To what degree patient-reported symptoms of central sensitization, kinesiophobia, disability, sleep, and life quality associated with 24-h heart rate variability and actigraphy measurements?

OBJECTIVES: Chronic musculoskeletal pain is associated with decreased parasympathetic and increased sympathetic activity in the autonomic nervous system. The objective of this study was to determine the associations between objective measures of heart rate variability (a measure of autonomic nervous system function), actigraphy (a measure of activity and sleep quality), respiration rates, and subjective patient-reported outcome measures (PROMs) of central sensitization, kinesiophobia, disability, the effect of pain on sleep, and life quality. METHODS: Thirty-eight study subjects were divided into two subgroups, including low symptoms of central sensitization (n = 18) and high symptoms of central sensitization (n = 20), based on patient-reported scores on the Central Sensitization Inventory (CSI). Heart rate variability (HRV) and actigraphy measurements were carried out simultaneously in 24 h measurement during wakefulness and sleep. RESULTS: A decrease in HRV during the first 2 h of sleep was stronger in the low CSI subgroup compared to the high CSI subgroup. Otherwise, all other HRV and actigraphy parameters and subjective measures of central sensitization, disability, kinesiophobia, the effect of pain on sleep, and quality of life showed only little associations. DISCUSSION: The high CSI subgroup reported significantly more severe symptoms of disability, kinesiophobia, sleep, and quality of life compared to the low CSI subgroup. However, there were only small and nonsignificant trend in increased sympathetic nervous system activity and poorer sleep quality on the high central sensitization subgroup. Moreover, very little differences in respiratory rates were found between the groups.

Which aspects facilitate the adherence of patients with low back pain to physiotherapy? A Delphi study.

BACKGROUND: The effectiveness of physiotherapy to reduce low back pain depends on patient adherence to treatment. Facilitators and barriers to patient adherence are multifactorial and include patient and therapist-related factors. This Delphi study aimed to identify an expert consensus on aspects facilitating the adherence of patients with back pain to physiotherapy. METHOD: International experts were invited to participate in a three-round standard Delphi survey. The survey contained 49 items (32 original and 17 suggested by experts) which were rated on 5-point Likert scales. The items were assigned to six domains. The consensus level was defined as 60%. RESULTS: Of 38 invited experts, 15 followed the invitation and completed all three rounds. A positive consensus was reached on 62% of the 49 proposed items to facilitate adherence. The highest consensus was achieved in the domains "Influence of biopsychosocial factors" (89%) and "Influence of cooperation between physiotherapists and patients" (79%). Additional important domains were the "Influence of competencies of physiotherapists" (71%) and "Interdisciplinary congruence" (78%). "Administration aspects" and the "Use of digital tools" did not reach expert consensus. CONCLUSIONS: Biopsychosocial factors, therapeutic skills, and patient-physiotherapist collaboration should be considered in physiotherapy practice to facilitate adherence in patients with LBP. Future studies should prospectively evaluate the effectiveness of individual or combined identified aspects for their influence on patient adherence in longitudinal study designs.

The association between mechanical temporal summation, state anxiety at baseline, and persistent low back pain: a 12-month prospective cohort study.

BACKGROUND: Persons with acute low back pain (LBP) have a good prognosis for regaining function, while pain often persists. Neurobiological and psychosocial factors are recognized to amplify pain responses, as reported for central sensitization. This study investigated the combination of mechanical temporal summation (TS) chosen to characterize central sensitization and state anxiety representing a psychological factor and their association with persistent pain. METHODS: A longitudinal prospective cohort study including 176 participants aged between 18 and 65 with acute LBP was performed. The following independent variables were analyzed at baseline: The mechanical TS at the lower back, of whom the Wind-up ratio (WUR) was calculated, and the state anxiety level measured with the State and Trait Anxiety Inventory (STAI-S). The outcome pain intensity was assessed at baseline and 2,3,6 and 12 months after the onset of acute LBP with the Numeric Rating Scale 0-10 (NRS). Linear mixed models (LMM) were used to analyze the association of the independent variables with pain intensity over time. RESULTS: The mean baseline WUR was 1.3 (SD 0.6) for the right and 1.5 (SD 1.0) for the left side. STAI-S revealed a mean score of 43.1 (SD 5.2). Pain intensity was, on average, 5.4 points (SD 1.6) on the NRS and decreased over one year to a mean of 2.2 (SD 2.4). After one year, 56% of the participants still experienced pain. The LMM revealed a considerable variation, as seen in large confidence intervals. Therefore, associations of the independent variables (WUR and STAI-S) with the course of the outcome pain intensity over one year were not established. CONCLUSION: This investigation did not reveal an association of mechanical TS and state anxiety at baseline with pain intensity during the one-year measurement period. Pain persistence, mediated by central sensitization, is a complex mechanism that single mechanical TS and state anxiety cannot capture.

