Spinal manipulation and mobilisation among infants, children, and adolescents: an international Delphi survey of expert physiotherapists.

OBJECTIVE: The aim of this study was to establish international consensus regarding the use of spinal manipulation and mobilisation among infants, children, and adolescents among expert international physiotherapists. METHODS: Twenty-six international expert physiotherapists in manual therapy and paediatrics voluntarily participated in a 3-Round Delphi survey to reach a consensus via direct electronic mail solicitation using Qualtrics®. Consensus was defined a-priori as ≥75% agreement on all items with the same ranking of agreement or disagreement. Round 1 identified impairments and conditions where spinal mobilisation and manipulation might be utilised. In Rounds 2 and 3, panelists agreed or disagreed using a 4-point Likert scale. RESULTS: Eleven physiotherapists from seven countries representing five continents completed all three Delphi rounds. Consensus regarding spinal mobilisation or manipulation included:Manipulation is not recommended: (1) for infants across all conditions, impairments, and spinal levels; and (2) for children and adolescents across most conditions and spinal levels.Manipulation may be recommended for adolescents to treat spinal region-specific joint hypomobility (thoracic, lumbar), and pain (thoracic).Mobilisation may be recommended for children and adolescents with hypomobility, joint pain, muscle/myofascial pain, or stiffness at all spinal levels. CONCLUSION: Consensus revealed spinal manipulation should not be performed on infants regardless of condition, impairment, or spinal level. Additionally, the panel agreed that manipulation may be recommended only for adolescents to treat joint pain and joint hypomobility (limited to thoracic and/or lumbar levels). Spinal mobilisation may be recommended for joint hypomobility, joint pain, muscle/myofascial pain, and muscle/myofascial stiffness at all spinal levels among children and adolescents.

Psychometric properties of clinician-reported and performance-based outcomes cited in a scoping review on spinal manipulation and mobilization for pediatric populations with diverse medical conditions: a systematic review.

INTRODUCTION: Risks and benefits of spinal manipulations and mobilization in pediatric populations are a concern to the public, policymakers, and international physiotherapy governing organizations. Clinical Outcome Assessments (COA) used in the literature on these topics are contentious. The aim of this systematic review was to establish the quality of clinician-reported and performance-based COAs identified by a scoping review on spinal manipulation and mobilization for pediatric populations across diverse medical conditions. METHOD AND ANALYSIS: Electronic databases, clinicaltrials.gov and Ebsco Open Dissertations were searched up to 21 October 2022. Qualitative synthesis was performed using Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines to select studies, perform data extraction, and assess risk of bias. Data synthesis used Grading of Recommendations, Assessment, Development and Evaluations (GRADE) to determine the certainty of the evidence and overall rating: sufficient (+), insufficient (-), inconsistent (±), or indeterminate (?). RESULTS: Four of 17 identified COAs (77 studies, 9653 participants) with supporting psychometric research were classified as:Performance-based outcome measures: AIMS - Alberta Infant Motor Scale (n = 51); or:Clinician-reported outcome measures: LATCH - Latch, Audible swallowing, Type of nipple, Comfort, Hold (n = 10),Cobb Angle (n = 15),Postural Assessment (n = 1).AIMS had an overall sufficient (+) rating with high certainty evidence, and LATCH had an overall sufficient (+) rating with moderate certainty of evidence. For the Cobb Angle and Postural Assessment, the overall rating was indeterminate (?) with low or very low certainty of evidence, respectively. CONCLUSION: The AIMS and LATCH had sufficient evidence to evaluate the efficacy of spinal manipulation and mobilization for certain pediatric medical conditions. Further validation studies are needed for other COAs.

Psychometric measurement properties of patient-reported and observer-reported outcome measures for spinal mobilisations and manipulation on paediatric subjects with diverse medical conditions: A systematic review.

