Emiel van Trijffel

Spinal mechanical load as a risk factor for low back pain: a systematic review of prospective cohort studies.

Study Design. Systematic review. Objective. To review and critically evaluate the past literature for spinal mechanical load as risk factor for low back pain (LBP). Summary of Background Data. LBP is a costly health problem worldwide, and treatments are often unsuccessful. Therefore, prevention might be more beneficial in the management of LBP. With respect to prevention, the knowledge of risk factors is essential. From the literature, exposures involving spinal mechanical load is frequently discussed as a potential risk factor for LBP. For a better understanding of this risk factor, we performed a systematic review of the literature. Additionally, we evaluated exposures of spinal mechanical load for possible dose-response relations with LBP. Methods. We systematically searched Medline, Embase, PsycINFO, and CINAHL databases (without language restriction) for full-report publications of prospective cohort studies, evaluating spinal mechanical load during work and/or leisure time activities as risk factors for nonspecific LBP in patients (>18 years of age) free of LBP at baseline. We assessed the methodology of each article and extracted information on population, response rates, characteristics of LBP, exposures, and estimated association(s), using standardized forms. We performed a best evidence synthesis of the obtained information. Results. In total, 18 studies were eligible (all rated as high methodologic quality) reporting on 24,315 subjects. Conclusion. We found strong evidence that leisure time sport or exercises, sitting, and prolonged standing/walking are not associated with LBP. Evidence for associations in leisure time activities (e.g., do-it-yourself home repair, gardening), whole-body vibration, nursing tasks, heavy physical work, and working with ones trunk in a bent and/or twisted position and LBP was conflicting. We found no studies, thus no evidence, for an association between sleeping or sporting on a professional level and LBP.

Inter-rater reliability for measurement of passive physiological range of motion of upper extremity joints is better if instruments are used: a systematic review

QUESTION What is the inter-rater reliability for measurements of passive physiological or accessory movements in upper extremity joints? DESIGN Systematic review of studies of inter-rater reliability. PARTICIPANTS Individuals with and without upper extremity disorders. OUTCOME MEASURES Range of motion and end-feel using methods feasible in clinical practice. RESULTS Twenty-one studies were included of which 11 demonstrated acceptable inter-rater reliability. Two studies satisfied all criteria for internal validity while reporting almost perfect reliability. Overall, the methodological quality of studies was poor. ICC ranged from 0.26 (95% CI -0.01 to 0.69) for measuring the physiological range of shoulder internal rotation using vision to 0.99 (95% CI 0.98 to 1.0) for the physiological range of finger and thumb flexion/extension using a goniometer. Measurements of physiological range of motion using instruments were more reliable than using vision. Measurements of physiological range of motion were also more reliable than measurements of end-feel or of accessory range of motion. CONCLUSIONS Inter-rater reliability for the measurement of passive movements of upper extremity joints varies with the method of measurement. In order to make reliable decisions about joint restrictions in clinical practice, we recommend that clinicians measure passive physiological range of motion using goniometers or inclinometers.

Inter-rater reliability for measurement of passive physiological movements in lower extremity joints is generally low: a systematic review

QUESTION What is the inter-rater reliability for measurements of passive physiological or accessory movements in lower extremity joints? DESIGN Systematic review of studies of inter-rater reliability. PARTICIPANTS Individuals with and without lower extremity disorders. OUTCOME MEASURES Range of motion and end-feel using methods feasible in daily practice. RESULTS 17 studies were included of which 5 demonstrated acceptable inter-rater reliability. Reliability of measurements of physiological range of motion ranged from Kappa -0.02 for measuring knee extension using a goniometer to ICC 0.97 for measuring knee flexion using vision. Measuring range of knee flexion consistently yielded acceptable reliability using either vision or instruments. Measurements of end-feel were unreliable for all hip and knee movements. Two studies satisfied all criteria for internal validity while reporting acceptable reliability for measuring physiological range of knee flexion and extension. Overall,however, methodological quality of included studies was poor. CONCLUSION Inter-rater reliability of measurement of passive movements in lower extremity joints is generally low. We provide specific recommendations for the conduct and reporting of future research. Awaiting new evidence, clinicians should be cautious when relying on results from measurements of passive movements in joints for making decisions about patients with lower extremity disorders.