Protocol of identical exercise programs with and without specific breathing techniques for the treatment of chronic non-specific low back pain: randomized feasibility trial with two-month follow-up.

BACKGROUND: Chronic low back pain (CLBP) is a leading cause of disability globally. Exercise therapies are one of the commonly prescribed treatment options for CLBP. The specific exercise therapies for CLBP most commonly target movement dysfunction, but seldom brain-based pain modulation. Exercise therapies with specific breathing techniques (SBTs) have been shown to influence and enhance brain-based structural and functional pain modulation. AIMS AND OBJECTIVES: To assess the feasibility of the SBTs protocol, eligibility criteria, randomization, and dropout rates. To quantify the changes in patient outcome measures and choose the most relevant measure for larger-scale study. To quantify self-adherence levels to home exercise and monitor and record possible pain medication and other treatment modality usage, and adverse events during exercise. DESIGN: A parallel randomised analyst-blinded feasibility trial with two-month follow-up. OUTCOME MEASURES: Feasibility related to aims and objectives. Multiple pain- and health-related patient-reported outcome measures of pain intensity, disability, central sensitization, anxiety, kinesiophobia, catastrophising, self-efficacy, sleep quality, quality of life, and health and well-being status. Exercise adherence, pain medication and other treatment modality usage, and possible adverse events related to exercises will be monitored and recorded. METHODS: Thirty participants will be randomized to movement control exercise with SBTs (15 subjects in experimental group) or movement control exercise without SBTs (15 subjects in control group) in private chiropractic practice setting with two-month follow-up. Trial registration number; NCT05268822. DISCUSSION: The clinical difference in effectiveness between practically identical exercise programs in uniform study settings with or without SBTs has not been studied before. This study aims to inform feasibility and help determine whether progression to a full-scale trial is worthwhile.

A Multi-component Intervention (NEXpro) Reduces Neck Pain-Related Work Productivity Loss: A Randomized Controlled Trial Among Swiss Office Workers.

Purpose Neck pain is common among office workers and leads to work productivity loss. This study aimed to investigate the effect of a multi-component intervention on neck pain-related work productivity loss among Swiss office workers. Methods Office workers, aged 18-65 years, and without serious neck-related health problems were recruited from two organisations for our stepped-wedge cluster randomized controlled trial. The 12-week multi-component intervention included neck exercises, health-promotion information, and workplace ergonomics. The primary outcome of neck pain-related work productivity loss was measured using the Work Productivity and Activity Impairment Questionnaire and expressed as percentages of working time. In addition, we reported the weekly monetary value of neck pain-related work productivity loss. Data was analysed on an intention-to-treat basis using a generalized linear mixed-effects model. Results Data from 120 participants were analysed with 517 observations. At baseline, the mean age was 43.7 years (SD 9.8 years), 71.7% of participants were female (N = 86), about 80% (N = 95) reported mild to moderate neck pain, and neck pain-related work productivity loss was 12% of working time (absenteeism: 1.2%, presenteeism: 10.8%). We found an effect of our multi-component intervention on neck pain-related work productivity loss, with a marginal predicted mean reduction of 2.8 percentage points (b = -0.27; 95% CI: -0.54 to -0.001, p = 0.049). Weekly saved costs were Swiss Francs 27.40 per participant. Conclusions: Our study provides evidence for the effectiveness of a multi-component intervention to reduce neck pain-related work productivity loss with implications for employers, employees, and policy makers.Trial Registration ClinicalTrials.gov, NCT04169646. Registered 15 November 2019-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04169646 .

[Low Back Pain - Value of Prevention and Physiotherapy?] / Rückenschmerzen.