INTRODUCTION: Reliable, valid, and responsive outcomes is foundational to address concerns about the risks and benefits of performing spinal manipulation and mobilization in pediatric populations. The aim of this systematic review was to synthesize evidence on measurement properties from cohort/case-control/cross-sectional/randomized studies on patient-reported (SQLI - Scoliosis Quality of Life Index; VAS-Visual Analog Scale; PAQLQ - Pediatric Asthma Quality of Life Questionnaire), observer-reported (Crying Diaries; ATEC - Autism Treatment Evaluation Checklist) and mixed (PedsQL - Pediatric Quality of Life Inventory) outcome measurements identified through a scoping review on manipulation and mobilization for pediatric populations with diverse medical conditions. METHOD AND ANALYSIS: Electronic databases, clinicaltrial.gov and Ebsco Open Dissertations were searched up to 21 October 202221 October 2022. Two independent reviewers selected studies, extracted data, and assessed risk of bias. Qualitative synthesis was performed using COSMIN and Cochrane GRADE methodology to establish the certainty of evidence and overall rating: sufficient (+), insufficient (-), inconsistent (±), indeterminate (?). RESULTS: Eighteen studies (2 SQLI for scoliosis; 1 VAS - perceived influence of exertion or movement/position on low back problems; 1 PAQLQ for asthma; 1 Crying Diaries for infantile colic; 8 ATEC for autism; 5 PedsQL for cerebral palsy/scoliosis/healthy) with 9653 participants were selected. ATEC and PedsQL had overall sufficient (+) measurement properties with moderate certainty evidence. PAQLQ had indeterminate measurement properties with moderate certainty evidence. Very low certainty of evidence identified measurement properties to be indeterminate (?) for SQLI, Crying Diaries, and VAS- perceived influence of exertion or movement/position on low back problems. CONCLUSION: ATEC for autism and PedsQL for asthma may be a suitable clinical outcome assessment (COA); additional validation studies on responsiveness and the minimal important difference are needed. Other COA require further validation.

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.

Spinal manipulation and mobilisation in the treatment of infants, children, and adolescents: a systematic scoping review.

PURPOSE: To i) identify and map the available evidence regarding effectiveness and harms of spinal manipulation and mobilisation for infants, children and adolescents with a broad range of conditions; ii) identify and synthesise policies, regulations, position statements and practice guidelines informing their clinical use. DESIGN: Systematic scoping review, utilising four electronic databases (PubMed, Embase, CINHAL and Cochrane) and grey literature from root to 4th February 2021. PARTICIPANTS: Infants, children and adolescents (birth to < 18 years) with any childhood disorder/condition. INTERVENTION: Spinal manipulation and mobilisation OUTCOME MEASURES: Outcomes relating to common childhood conditions were explored. METHOD: Two reviewers (A.P., L.L.) independently screened and selected studies, extracted key findings and assessed methodological quality of included papers using Joanna Briggs Institute Checklist for Systematic Reviews and Research Synthesis, Joanna Briggs Institute Critical Appraisal Checklist for Text and Opinion Papers, Mixed Methods Appraisal Tool and International Centre for Allied Health Evidence Guideline Quality Checklist. A descriptive synthesis of reported findings was undertaken using a levels of evidence approach. RESULTS: Eighty-seven articles were included. Methodological quality of articles varied. Spinal manipulation and mobilisation are being utilised clinically by a variety of health professionals to manage paediatric populations with adolescent idiopathic scoliosis (AIS), asthma, attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), back/neck pain, breastfeeding difficulties, cerebral palsy (CP), dysfunctional voiding, excessive crying, headaches, infantile colic, kinetic imbalances due to suboccipital strain (KISS), nocturnal enuresis, otitis media, torticollis and plagiocephaly. The descriptive synthesis revealed: no evidence to explicitly support the effectiveness of spinal manipulation or mobilisation for any condition in paediatric populations. Mild transient symptoms were commonly described in randomised controlled trials and on occasion, moderate-to-severe adverse events were reported in systematic reviews of randomised controlled trials and other lower quality studies. There was strong to very strong evidence for 'no significant effect' of spinal manipulation for managing asthma (pulmonary function), headache and nocturnal enuresis, and inconclusive or insufficient evidence for all other conditions explored. There is insufficient evidence to draw conclusions regarding spinal mobilisation to treat paediatric populations with any condition. CONCLUSION: Whilst some individual high-quality studies demonstrate positive results for some conditions, our descriptive synthesis of the collective findings does not provide support for spinal manipulation or mobilisation in paediatric populations for any condition. Increased reporting of adverse events is required to determine true risks. Randomised controlled trials examining effectiveness of spinal manipulation and mobilisation in paediatric populations are warranted.

Differences in balance control despite self-reported resolution of pregnancy-related pelvic girdle pain. A cross-sectional study.

