP, it has no significant effect on the thickness of IO, EO, and LM muscles. In addition, the obtained results indicated that this intervention has no significant effect on kinesiophobia, fear-avoidance beliefs, and disability..

Does motor control training improve pain and function in adults with symptomatic lumbar disc herniation? A systematic review and meta-analysis of 861 subjects in 16 trials.

OBJECTIVE: To evaluate the effectiveness of motor control training (MCT) compared with other physical therapist-led interventions, minimal/no intervention or surgery in patients with symptomatic lumbar disc herniation (LDH). DESIGN: Systematic review and meta-analysis. DATA SOURCES: Eight databases and the ClinicalTrials.gov were searched from inception to April 2021. ELIGIBILITY CRITERIA: We included clinical trial studies with concurrent comparison groups which examined the effectiveness of MCT in patients with symptomatic LDH. Primary outcomes were pain intensity and functional status which were expressed as mean difference (MD) and standardised mean difference (SMD), respectively. RESULTS: We screened 6695 articles, of which 16 clinical trials (861 participants) were eligible. Fourteen studies were judged to have high risk of bias and two studies had some risk of bias. In patients who did not undergo surgery, MCT resulted in clinically meaningful pain reduction compared with other physical therapist-led interventions (ie, transcutaneous electrical nerve stimulation (TENS)) at short-term (MD -28.85, -40.04 to -17.66, n=69, studies=2). However, the robustness of the finding was poor. For functional status, a large and statistically significant treatment effect was found in favour of MCT compared with traditional/classic general exercises at long-term (SMD -0.83 to -1.35 to -0.31, n=63, studies=1) and other physical therapist-led interventions (ie, TENS) at short-term (SMD -1.43 to -2.41 to -0.46, n=69, studies=2). No studies compared MCT with surgery. In patients who had undergone surgery, large SMDs were seen. In favour of MCT compared with traditional/classic general exercises (SMD -0.95 to -1.32 to -0.58, n=124, studies=3), other physical therapist-led interventions (ie, conventional treatments; SMD -2.30 to -2.96 to -1.64, n=60, studies=1), and minimal intervention (SMD -1.34 to -1.87 to -0.81, n=68, studies=2) for functional improvement at short-term. The overall certainty of evidence was very low to low. CONCLUSION: At short-term, MCT improved pain and function compared with TENS in patients with symptomatic LDH who did not have surgery. MCT improved function compared with traditional/classic general exercises at long-term in patients who had undergone surgery. However, the results should be interpreted with caution because of the high risk of bias in the majority of studies. PROSPERO REGISTRATION NUMBER: CRD42016038166.

Spinopelvic alignment and low back pain after total hip arthroplasty: a scoping review.

OBJECTIVE: Spinopelvic alignment is increasingly considered as an essential factor for maintaining an energy-efficient posture in individuals with normal or pathological status. Although several previous studies have shown that changes in the sagittal spinopelvic alignment may occur in patients undergoing total hip arthroplasty (THA), no review of this area has been completed so far. Thus, the objective of this scoping review was to summarize the evidence investigating changes in spinopelvic alignment and low back pain (LBP) following THA. DATA SOURCES: We adhered to the established methodology for scoping reviews. Four electronic databases were systematically searched from inception-December 31, 2021. STUDY SELECTION: We selected prospective or retrospective observational or intervention studies that included patients with THA. DATA EXTRACTION: Data extraction and levels of evidence were independently performed using standardized checklists. DATA SYNTHESIS: A total of 45 papers were included in this scoping review, involving 5185 participants with THA. Pelvic tilt was the most common parameter measured in the eligible studies (n = 26). The results were not consistent across all studies; however, it was demonstrated that the distribution of pelvic tilt following THA had a range of 25° posterior to 20° anterior. Moreover, decreased sacral slope and lower pelvic incidence were associated with increased risk of dislocation in patients with THA. Lumbar spine scoliosis did not change significantly after THA in patients with bilateral hip osteoarthritis (5.50°(1.16°) vs. 3.73°(1.16°); P-value = 0.29). Finally, one study indicated that LBP improvement was not correlated with postoperative changes in spinopelvic alignment parameters. Several methodological issues were addressed in this study, including no sample size calculation and no type-I error adjustment for outcome multiplicity. CONCLUSIONS: Changes in spinopelvic alignment may occur after THA and may improve with time. Patients with a THA dislocation usually show abnormal spinopelvic alignment compared to patients without a THA dislocation. LBP usually improves markedly over time following THA.