Low Back Pain - Value of Prevention and Physiotherapy? Abstract. Physiotherapy plays a central role in the prevention and treatment of lumbar back pain. There is no clear evidence in science on the effectiveness of individual preventive measures; however, movement and active training as central elements are indispensable here. In the treatment of lumbar back pain, however, the picture is clear: while passive measures such as heat or cold applications as well as ultrasound and electrotherapy should no longer be used alone due to the lack of evidence, the combination of active exercises and patient education shows promising success. If these are supplemented by sporadically applied manual therapy methods, the result is an evidence-based management of both acute and chronic lumbar back pain. One example of a successful implementation of current evidence for the treatment of back pain is GLA:D®, which is also in use in Switzerland since 2021.

Effect of Graded Sensorimotor Retraining on Pain Intensity in Patients With Chronic Low Back Pain: A Randomized Clinical Trial.

Importance: The effects of altered neural processing, defined as altering neural networks responsible for perceptions of pain and function, on chronic pain remains unclear. Objective: To estimate the effect of a graded sensorimotor retraining intervention (RESOLVE) on pain intensity in people with chronic low back pain. Design, Setting, and Participants: This parallel, 2-group, randomized clinical trial recruited participants with chronic (>3 months) nonspecific low back pain from primary care and community settings. A total of 276 adults were randomized (in a 1:1 ratio) to the intervention or sham procedure and attention control groups delivered by clinicians at a medical research institute in Sydney, Australia. The first participant was randomized on December 10, 2015, and the last was randomized on July 25, 2019. Follow-up was completed on February 3, 2020. Interventions: Participants randomized to the intervention group (n = 138) were asked to participate in 12 weekly clinical sessions and home training designed to educate them about and assist them with movement and physical activity while experiencing lower back pain. Participants randomized to the control group (n = 138) were asked to participate in 12 weekly clinical sessions and home training that required similar time as the intervention but did not focus on education, movement, and physical activity. The control group included sham laser and shortwave diathermy applied to the back and sham noninvasive brain stimulation. Main Outcomes and Measures: The primary outcome was pain intensity at 18 weeks, measured on an 11-point numerical rating scale (range, 0 [no pain] to 10 [worst pain imaginable]) for which the between-group minimum clinically important difference is 1.0 point. Results: Among 276 randomized patients (mean [SD] age, 46 [14.3] years; 138 [50%] women), 261 (95%) completed follow-up at 18 weeks. The mean pain intensity was 5.6 at baseline and 3.1 at 18 weeks in the intervention group and 5.8 at baseline and 4.0 at 18 weeks in the control group, with an estimated between-group mean difference at 18 weeks of -1.0 point ([95% CI, -1.5 to -0.4]; P = .001), favoring the intervention group. Conclusions and Relevance: In this randomized clinical trial conducted at a single center among patients with chronic low back pain, graded sensorimotor retraining, compared with a sham procedure and attention control, significantly improved pain intensity at 18 weeks. The improvements in pain intensity were small, and further research is needed to understand the generalizability of the findings. Trial Registration: ANZCTR Identifier: ACTRN12615000610538.

Cross-cultural adaptation and validation of the Finnish version of the central sensitization inventory and its relationship with dizziness and postural control.