BACKGROUND: Motor control patterns are altered when women with pregnancy-related pelvic girdle pain (PGP) experience pain. In low back pain, these adaptations can persist after recovery. OBJECTIVES: This study aimed to assess balance control in postpartum women with and without a history of PGP during pregnancy. DESIGN: Cross-sectional study. METHOD: Eighteen postpartum women who reported to be recovered from PGP, and twelve postpartum women without a history of PGP during pregnancy performed two clinical tests: the single leg stance and active straight leg raise test. Primary outcomes were ground reaction forces measured with a force platform. RESULTS: Multiple linear regression analyses showed smaller lateral displacement (ß = -11cm; 95%CI: 19 to -3; p = 0.008) and lower displacement velocity of the Centre of Pressure (COP) (Ratio of Geometric Means (RGM) 0.76; 95%CI: 0.59 to 0.99; p = 0.043) during single leg stance in the participants with a history of PGP compared to participants without a history of PGP. Push-off force (ß = -4.8 N; 95%CI: 22.0 to 12.5; p = 0.57) and asymmetry of push-off force (RGM 1.77; 95%CI: 0.62 to 5.04; p = 0.27) did not differ between groups. During the active straight leg raise test, no differences in lateral displacement (ß = 3 cm; 95%CI: 3 to 8; p = 0.30) and COP displacement velocity (RGM 1.03; 95%CI: 0.70 to 1.52; p = 0.87) were observed. CONCLUSIONS: Although the women with a history of PGP considered themselves recovered, their balance control during single leg stance was poorer compared to those without a history of PGP. No differences were found during the active straight leg raise test.

Reliability and validity of assessment methods available in primary care for bladder outlet obstruction and benign prostatic obstruction in men with lower urinary tract symptoms: a systematic review.

OBJECTIVES: To systematically review the literature regarding the reliability and validity of assessment methods available in primary care for bladder outlet obstruction or benign prostatic obstruction in men with lower urinary tract symptoms (LUTS). DESIGN: Systematic review with best evidence synthesis. SETTING: Primary care. PARTICIPANTS: Men with LUTS due to bladder outlet obstruction or benign prostatic obstruction. REVIEW METHODS: PubMed, Ebsco/CINAHL and Embase databases were searched for studies on the validity and reliability of assessment methods for bladder outlet obstruction and benign prostatic obstruction in primary care. Methodological quality was assessed with the COSMIN checklist. Studies with poor methodology were excluded from the best evidence synthesis. RESULTS: Of the 5644 studies identified, 61 were scored with the COSMIN checklist, 37 studies were included in the best evidence synthesis, 18 evaluated bladder outlet obstruction and 17 benign prostatic obstruction, 2 evaluated both. Overall, reliability was poorly evaluated. Transrectal and transabdominal ultrasound showed moderate to good validity to evaluate bladder outlet obstruction. Measured prostate volume with these ultrasound methods, to identify benign prostatic obstruction, showed moderate to good accuracy, supported by a moderate to high level of evidence. Uroflowmetry for bladder outlet obstruction showed poor to moderate diagnostic accuracy, depending on used cut-off values. Questionnaires were supported by high-quality evidence, although correlations and diagnostic accuracy were poor to moderate compared with criterion tests. Other methods were supported by low level evidence. CONCLUSION: Clinicians in primary care can incorporate transabdominal and transrectal ultrasound or uroflowmetry in the evaluation of men with LUTS but should not solely rely on these methods as the diagnostic accuracy is insufficient and reliability remains insufficiently researched. Low-to-moderate levels of evidence for most assessment methods were due to methodological shortcomings and inconsistency in the studies. This highlights the need for better study designs in this domain.

Longitudinal outcome evaluations of Interdisciplinary Multimodal Pain Treatment programmes for patients with chronic primary musculoskeletal pain: A systematic review and meta-analysis.