Intra-examiner and inter-examiner reliability of rehabilitative ultrasound imaging for lumbar multifidus and anterolateral abdominal muscles in females with recurrent low back pain: an observational, cross-sectional study.

Aim: To examine the reliability of rehabilitative ultrasound imaging performed to measure the thickness of the transverse abdominis, internal oblique, external oblique, and lumbar multifidus muscles in females with recurrent low back pain. Material and methods: A sample of 15 women was recruited. Two independent examiners recorded the thickness of their deep abdominal and spinal muscles by rehabilitative ultrasound imaging. Imaging scans of the transverse abdominis, internal oblique, and external oblique muscles were performed in the supine position and in the midaxillary line, between the lower edge of the ribcage and the iliac crest. Imaging of the lumbar multifidus was done in the prone position and at the level of the L5/S1 zygapophyseal joints. Imaging scans were performed bilaterally in rest and contraction, three times by the first examiner (at baseline, after two hours, and one week later) and once by the second examiner. Results: Good to excellent within-session intra-rater (ICC = 0.76, 0.97), good to excellent between-session intra-rater reliability (ICC = 0.73, 0.93), and good to excellent inter-rater reliability (ICC = 0.73, 0.98) were obtained. Conclusions: The results showed that rehabilitative ultrasound imaging can be used as an excellent reliable instrument by one or two examiners to measure the thickness of the transverse abdominis, internal oblique, external oblique and lumbar multifidus muscles in females with recurrent low back pain.

Dry Needling for the Treatment of Tension-Type, Cervicogenic, or Migraine Headaches: A Systematic Review and Meta-Analysis.

OBJECTIVE: Dry needling is a treatment technique used by clinicians to relieve symptoms in patients with tension-type headache (TTH), cervicogenic headache (CGH), or migraine. This systematic review's main objective was to assess the effectiveness of dry needling on headache pain intensity and related disability in patients with TTH, CGH, or migraine. METHODS: Medline/PubMed, Scopus, Embase, PEDro, Web of Science, Ovid, Allied and Complementary Medicine Database/EBSCO, Cochrane Central Register of Controlled Clinical Trials, Google Scholar, and trial registries were searched until April 1, 2020, along with reference lists of eligible studies and related reviews. Randomized clinical trials or observational studies that compared the effectiveness of dry needling with any other interventions were eligible for inclusion. Three reviewers independently selected studies, extracted data, and assessed risk of bias. Random-effects meta-analyses were performed to produce pooled-effect estimates (Morris dppc2) and their respective CIs. RESULTS: Of 2715 identified studies, 11 randomized clinical trials were eligible for qualitative synthesis and 9 for meta-analysis. Only 4 trials were of high quality. Very low-quality evidence suggested that dry needling is not statistically better than other interventions for improving headache pain intensity in the short term in patients with TTH (SMD -1.27, 95% CI = -3.56 to 1.03, n = 230), CGH (SMD -0.41, 95% CI = -4.69 to 3.87, n = 104), or mixed headache (TTH and migraine; SMD 0.03; 95% CI = -0.42 to 0.48, n = 90). Dry needling provided significantly greater improvement in related disability in the short term in patients with TTH (SMD -2.28, 95% CI = -2.66 to -1.91, n = 160) and CGH (SMD -0.72, 95% CI = -1.09 to -0.34, n = 144). The synthesis of results showed that dry needling could significantly improve headache frequency, health-related quality of life, trigger point tenderness, and cervical range of motion in TTH and CGH. CONCLUSIONS: Dry needling produces similar effects to other interventions for short-term headache pain relief, whereas dry needling seems to be better than other therapies for improvement in related disability in the short term. IMPACT: Although further high-methodological quality studies are warranted to provide a more robust conclusion, our systematic review suggested that for every 1 or 2 patients with TTH treated by dry needling, 1 patient will likely show decreased headache intensity (number needed to treat [NNT] = 2; large effect) and improved related disability (NNT = 1; very large effect). In CGH, for every 3 or 4 patients treated by dry needling, 1 patient will likely exhibit decreased headache intensity (NNT = 4; small effect) and improved related disability (NNT = 3; medium effect).