BACKGROUND: Central Sensitization (CS) involves dysfunction in neurophysiological mechanisms that increase neuronal responses to both noxious and non-noxious stimuli in the central nervous system. The Central Sensitization Inventory (CSI) is considered the leading patient-reported outcome measure for assessing CS-related symptoms. The aim of this study was to translate and cross-culturally adapt the CSI into Finnish (CSI-FI) and to evaluate its psychometric properties. METHODS: Translation and cross-cultural validation of the CSI was conducted according to established guidelines. The validation sample was 229 subjects, including 42 pain free controls and 187 subjects with chronic musculoskeletal pain. The CSI-FI was evaluated for internal consistency, test-retest reliability, exploratory factor analysis with maximum likelihood extraction, relationship with subject-reported outcome measures [Tampa scale of kinesiophobia (TSK), the Depression scale (DEPS), 5-level EQ-5D version (EQ-5 L-5D), Roland-Morris Disability Questionnaire (RMDQ), and Pain and Sleep Questionnaire Three-Item Index (PSQ-3)], pain history, subjective symptoms of dizziness, and CS-related diagnoses on CSI part B. Furthermore, we studied the ability of the CSI-FI to distinguish pain free controls, subjects with chronic pain in a single body area, and subjects with multisite chronic pain. In addition, we studied the relationship of CSI-FI scores with postural control on a force plate. RESULTS: The CSI-FI demonstrated good internal consistency (0.884) and excellent test-retest reliability (0.933) with a 7 ± 1 day gap between test administrations. Exploratory factor analysis with maximum likelihood extraction yielded a one factor solution. Fair to good correlations were found between the CSI-FI and the TSK, DEPS, EQ-5 L-5D, RMDQ, and PSQ-3. Subjective symptoms of dizziness correlated better with CSI-FI scores than any of the CS-related diagnoses on CSI part B. Total CSI-FI scores successfully distinguished between pain free controls, subjects with chronic pain in a single body area, and subjects with multisite chronic pain. The multisite pain group reported significantly more dizziness symptoms than the other two groups. Force plate measurements showed no relationship between postural control and CSI-FI scores. CONCLUSION: The CSI-FI translation was successfully cross-culturally adapted and validated into Finnish. CSI-FI psychometric properties and scores were all in acceptable levels and in line with previous CSI validations. The CSI-FI appears to be a valid and reliable instrument for assessing CS-related symptomology in Finnish-speaking populations.

No evidence for an effect of working from home on neck pain and neck disability among Swiss office workers: Short-term impact of COVID-19.

PURPOSE: The aim of this study was to investigate the effect of working from home on neck pain (NP) among office workers during the COVID-19 pandemic. METHODS: Participants from two Swiss organisations, aged 18-65 years and working from home during the lockdown (n = 69) were included. Baseline data collected in January 2020 before the lockdown (office work) were compared with follow-up data in April 2020 during lockdown (working from home). The primary outcome of NP was assessed with a measure of intensity and disability. Secondary outcomes were quality of workstation ergonomics, number of work breaks, and time spent working at the computer. Two linear mixed effects models were fitted to the data to estimate the change in NP. RESULTS: No clinically relevant change in the average NP intensity and neck disability was found between measurement time points. Each working hour at the computer increased NP intensity by 0.36 points (95% CI: 0.09 to 0.62) indicating strong evidence. No such effect was found for neck disability. Each work break taken reduced neck disability by 2.30 points (95% CI: - 4.18 to - 0.42, evidence). No such effect was found for NP intensity. There is very strong evidence that workstation ergonomics was poorer at home. CONCLUSION: The number of work breaks and hours spent at the computer seem to have a greater effect on NP than the place of work (office, at home), measurement time point (before COVID-19, during lockdown) or the workstation ergonomics. Further research should investigate the effect of social and psychological factors. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04169646. Registered 15 November 2019-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04169646 .

Prediction and trend of tactile acuity, pain and disability in acute LBP: a six-month prospective cohort study.

BACKGROUND: Chronic back pain is known to be associated with altered tactile acuity. Tactile acuity is measured using the Two-Point Discrimination (TPD) test in both clinical and research settings. In subjects with chronic low back pain, the TPD threshold (TPDT) is increased and is associated with persistent pain. It remains unknown, however, whether TPDT is also altered in cases of clinical acute pain, or whether it could be used as a predictor of future pain and disability at an early stage of LBP. The main objective of this study was to investigate the predictive value of baseline TPDT for pain and disability at 3 and 6 months after the onset of acute LBP. The TPDT in acute low back pain (LBP) and the development of TPDT over 6 months has also been assessed. METHODS: LBP participants (n = 124) with acute LBP (< 4 weeks) were included. Subjects were examined within 4 weeks of pain onset and followed-up after 3 and 6 months of pain onset. Horizontal and vertical TPDTs of the lower back were collected. Linear mixed models were subsequently used to evaluate the association of TPDT with pain and disability over time. RESULTS: The vertical TPDT showed a mean (SD) of 4.9 cm (1.6) and the horizontal TPDT a mean (SD) of 6.0 cm (1.5) at baseline. The vertical TPDT altered from baseline up to 6 months from 4.9 to 4.6 cm and the horizontal TPDT from 6.0 to 5.4 cm. The association between the TPDT and the Oswestry Disability Index (ODI) after 6 months was moderate. Linear mixed models revealed no association between TPDT, pain and disability over the progression of LBP. CONCLUSION: TPDTs appear to be raised in subjects with acute LBP. However, our study revealed no predictive capability of the TPDT for disability and pain. No comparisons are possible in the absence of similar studies, indicating the need for further research is in this area.