BACKGROUND AND OBJECTIVES: Although Interdisciplinary Multimodal Pain Treatment (IMPT) programmes share a biopsychosocial approach to increase the wellbeing of patients with chronic pain, substantial variation in content and duration have been reported. In addition, it is unclear to what extent any favourable health outcomes are maintained over time. Therefore, our first aim was to identify and analyse the change over time of patient-related outcome measures in cohorts of patients who participated in IMPT programmes. Our second aim was to acquire insight into the heterogeneity of IMPT programmes. DATABASES AND DATA TREATMENT: The study protocol was registered in Prospero under CRD42018076093. We searched Medline, Embase, PsycInfo and Cinahl from inception to May 2020. All study selection, data extraction and risk of bias assessments were independently performed by two researchers. Study cohorts were eligible if they included adult patients with chronic primary musculoskeletal pain for at least 3 months. We assessed the change over time, by calculating pre-post, post-follow-up and pre-follow-up contrasts for seven different patient-reported outcome domains. To explore the variability between the IMPT programmes, we summarized the patient characteristics and treatment programmes using the intervention description and replication checklist. RESULTS: The majority of the 72 included patient cohorts significantly improved during treatment. Importantly, this improvement was generally maintained at follow-up. In line with our expectations and with previous studies, we observed substantial methodological and statistical heterogeneity. CONCLUSIONS: This study shows that participation in an IMPT programme is associated with considerable improvements in wellbeing that are generally maintained at follow-up. The current study also found substantial heterogeneity in dose and treatment content, which suggests different viewpoints on how to optimally design an IMPT programme. SIGNIFICANCE: The current study provides insight into the different existing approaches regarding the dose and content of IMPT programs. This analysis contributes to an increased understanding of the various approaches by which a biopsychosocial perspective on chronic pain can be translated to treatment programs. Furthermore, despite theoretical and empirical assertions regarding the difficulty to maintain newly learned health behaviors over time, the longitudinal analysis of health outcomes did not find a relapse pattern for patients who participated in IMPT programs.

Interexaminer Agreement and Reliability of an Internationally Endorsed Screening Framework for Cervical Vascular Risks Following Manual Therapy and Exercise: The Go4Safe Project.

OBJECTIVE: Clinicians are recommended to use the clinical reasoning framework developed by the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) to provide guidance regarding assessment of the cervical spine and potential for cervical artery dysfunction prior to manual therapy and exercise. However, the interexaminer agreement and reliability of this framework is unknown. This study aimed to estimate the interexaminer agreement and reliability of the IFOMPT framework among physical therapists in primary care. METHODS: Ninety-six patients who consulted a physical therapist for neck pain or headache were included in the study. Each patient was tested independently by 2 physical therapists, from a group of 17 physical therapists (10 pairs) across The Netherlands. Patients and examiners were blinded to the test results. The overall interexaminer agreement, specific agreement per risk category (high-, intermediate-, and low-risk), and interexaminer reliability (weighted κ) were calculated. RESULTS: Overall agreement was 71% (specific agreement in high-risk category = 63%; specific agreement in intermediate-risk category = 38%; specific agreement in low-risk category = 84%). Overall reliability was moderate (weighted κ = 0.39; 95% CI = 0.21-0.57) and varied considerably between pairs of physical therapists (κ = 0.14-1.00). CONCLUSION: The IFOMPT framework showed an insufficient interexaminer agreement and fair interexaminer reliability among physical therapists when screening the increased risks for vascular complications following manual therapy and exercise prior to treatment. IMPACT: The IFOMPT framework contributes to the safety of manual therapy and exercise. It is widely adopted in clinical practice and educational programs, but the measurement properties are unknown. This project describes the agreement and reliability of the IFOMPT framework.

Exploring the Feasibility of Relapse Prevention Strategies in Interdisciplinary Multimodal Pain Therapy Programs: Qualitative Study.

BACKGROUND: Although interdisciplinary multimodal pain treatment (IMPT) programs are widely regarded as treatment of choice for patients with chronic pain, there are signs that many patients are unable to maintain their treatment gains in the long term. To facilitate the maintenance of positive treatment outcomes over time, we developed two relapse prevention strategies. OBJECTIVE: The main objective of this study was to explore the feasibility of these strategies within the context of IMPT programs. METHODS: We performed a feasibility study using 3 workbook prototypes containing either one or both strategies. For a period of 6 months, the workbooks were made available in two IMPT facilities. Qualitative data were collected through a focus group and semistructured interviews. We performed a thematic analysis using a deductive approach with (1) applicability to the treatment program, (2) acceptability of the workbook content, and (3) form, as predefined themes. RESULTS: The final dataset consisted of transcripts from a focus group with health care providers and 11 telephone interviews and 2 additional in-depth interviews with patients. In general, the intervention was perceived as useful, easy to use, and in line with the treatment program. The data also include suggestions to further improve the use of both strategies, including more specific implementation guidelines, revised goal-setting procedure, and development of a mobile health version. However, several factors, including a high dropout rate and small sample size, impact the external validity of our findings. CONCLUSIONS: This study should be regarded as a first step in the process of transforming the prototype workbook into an effective intervention for clinical practice. Although these initial results indicate a favorable evaluation of both behavior regulation strategies within the workbook, this study encountered multiple barriers regarding implementation and data collection that limit the generalizability of these results. Future research efforts should specifically address the fidelity of HCPs and patients and should include clear procedures regarding recruitment and use of both relapse prevention strategies during treatment.