Efficacy of passive extension mobilization in addition to exercise in the osteoarthritic knee: An observational parallel-group study

STUDY DESIGN Pretest post-test observational parallel-group design. OBJECTIVES To evaluate the efficacy of passive knee extension mobilization in addition to exercise therapy on extension range of motion (ROM) in patients with osteoarthritis (OA) of the knee. Secondary objectives were to determine changes in pain and functional abilities. BACKGROUND Patients with knee OA complain of pain, limited range of motion, and impaired activities. Efficacy of mobilization as a treatment option next to exercises has not been studied rigorously. METHODS AND MEASURES Thirty-four participants with persistent knee pain, a positive radiography for knee OA, and a passive extension deficit were included. Seventeen participants (mean age±SD, 59.8±6.1years) were treated with an exercise protocol and were additionally given manual mobilizations to improve passive extension ROM. The other group (mean age±SD, 61.5±7.3years) with equal characteristics was treated with an identical exercise therapy protocol only. Prior to participation, detailed ROM measurements were recorded next to muscle function tests, pain (VAS), six-minute walking tests (6MWTs), a condition-specific questionnaire, and the patient-specific function scale (PSFS). Participants in both groups completed 16 treatment sessions each. RESULTS Passive mobilization significantly improved extension ROM in the intervention group (5.2 versus 8.6°, p=.017). The manually mobilized group also had better physical capacities as assessed by 6MWT, less pain, and a lower PSFS score. CONCLUSION A combined protocol including exercise therapy and passive mobilization was beneficial for patients with OA of the knee complaining of pain, decreased extension ROM and decreased limited abilities. LEVEL OF EVIDENCE Therapy, 2b.

Manual Physical Therapists’ Use of Biopsychosocial History Taking in the Management of Patients with Back or Neck Pain in Clinical Practice

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

Evaluative Measurement Properties of the Patient-Specific Functional Scale for Primary Shoulder Complaints in Physical Therapy Practice

STUDY DESIGN Clinical measurement, longitudinal. OBJECTIVES To assess the test-retest reliability, construct validity, and responsiveness of the Patient-Specific Functional Scale (PSFS) in patients with a primary shoulder complaint. BACKGROUND Health measurement outcomes have become increasingly important for evaluating treatment. Patient-specific questionnaires are useful tools for determining treatment goals and evaluating treatment in individual patients. These questionnaires have not yet been validated in patients with nonspecific shoulder pain. METHODS Patients completed the PSFS, the numeric pain rating scale, and the Shoulder Pain and Disability Index at baseline, and after 1 week and 4 to 6 weeks. Test-retest reliability was determined using intraclass correlation coefficients. To assess convergent validity, change scores of the PSFS were correlated with the numeric pain rating scale and Shoulder Pain and Disability Index change scores. Responsiveness was assessed by calculating the area under the curve, the minimal clinically important change, and minimal detectable change, using the global rating of change as an external criterion. RESULTS Fifty patients (37 men; mean age, 47.7 years) participated in the study. Reliability was high (intraclass correlation coefficient = 0.87; 95% confidence interval [CI]: 0.72, 0.94). The correlations between the change scores of the PSFS and those of the Shoulder Pain and Disability Index and numeric pain rating scale were 0.45 (95% CI: 0.17, 0.80) and 0.55 (95% CI: 0.29, 0.73), respectively. The area under the curve for the PSFS was 0.67 (95% CI: 0.51, 0.83). The minimal detectable change and minimal clinically important change were 0.97 and 1.29 points, respectively. CONCLUSION These results suggest that the PSFS is a reliable, valid, and responsive instrument that can be used as an evaluative instrument in patients with a primary shoulder complaint.

Indicating spinal joint mobilisations or manipulations in patients with neck or low-back pain: protocol of an inter-examiner reliability study among manual therapists

BackgroundManual spinal joint mobilisations and manipulations are widely used treatments in patients with neck and low-back pain. Inter-examiner reliability of passive intervertebral motion assessment of the cervical and lumbar spine, perceived as important for indicating these interventions, is poor within a univariable approach. The diagnostic process as a whole in daily practice in manual therapy has a multivariable character, however, in which the use and interpretation of passive intervertebral motion assessment depend on earlier results from the diagnostic process. To date, the inter-examiner reliability among manual therapists of a multivariable diagnostic decision-making process in patients with neck or low-back pain is unknown.MethodsThis study will be conducted as a repeated-measures design in which 14 pairs of manual therapists independently examine a consecutive series of a planned total of 165 patients with neck or low-back pain presenting in primary care physiotherapy. Primary outcome measure is therapists’ decision about whether or not manual spinal joint mobilisations or manipulations, or both, are indicated in each patient, alone or as part of a multimodal treatment. Therapists will largely be free to conduct the full diagnostic process based on their formulated examination objectives. For each pair of therapists, 2×2 tables will be constructed and reliability for the dichotomous decision will be expressed using Cohen’s kappa. In addition, observed agreement, prevalence of positive decisions, prevalence index, bias index, and specific agreement in positive and negative decisions will be calculated. Univariable logistic regression analysis of concordant decisions will be performed to explore which demographic, professional, or clinical factors contributed to reliability.DiscussionThis study will provide an estimate of the inter-examiner reliability among manual therapists of indicating spinal joint mobilisations or manipulations in patients with neck or low-back pain based on a multivariable diagnostic reasoning and decision-making process, as opposed to reliability of individual tests. As such, it is proposed as an initial step toward the development of an alternative approach to current classification systems and prediction rules for identifying those patients with spinal disorders that may show a better response to manual therapy which can be incorporated in randomised clinical trials. Potential methodological limitations of this study are discussed.