Correction to: On-site multi-component intervention to improve productivity and reduce the economic and personal burden of neck pain in Swiss office-workers (NEXpro): protocol for a cluster-randomized controlled trial.

An amendment to this paper has been published and can be accessed via the original article.

On-site multi-component intervention to improve productivity and reduce the economic and personal burden of neck pain in Swiss office-workers (NEXpro): protocol for a cluster-randomized controlled trial.

BACKGROUND: Non-specific neck pain and headache are major economic and individual burden in office-workers. The aim of this study is to investigate the effect of a multi-component intervention combining workstation ergonomics, health promotion information group workshops, neck exercises, and an app to enhance intervention adherence to assess possible reductions in the economic and individual burden of prevalent and incident neck pain and headache in office workers. METHODS/DESIGN: This study is a stepped wedge cluster-randomized controlled trial. Eligible participants will be any office-worker aged 18-65 years from two Swiss organisations in the Cantons of Zurich and Aargau, working more than 25 h a week in predominantly sedentary office work and without serious health conditions of the neck. One hundred twenty voluntary participants will be assigned to 15 clusters which, at randomly selected time steps, switch from the control to the intervention group. The intervention will last 12 weeks and comprises workstation ergonomics, health promotion information group workshops, neck exercises and an adherence app. The primary outcome will be health-related productivity losses (presenteeism, absenteeism) using the Work Productivity and Activity Impairment Questionnaire. Secondary outcomes are neck disability and pain (measured by the Neck Disability Index, and muscle strength and endurance measures), headache (measured by the short-form headache impact test), psychosocial outcomes (e.g. job-stress index, Fear-Avoidance Beliefs Questionnaire), workplace outcomes (e.g. workstation ergonomics), adherence to intervention, and additional measures (e.g. care-seeking). Measurements will take place at baseline, 4 months, 8 months, and 12 months after commencement. Data will be analysed on an intention to treat basis and per protocol. Primary and secondary outcomes will be examined using linear mixed-effects models. DISCUSSION: To the authors' knowledge, this study is the first that investigates the impact of a multi-component intervention combining current evidence of effective interventions with an adherence app to assess the potential benefits on productivity, prevalent and incident neck pain, and headache. The outcomes will impact the individual, their workplace, as well as private and public policy by offering evidence for treatment and prevention of neck pain and headache in office-workers. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04169646. Registered 15 November 2019 - Retrospectively registered.

Effective therapy to reduce edema after total knee arthroplasty Multi-layer compression therapy or standard therapy with cool pack - a randomized controlled pilot trial / Lymphologischer Kompressionsverband oder Standardbehandlung mit Kältepackung zur Schwellungsreduktion nach Knietotalprothesen-Operation. Eine randomisiert-kontrollierte, einfach verblindete Pilotstudie

Background: After total knee arthroplasty (TKA) efficient control and reduction of postoperative edema is of great importance. Aim: The aim of this pilot study (EKNZ 2014 ­ 225 DRKS00006271) was to investigate the effectiveness of multi-layer compression therapy (MLCT) to reduce edema in the early period after surgery compared to the standard treatment with Cool Pack. Methods: In this randomized controlled pilot trial, sixteen patients after TKA were randomized into an intervention group (IG) or a control group (CG). Circumferential measurements were used to assess edema. Secondary outcomes were range of motion (ROM), pain (numeric rating scale, NRS) and function as measured with the fast Self Paced Walking Test (fSPWT). Results: Clinically relevant differences in edema reduction between the two groups were found in the early postoperative period and at the six weeks follow up. Six days postoperatively the group time interaction (IE) in favor of the IG were −3.8 cm (95 % CI: −5.1; −2.4) when measured 10 cm proximal to the joint space and −2.7 cm (CI: −4.1; −1.3) when measured 5 cm proximally. We further observed differences in secondary outcomes in favor of the CG. Six days postoperatively the IE for knee flexion was ­8.3 ° (CI: −22.0; 5.4) and for the fSPWT it was 12.8 seconds (CI: −16.4; 41.3). Six weeks postoperatively these differences diminished. Conclusions: The findings suggest that MLCT could be an alternative treatment to reduce postoperative edema in patients after total knee arthroplasty. Eventually possible negative effects on early knee flexion and function must be considered.