Validity of Clinical Measurement Instruments Assessing Scapular Function: Insufficient Evidence to Recommend Any Instrument for Assessing Scapular Posture, Movement, and Dysfunction-A Systematic Review.

OBJECTIVE: To determine the construct validity, criterion validity, and responsiveness of measurement instruments evaluating scapular function. DESIGN: Systematic review of measurement properties. LITERATURE SEARCH: The MEDLINE, Embase, CINAHL, and SPORTDiscus databases were systematically searched from inception until March 2019. STUDY SELECTION CRITERIA: Studies published in Dutch, English, or German were included when they evaluated at least 1 of the measurement properties of interest. No restrictions were made regarding participants' health status. DATA SYNTHESIS: Two reviewers independently evaluated study quality using the COSMIN checklist and extracted and analyzed data. Quality of evidence was graded by measurement property for each distinctive type of measurement. RESULTS: Thirty-one measurement instruments in 14 studies were categorized into instruments to measure scapular posture and movement, and to assess scapular dyskinesis. Quality of evidence was at most moderate for 4 instruments with respect to criterion validity. Of these, criterion validity for instruments measuring scapular protraction/retraction posture and rotation angles up to 120° of thoracohumeral elevation was sufficient. Criterion validity for instruments measuring asymmetrical scapular posture, range of motion, and the lateral scapular slide test was insufficient. Quality of evidence for measurement properties of all other instruments was graded lower. CONCLUSION: There is currently insufficient evidence to recommend any instrument for the clinical examination of scapular function. Measurement instruments to assess scapular dyskinesis are prone to misinterpretation and should therefore not be used as such. J Orthop Sports Phys Ther 2020;50(11):632-641. doi:10.2519/jospt.2020.9265.

Physical Treatments Reduce Pain in Children with Tension-Type Headache: A Systematic Review and Meta-Analysis.

AIMS: To assess the effectiveness of a variety of physical treatments in the management of tension-type headache (TTH) in children. METHODS: This review is reported in accordance with the PRISMA guidelines and was registered in the PROSPERO database (CRD42014015290). Randomized and nonrandomized controlled trials that examined the effects of all treatments with a physical component in the management of TTH in children and compared these treatments to a placebo intervention, no intervention, or a controlled comparison intervention were included. The Physiotherapy Evidence Database (PEDro) criteria for bias assessment and the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) Working Group criteria were used to assess the quality of the body of evidence. The outcome measures were pain, functioning, and quality of life. Only RCTs were included in the meta-analyses. RESULTS: An initial search produced 10,464 published articles. Of these, 17 were relevant trials, including 1,815 participants. The overall GRADE rating of the included studies was moderate, and 11 of the 17 studies could be used in the meta-analyses. The effectiveness of physical treatments in terms of a reduction of pain of 50% or more showed a risk ratio (RR) of 2.37 (95% CI: 1.69 to 3.33). Relaxation training was the most evaluated intervention and proved to be significantly effective (RR: 3.00 [95% CI: 1.94 to 4.63]). In children having TTH combined with temporomandibular disorders, occlusal appliances were effective (RR: 2.58 [95% CI: 1.37 to 4.85]). CONCLUSION: This review supports the use of physical treatments to reduce pain in children with TTH.

Mobile Health App (AGRIPPA) to Prevent Relapse After Successful Interdisciplinary Treatment for Patients With Chronic Pain: Protocol for a Randomized Controlled Trial.