“Clinical biopsychosocial physiotherapy assessment of patients with chronic pain: The first step in pain neuroscience education” by Amarins J Wijma et al., 2016

Department of Manual Therapy, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium; Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands; Pain in Motion International Research Group, Vrije Universiteit Brussel, Brussels, Belgium; Department of Public Health and Research, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands; Methodological Health-Skilled Institute, Beuningen, The Netherlands; Department of Physiotherapy, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland; Neurocognitive Laboratory, Centre for Modern Interdisciplinary Technologies, Nicolaus Copernicus University, Toruń, Poland; Department of Nursing Sciences, Faculty of Health, University Witten/Herdecke, Witten, Germany; SOMT Educational Institute for Musculoskeletal Therapy, Amersfoort, The Netherlands; Department Medical Psychology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands

Risk reduction of serious complications from manual therapy: Are we reducing the risk?: Correspondence to: International Framework for Examination of the Cervical Region for Potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy Intervention by A. Rushton et al.

Please cite this article in press as: Scholten-P the risk?, Manual Therapy (2014), http://dx We would like to congratulate Rushton et al. for the study entitled “International Framework for Examination of the Cervical Region for Potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy Intervention” as published in this journal. We praise the initiative of conducting a clinical reasoning framework for best practice for the examination of the cervical spine region. It is important to aid clinicians in their clinical reasoning process to providence effective and safe manual therapy. As serious conditions such as cervical artery dissection (CAD) or upper cervical instability may mimic musculoskeletal dysfunction in the early stages, these should be recognized in the patient’s history and clinical assessment. We agree with the authors that the manual therapist cannot rely on the results of one test to draw firm conclusions regarding the presence or risk of CAD. The authors developed a clinically reasoned understanding of the patient’s presentation, including a risk benefit analysis. Their study provides important information for clinicians to reconsider before applying manual therapy interventions. However, there are some topics specifically related to the identification of a person at risk for CAD that we would like to debate. The strength of possible risk factors for neuro-vascular pathology such as CAD is largely unknown (Arnold and Bousser, 2005; Kerry et al., 2008). It is important here to realize that the limited available data concern risk factors for CAD in general, and not for CAD as a possible consequence of cervical manipulation. In addition, a number of cardiovascular risk factors are associated with atherosclerosis which is an intermediate outcome for CAD while the relationship between atherosclerosis and CAD is not yet clear (Rubinstein et al., 2005; Kerry et al., 2008). Furthermore, when the association of cardiovascular risk factors (hypertension, smoking status, high cholesterol) with CAD is critically examined, there seems to be a protective effect instead of a risk effect (Thomas et al., 2011). Therefore, the question arises whether we are measuring the right risk factors. The measurement of hypertension

Few promising multivariable prognostic models exist for recovery of people with non-specific neck pain in musculoskeletal primary care: a systematic review

QUESTION Which multivariable prognostic model(s) for recovery in people with neck pain can be used in primary care? DESIGN Systematic review of studies evaluating multivariable prognostic models. PARTICIPANTS People with non-specific neck pain presenting at primary care. DETERMINANTS Baseline characteristics of the participants. OUTCOME MEASURES Recovery measured as pain reduction, reduced disability, or perceived recovery at short-term and long-term follow-up. RESULTS Fifty-three publications were included, of which 46 were derivation studies, four were validation studies, and three concerned combined studies. The derivation studies presented 99 multivariate models, all of which were at high risk of bias. Three externally validated models generated usable models in low risk of bias studies. One predicted recovery in non-specific neck pain, while two concerned participants with whiplash-associated disorders (WAD). Discriminative ability of the non-specific neck pain model was area under the curve (AUC) 0.65 (95% CI 0.59 to 0.71). For the first WAD model, discriminative ability was AUC 0.85 (95% CI 0.79 to 0.91). For the second WAD model, specificity was 99% (95% CI 93 to 100) and sensitivity was 44% (95% CI 23 to 65) for prediction of non-recovery, and 86% (95% CI 73 to 94) and 55% (95% CI 41 to 69) for prediction of recovery, respectively. Initial Neck Disability Index scores and age were identified as consistent prognostic factors in these three models. CONCLUSION Three externally validated models were found to be usable and to have low risk of bias, of which two showed acceptable discriminative properties for predicting recovery in people with neck pain. These three models need further validation and evaluation of their clinical impact before their broad clinical use can be advocated. REGISTRATION PROSPERO CRD42016042204. [Wingbermühle RW, van Trijffel E, Nelissen PM, Koes B, Verhagen AP (2018) Few promising multivariable prognostic models exist for recovery of people with non-specific neck pain in musculoskeletal primary care: a systematic review. Journal of Physiotherapy 64: 16-23].