Intertester and intratester reliability of movement control tests on the hip for patients with hip osteoarthritis.

BACKGROUND: Hip joint complaints are a problem associated with increasing age and impair the mobility of a large section of the elderly population. Reliable and valid tests are necessary for a thorough investigation of a joint. A fundamental function of the hip joint is movement control and a test of this function forms a part of the standard examination. Until now there have been few scientific studies which specifically investigate the reliability of measurement tests of movement control of the hip joint. The aim of this study was to examine the intratester and intertester reliability of the movement control tests of the hip joint which are in use in current clinical practice. METHODS: Sixteen participants with hip joint complaints and 14 without hip joint impairment were recruited. All participants performed five active movement control tests for the hip joint and were video filmed whilst performing these tests. These films formed the basis for the evaluation and were assessed by two independent physiotherapists. For the intertester and intratester reliability calculations specially set weighted kappa values and the calculated percentages were used. RESULTS: The intertester reliability of the five examined movement control tests of the hip joint showed good to almost perfect values (weighted kappa (wk) = 0.56-0.87). The intratester reliability of the more experienced evaluator A was better in regards to the less experienced evaluator B (average wk = 0.62 vs 0.38). CONCLUSION: The visual evaluation of movement control tests of the hip joint is especially reliable when carried out by an experienced evaluator. 4 out of 5 tests also showed good results for intertester reliability and support their use in clinical practice.

Correlation between lumbar dysfunction and fat infiltration in lumbar multifidus muscles in patients with low back pain.

BACKGROUND: Lumbar multifidus muscles (LMM) are important for spinal motion and stability. Low back pain (LBP) is often associated with fat infiltration in LMM. An increasing fat infiltration of LMM may lead to lumbar dysfunction. The purpose of this study was to investigate whether there is a correlation between the severity of lumbar dysfunction and the severity of fat infiltration of LMM. METHODS: In a cross-sectional study, 42 patients with acute or chronic LBP were recruited. Their MRI findings were visually rated and graded using three criteria for fat accumulation in LMM: Grade 0 (0-10%), Grade 1 (10-50%) and Grade 2 (>50%). Lumbar sagittal range of motion, dynamic upright and seated posture control, sagittal movement control, body awareness and self-assessed functional disability were measured to determine the patients' low back dysfunction. RESULTS: The main result of this study was that increased severity of fat infiltration in the lumbar multifidus muscles correlated significantly with decreased range of motion of lumbar flexion (p = 0.032). No significant correlation was found between the severity of fat infiltration in LMM and impaired movement control, posture control, body awareness or self-assessed functional disability. CONCLUSION: This is the first study investigating the relationship between the severity of fat infiltration in LMM and the severity of lumbar dysfunction. The results of this study will contribute to the understanding of the mechanisms leading to fat infiltration of LMM and its relation to spinal function. Further studies should investigate whether specific treatment strategies are effective in reducing or preventing fat infiltration of LMM.

Comparison of clinical vignettes and standardized patients as measures of physiotherapists' activity and work recommendations in patients with non-specific low back pain.

OBJECTIVE: To validate clinical vignettes as a measure of physiotherapists' activity and work recommendations given to patients with non-specific low back pain. DESIGN: Validation study comparing two methods for measuring aspects of health providers' clinical management: Clinical vignettes and unannounced visits of standardized patients (the gold standard). SETTING: Outpatient physiotherapy clinics. SUBJECTS: Physiotherapists (N = 59) who consented to see unannounced standardized patients in their clinical practice. MAIN MEASURES: Clinical vignettes were used to initially measure physiotherapists' self-reported activity and work recommendations. Subsequently, actors performing as standardized patients visited physiotherapists in their clinical practice and rated the advice given by the physiotherapist regarding activity and work. A total of 23 standardized patients were randomly scheduled to physiotherapists. Physiotherapists were blinded towards the standardized patients. To test whether standardized patients were detected, physiotherapists reported if they suspected that they had treated an actor. RESULTS: The 23 standardized patients visited 22 different physiotherapists. Physiotherapists detected 12 out of 23 unannounced standardized patients (detection rate: 52%). The estimated agreement between the two measures was poor, for both activity and work recommendations (weighted kappa coefficients: 0.29 resp. -0.21). CONCLUSION: The poor concordance between clinical vignettes and standardized patients indicates the potentially limited validity of clinical vignettes as a measure of health providers' activity and work recommendations in low back pain practice.