BACKGROUND: To facilitate adherence to adaptive pain management behaviors after interdisciplinary multimodal pain treatment, we developed a mobile health app (AGRIPPA app) that contains two behavior regulation strategies. OBJECTIVE: The aims of this project are (1) to test the effectiveness of the AGRIPPA app on pain disability; (2) to determine the cost-effectiveness; and (3) to explore the levels of engagement and usability of app users. METHODS: We will perform a multicenter randomized controlled trial with two parallel groups. Within the 12-month inclusion period, we plan to recruit 158 adult patients with chronic pain during the initial stage of their interdisciplinary treatment program in one of the 6 participating centers. Participants will be randomly assigned to the standard treatment condition or to the enhanced treatment condition in which they will receive the AGRIPPA app. Patients will be monitored from the start of the treatment program until 12 months posttreatment. In our primary analysis, we will evaluate the difference over time of pain-related disability between the two conditions. Other outcome measures will include health-related quality of life, illness perceptions, pain self-efficacy, app system usage data, productivity loss, and health care expenses. RESULTS: The study was approved by the local Medical Research Ethics Committee in October 2019. As of March 20, 2020, we have recruited 88 patients. CONCLUSIONS: This study will be the first step in systematically evaluating the effectiveness and efficiency of the AGRIPPA app. After 3 years of development and feasibility testing, this formal evaluation will help determine to what extent the app will influence the maintenance of treatment gains over time. The outcomes of this trial will guide future decisions regarding uptake in clinical practice. TRIAL REGISTRATION: Netherlands Trial Register NL8076; https://www.trialregister.nl/trial/8076. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/18632.

Treatment based classification systems for patients with non-specific neck pain. A systematic review.

OBJECTIVE: We aimed to identify published classification systems with a targeted treatment approach (treatment-based classification systems (TBCSs)) for patients with non-specific neck pain, and assess their quality and effectiveness. DESIGN: Systematic review. DATA SOURCES: MEDLINE, CINAHL, EMBASE, PEDro and the grey literature were systematically searched from inception to December 2019. STUDY APPRAISAL AND SYNTHESIS: The main selection criterium was a TBCS for patients with non-specific neck pain with physiotherapeutic interventions. For data extraction of descriptive data and quality assessment we used the framework developed by Buchbinder et al. We considered as score of ≤3 as low quality, a score between 3 and 5 as moderate quality and a score ≥5 as good quality. To assess the risk of bias of studies concerning the effectiveness of TBCSs (only randomized clinical trials (RCTs) were included) we used the PEDro scale. We considered a score of ≥ six points on this scale as low risk of bias. RESULTS: Out of 7664 initial references we included 13 studies. The overall quality of the TBCSs ranged from low to moderate. We found two RCTs, both with low risk of bias, evaluating the effectiveness of two TBCSs compared to alternative treatments. The results showed that both TBCSs were not superior to alternative treatments. CONCLUSION: Existing TBCSs are, at best, of moderate quality. In addition, TBCSs were not shown to be more effective than alternatives. Therefore using these TBCSs in daily practice is not recommended.

Completeness of the description of manipulation and mobilisation techniques in randomized controlled trials in neck pain; A review using the TiDieR checklist.

STUDY DESIGN: A secondary analysis of a systematic review. BACKGROUND: Manipulations or mobilizations are commonly used interventions in patients with mechanical neck pain. The treatment effects have often been studied in randomized controlled trials (RCT) which are generally considered the gold standard in evaluating the treatment effects, mainly due to its high internal validity. External validity is defined as the extent to which the effects can be generalised to clinical practice. An important prerequisite for this is that interventions used in clinical trials can be replicated in clinical practice. It can be questioned if interventions utilized in randomized controlled trials can be translated into clinical practice. OBJECTIVES: The overall aim of this study is to examine whether the quality of the description of manipulation and mobilization interventions is sufficient for to replication of these interventions in clinical practice. METHODS: A comprehensive literature search was performed. Two independent researchers used the Template for Intervention Description and Replication (TIDieR) which is a 12-item checklist for describing the completeness of the interventions. RESULTS: Sixty-seven articles were included that used manipulation and/or mobilization interventions for patients with mechanical neck pain. None of the articles describe the intervention e.g. all the items on the TIDieR list. Considering item 8 (a-f) of the TIDieR checklist only one article described the used techniques completely. CONCLUSION: Manipulation or a mobilization interventions are poorly reported in RCTs, which jeopardize the external validity of RCTs, making it difficult for clinicians and researchers to replicate these interventions.