The reliability and concurrent validity of a new iPhone® application for measuring active lumbar spine flexion and extension range of motion in patients with low back pain.

Objective: To investigate the reliability and validity of an iPhone® application (iHandy® Level) for measuring active lumbar flexion-extension range of motion (ROM) in chronic nonspecific low back pain (CNLBP) patients. Methods: Fifteen CNLBP patients were recruited. The participants stood in a relaxed position and the T12-L1 and S1-S2 spinal levels were identified through palpation and were marked on the skin. Two blinded examiners used a gravity-based inclinometer and the application in order to measure ROM. The instruments were lined up appropriately and the participants were asked to perform maximum lumbar flexion following by maximum extension. First, each examiner placed the instruments over the T12-L1 level and then over the S1-S2 level during the movements. In order to calculate flexion-extension ROM, the measurement which was obtained from T12-L1 was subtracted from S1-S2. Intraclass correlation coefficient (ICC) models (3, k) and (2, k) were used in order to determine the intrarater and inter-rater reliability, respectively. The Spearman's correlation coefficients (rs ) and Bland-Altman plots were used in order to examine the validity. Results: Fair-to-excellent intrarater (ICC = 0.39-0.89) and moderate-to-good inter-rater reliability (ICC = 0.55-0.77) were observed using the inclinometer. Moreover, poor-to-good intrarater (ICC = 0.30-70) and inter-rater (ICC = 0.13-0.70) reliability were found with the application. The Spearman's correlation coefficients demonstrated low-to-moderate associations between the measures of the two instruments (rs ≥ 0.22). The Bland-Altman plots indicated that there was a significant difference between the instruments for measuring flexion ROM. The difference was not significant for measuring extension ROM. Conclusion: The iHandy® Level application does not have sufficient validity for measuring active lumbar flexion ROM in CNLBP patients.

Effectiveness of Proprioceptive Neuromuscular Facilitation on Pain Intensity and Functional Disability in Patients with Low Back Pain: A Systematic Review and Meta-Analysis.

BACKGROUND: This systematic review aimed to investigate the effectiveness of proprioceptive neuromuscular facilitation (PNF) training on back pain intensity and functional disability in people with low back pain (LBP). METHODS: Totally, five electronic databases, including PubMed/Medline (NLM), Scopus, Google Scholar, PEDro, and Cochrane Central Register of Controlled Clinical Trials were searched up to October 31, 2018. Clinical trials with a concurrent comparison group (s) that compared the effectiveness of PNF training with any other physical therapy intervention were selected. Publication language was restricted to English language articles. Methodologic quality was assessed using the PEDro scale. The measures of continuous variables were summarized as Hedges's g. RESULTS: In total, 20 eligible trials were identified with 965 LBP patients. A large effect size (standardized mean difference [SMD]=-2.14, 95% confidence interval [CI]=3.23 to -1.05) and significant effect were observed favoring the use of PNF training to alleviate back pain intensity in patients with LBP. Moreover, large effect size and the significant result were also determined for the effect of PNF training on functional disability improvement (SMD=-2.68, 95% CI=-3.36 to -2.00) in population with LBP. A qualitative synthesis of results indicated that PNF training can significantly improve sagittal spine ROM. Statistical heterogeneity analysis showed that there was considerable statistical heterogeneity among the selected trials for the primary outcomes (I2 ≥ 86.6%). CONCLUSION: There is a low quality of evidence and weak strength of recommendation that PNF training has positive effects on back pain and disability in LBP people. Further high-quality randomized clinical trials regarding long-term effects of PNF training versus validated control intervention in a clinical setting is recommendable.