Sub-classification based specific movement control exercises are superior to general exercise in sub-acute low back pain when both are combined with manual therapy: A randomized controlled trial.

BACKGROUND: Clinical guidelines recommend research on sub-groups of patients with low back pain (LBP) but, to date, only few studies have been published. One sub-group of LBP is movement control impairment (MCI) and clinical tests to identify this sub-group have been developed. Also, exercises appear to be beneficial for the management of chronic LBP (CLBP), but very little is known about the management of sub-acute LBP. METHODS: A randomized controlled trial (RCT) was conducted to compare the effects of general exercise versus specific movement control exercise (SMCE) on disability and function in patients with MCI within the recurrent sub-acute LBP group. Participants having a MCI attended five treatment sessions of either specific or general exercises. In both groups a short application of manual therapy was applied. The primary outcome was disability, assessed by the Roland-Morris Disability Questionnaire (RMDQ). The measurements were taken at baseline, immediately after the three months intervention and at twelve-month follow-up. RESULTS: Seventy patients met the inclusion criteria and were eligible for the trial. Measurements of 61 patients (SMCE n = 30 and general exercise n = 31) were completed at twelve months. (Drop-out rate 12.9 %). Patients in both groups reported significantly less disability (RMDQ) at twelve months follow-up. However, the mean change on the RMDQ between baseline and the twelve-month measurement showed statistically significantly superior improvement for the SMCE group -1.9 points (-3.9 to -0.5) 95 % (CI). The result did not reach the clinically significant three point difference. There was no statistical difference between the groups measured with Oswestry Disability Index (ODI). CONCLUSION: For subjects with non-specific recurrent sub-acute LBP and MCI an intervention consisting of SMCE and manual therapy combined may be superior to general exercise combined with manual therapy. TRIAL REGISTRATION: The study protocol registration number is ISRCTN48684087 . It was registered retrospectively 18th Jan 2012.

Short-term effect on pain and function of neurophysiological education and sensorimotor retraining compared to usual physiotherapy in patients with chronic or recurrent non-specific low back pain, a pilot randomized controlled trial.

BACKGROUND: Non-specific chronic low back pain (NSCLBP) is a major health problem. Identification of subgroups and appropriate treatment regimen was proposed as a key priority by the Cochrane Back Review Group. We developed a multimodal treatment (MMT) for patients with moderate to severe disability and medium risk of poor outcome. MMT includes a) neurophysiological education on the perception of pain to decrease self-limitation due to catastrophizing believes about the nature of NSCLBP, b) sensory training of the lower trunk because these patients predominantly show poor sensory acuity of the trunk, and c) motor training to regain definite movement control of the trunk. A pilot study was conducted to investigate the feasibility of MMT, prior to a larger RCT, with focus on patients' adherence and the evaluation of short-term effects on pain and disability of MMT when compared to usual physiotherapy. METHOD: We conducted a randomised controlled trial (RCT) in a primary care physiotherapy centre in Switzerland. Outcome assessment was 12 weeks after baseline. Patients with NSCLBP, considerable disability (five or more points on the Roland and Morris Disability Questionnaire (RMDQ) and medium or high risk of poor outcome on the Keele Start Back Tool (KSBT) were randomly allocated to either MMT or usual physiotherapy treatment (UPT) by an independent research assistant. Treatment included up to 16 sessions over 8 to 12 weeks. Both groups were given additional home training of 10 to 30 minutes to be performed five times per week. Adherence to treatment was evaluated in order to assess the feasibility of the treatment. Assessments were conducted by an independent blinded person. The primary outcome was pain (NRS 0-10) and the secondary outcome was disability (RMDQ). Between-group effects with Student's t-test or the Mann-Whitney U test and the standardized mean difference of the primary outcome were calculated. RESULTS: Twenty-eight patients (46% male, mean age 41.5 years (SD 10.6)) were randomized to MMT (n = 14) or UPT (n = 14). Patients' adherence to treatment was >80% in both groups. Pain reduction (NRS; [95% CI]) was 2.14 [1.0 to 3.5] in the MMT and 0.69 [-2.0 to 2.5.] in the UPT. The between-group difference was 1.45 [0.0 to 4.0] (p = 0.03), representing a moderate effect size of 0.66 [-0.1 to 1.5]. Reduction in disability on the RMDQ was 6.71 [4.2 to 9.3] in MMT and 4.69 [1.9 to 7.4] in UPT, with a non-significant between-group difference of 2.02 [-1.5 to 5.6] (p = 0.25). The required sample size for a RCT with six months follow-up was estimated at 170 patients. CONCLUSIONS: MMT was found to be feasible and to significantly reduce pain in the short term when compared with UPT. A future RCT with a six-month follow-up would require approximately 170 patients. TRIAL REGISTRATION: Current Controlled Trials ISRCTN66262199. Registered 8 January 2014.