Fear-avoidance beliefs are associated with a high fat content in the erector spinae: a 1.5 tesla magnetic resonance imaging study.

Background: Intramuscular adipose tissue (IMAT) is a feature of degenerative muscle composition and is a common feature in populations with chronic low back pain (CLBP). Avoidance behavior is a possible cause of morphological muscle composition due to disuse of the paraspinal muscles. Therefore it is of clinical interest to determine the association between fear-avoidance beliefs and IMAT of the paraspinal muscles in populations with CLBP. Methods: In this cross-sectional study, we examined twenty-four adults, featuring a mean age of 48.63 years (SD ± 14.73), with CLBP. Axial T2-weighted Magnetic Resonance Imaging (MRI) images were selected on the same level as the intervertebral disc of segments L4-L5 and L5-S1. After determine the region of interest, the amount of IMAT was measured by an automatic-threshold method to distinguish fat from muscle tissue. Fear-avoidance beliefs were measured with the Fear-Avoidance Beliefs Questionnaire, with regard to Physical Activity (FABQ-PA). Bivariate correlation and multiple regression analysis were used to determine the association between IMAT of the paraspinal muscles and fear-avoidance beliefs. Results: There is a significant bivariate association between the FABQ-PA and ES IMAT (r = 0.484, P = 0.017), but not for LMM (r = 0.228, P = 0.284). The association between the FABQ-PA and ES IMAT remained moderate after adjusting for covariates (ß = 0.381, P = 0.028). Conclusion: Fear-avoidance beliefs are moderately associated with ES IMAT and poorly associated with LMM IMAT in a population with CLBP. Results should be interpreted with caution due to a small and selected study population.

Clinical reasoning in unimodal interventions in patients with non-specific neck pain in daily physiotherapy practice, a Delphi study.

BACKGROUND: Neck pain is the fourth major cause of disability worldwide but sufficient evidence regarding treatment is not available. This study is a first exploratory attempt to gain insight into and consensus on the clinical reasoning of experts in patients with non-specific neck pain. OBJECTIVE: First, we aimed to inventory expert opinions regarding the indication for physiotherapy when, other than neck pain, no positive signs and symptoms and no positive diagnostic tests are present. Secondly, we aimed to determine which measurement instruments are being used and when they are used to support and objectify the clinical reasoning process. Finally, we wanted to establish consensus among experts regarding the use of unimodal interventions in patients with non-specific neck pain, i.e. their sequential linear clinical reasoning. STUDY DESIGN: A Delphi study. METHODS: A Web-based Delphi study was conducted. Fifteen experts (teachers and researchers) participated. RESULTS: Pain alone was deemed not be an indication for physiotherapy treatment. PROMs are mainly used for evaluative purposes and physical tests for diagnostic and evaluative purposes. Eighteen different variants of sequential linear clinical reasoning were investigated within our Delphi study. Only 6 out of 18 variants of sequential linear clinical reasoning reached more than 50% consensus. CONCLUSION: Pain alone is not an indication for physiotherapy. Insight has been obtained into which measurement instruments are used and when they are used. Consensus about sequential linear lines of clinical reasoning was poor.

The clinical reasoning process in randomized clinical trials with patients with non-specific neck pain is incomplete: A systematic review.

OBJECTIVE: Primarily to evaluate the completeness of the description of the clinical reasoning process in RCTs with patients with non-specific neck pain with an argued or diagnosed cause i.e. an impairment or activity limitation. Secondly, to determine the association between the completeness of the clinical reasoning process and the degree of risk of bias. DATA SOURCES: Pubmed, Cinahl and PEDro were systematically searched from inception to July 2016. STUDY SELECTION: RCTs (n = 122) with patients with non-specific neck pain receiving physiotherapy treatment published in English were included. DATA EXTRACTION: Data extraction included study characteristics and important features of the clinical reasoning process based on the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II)]. DATA SYNTHESIS: Thirty-seven studies (30%) had a complete clinical reasoning process of which 8 (6%) had a 'diagnosed cause' and 29 (24%) had an 'argued cause'. The Spearmans rho association between the extent of the clinical reasoning process and the risk of bias was -0.2. CONCLUSIONS: In the majority of studies (70%) the described clinical reasoning process was incomplete. A very small proportion (6%) had a 'diagnosed cause'. Therefore, a better methodological quality does not necessarily imply a better described clinical reasoning process.