Reliability of movement control tests on the cervical spine.

BACKGROUND: Movement control impairment reduces active control of movement. Patients with this might form an important subgroup among patients with mechanical cervical pain. Diagnosis is based on the observation of active movement tests. Although widely used clinically, few studies have been performed to determine the reliability of a test battery. The aim of this study was to determine the inter-tester reliability of movement control impairment [MCI] tests on the cervical spine. METHODS: Forty-five subjects (31 patients with neck pain, 14 healthy controls) were videotaped while performing a standardized test battery consisting of 13 tests of active movement control. Using observation, two experienced physiotherapists independently rated test performances as correct or incorrect. One of them was blinded to all other patient information and both to each other. Kappa coefficients and 95% confidence intervals [CI] for inter-tester results were calculated. RESULTS: The kappa values for inter-tester reliability ranged in from 0.47-1.0 of the 13 tests, 2 demonstrated perfect reliability (k = 1.0), 4 excellent (k 0.81-0.99), 6 substantial (k 0.61-0.8) and 1 good (k 0.41-0.6). CONCLUSIONS: The physiotherapists were able reliably rate the majority the tests in this series of motor control tasks. There have been studies performed describing the assessment and treatment of movement control impairment problems and low back pain. However, no study has involved the assessment of the cervical dysfunction subgroup. This study presents a reliable test battery, for clinical use, to perform more specific examination of this subgroup.

Head-eye movement control tests in patients with chronic neck pain; inter-observer reliability and discriminative validity.

BACKGROUND: Head-eye movement control deficit is an identified problem in patients with chronic neck pain, particularly in cases of whiplash associated disorders (WAD). To date, there is no evidence concerning the reliability and validity of visually assessed active head-eye movement control tests. Therefore, the objectives of the present cross-sectional study were, a) to develop a test battery; and b) to investigate inter-observer reliability and discriminative validity in patients with chronic neck pain compared to healthy controls. METHODS: The study was conducted at two physiotherapy clinics in Switzerland. Ethics Committee approval was obtained. Ten active head-eye coordination tests, on 23 patients with chronic neck pain and associated symptoms and 19 healthy controls, were videotaped. The tests included eye movements in the neutral head position and 45° relative neck rotation, gaze stability and sequential head-eye movements. All tests were performed in the sitting and standing positions. Two blinded physiotherapists independently rated the randomized videos. Performance was rated as "negative", "moderately positive" or "clearly positive". Weighted kappa (wK) and 95% confidence intervals (CI) were calculated to investigate inter-observer reliability. Good reliability was defined as wK >0.5 with a lower boundary of 95% CI >0.2. Odds ratios (to define cut-off points) and the distribution of the classificator, numbers of positive tests, were calculated. RESULTS: Three out of ten tests showed "excellent" (wK 0.82 to 0.86), five out of ten tests showed "substantial" (wK 0.69 to 0.79) and two out of ten tests showed "moderate" (wK 0.54 to 0.59) reliability. Results were comparable in the sitting and standing positions. On average, three out of five tests were rated positive in patients and one out of five tests was rated positive in healthy controls. An odds ratio of 13.3 to 18.6 was obtained using ≥2/5 tests as a cut-off point. CONCLUSION: Visual assessment by physiotherapists of head-eye movement control tests is reliable. The test battery is able to discriminate between patients with chronic neck pain and healthy controls. There were no differences in performance between the sitting and standing positions. The test battery can therefore be reduced to five tests. Further research is needed to identify the test-retest stability and responsiveness.