Nathan Hutting

Diagnostic accuracy of premanipulative vertebrobasilar insufficiency tests: A systematic review

STUDY DESIGN A systematic review of diagnostic accuracy studies. OBJECTIVE To evaluate the diagnostic accuracy of the premanipulative vertebrobasilar insufficiency (VBI) tests. SUMMARY OF BACKGROUND DATA The aim of premanipulative vertebrobasilar testing is to evaluate the adequacy of blood supply to the brain, by compressing the vertebral artery and examining for the onset of signs and symptoms of cerebrovascular ischemia. Although clinicians consider pre-manipulative testing important before applying spinal manipulations, the diagnostic accuracy has not been systematically reviewed. METHODS A search was made in PUBMED, CINAHL and EMBASE databases from their date of inception until 2nd May 2012. Studies were included if they compared a VBI test with a reference test, and sensitivity and specificity were reported or could be calculated. The methodological quality of the studies was evaluated using QUADAS. Agreement between reviewers was calculated and expressed as a percentage and quantified by kappa statistics. RESULTS Of the 1677 potential citations only 4 studies were included, all of questionable quality. Sensitivity was low and ranged from 0 to 57%, specificity from 67 to 100%, positive predictive value from 0% to 100%, and negative predictive value from 26 to 96%. The positive likelihood ratio ranged from 0.22 to 83.25 and the negative likelihood ratio from 0.44 to 1.40. CONCLUSION Based on this systematic review of only 4 studies it was not possible to draw firm conclusions about the diagnostic accuracy of premanipulative tests. However, data on diagnostic accuracy indicate that the premanipulative tests do not seem valid in the premanipulative screening procedure. A surplus value for premanipulative tests seems unlikely.

Diagnostic Accuracy of Upper Cervical Spine Instability Tests: A Systematic Review

Background Patients with neck pain, headache, torticollis, or neurological signs should be screened carefully for upper cervical spine instability, as these conditions are “red flags” for applying physical therapy interventions. However, little is known about the diagnostic accuracy of upper cervical spine instability tests. Purpose The purpose of this study was to evaluate the diagnostic accuracy of upper cervical spine instability screening tests in patients or people who are healthy. Data Sources PubMed, CINAHL, EMBASE, and RECAL Legacy databases were searched from their inception through October 2012. Study Selection Studies were included that assessed the diagnostic accuracy of upper cervical instability screening tests in patients or people who are healthy and in which sensitivity and specificity were reported or could be calculated using a 2 × 2 table. Data Extraction and Quality Assessment Two reviewers independently performed data extraction and the methodological quality assessment using the QUADAS-2. Data Synthesis Depending on heterogeneity, statistical pooling was performed. All diagnostic parameters (sensitivity, specificity, predictive values, and likelihood ratios) were recalculated, if possible. Results Five studies were included in this systematic review. Statistical pooling was not possible due to clinical and statistical heterogeneity. Specificity of 7 tests was sufficient, but sensitivity varied. Predictive values were variable. Likelihood ratios also were variable, and, in most cases, the confidence intervals were large. Limitations The included studies suffered from several biases. None of the studies evaluated upper cervical spine instability tests in patients receiving primary care. Conclusions The membranes tests had the best diagnostic accuracy, but their applicability as a test for diagnosing upper cervical spine instability in primary care has yet to be confirmed.

Effect evaluation of a self-management programme for employees with complaints of the arm, neck or shoulder: a randomised controlled trial

Objective To evaluate the effectiveness of a self-management intervention (including an eHealth module), compared with usual care, in employees with chronic non-specific complaints of the arm, neck or shoulder (persisting >3 months). Methods Participants were randomised into the self-management group (SG) or usual care group (UCG). The SG participated in 6 self-management sessions and could use an eHealth module; the UCG could use all available usual care. The primary outcome of the study was score on the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH). Secondary outcomes included: absenteeism, pain in the previous week, quality of life, pain catastrophising, self-efficacy, work style, presenteeism, fatigue, and limitations experienced during work. Data were analysed using generalised estimating equations (GEE) linear regression and Mann-Whitney U tests, and were collected at baseline, 3-month, 6-month, and 12-month follow-up. Results On the general module of the DASH, no significant difference between SG and the UCG was detected. On most of the other outcome measures, there were no significant between-group differences. In the DASH work module, the between-group effect was −3.82 (95% CI −7.46 to −0.19, p=0.04). For limitations experienced in job-related activities the between-group effect was −1.01 (95% CI −1.97 to −0.04, p=0.04). The mean hours of sport activities in the past 3 months, measured at 12 months, was 1.00 h (95% CI −1.90 to −0.12 h, p=0.03) less in the SG compared with the UCG. Conclusions The self-management intervention improved the participants’ perceived disability during work. Since no significant between-group differences were found on most outcome measures, the results of this study should be interpreted with caution. Trial registration number Dutch Trial Registration number NTR 3816.

Experiences of employees with arm, neck or shoulder complaints: a focus group study

BackgroundMany people suffer from complaints of the arm, neck or shoulder (CANS). CANS causes significant work problems, including absenteeism (sickness absence), presenteeism (decreased work productivity) and, ultimately, job loss. There is a need for intervention programs for people suffering from CANS. Management of symptoms and workload, and improving the workstyle, could be important factors in the strategy to deal with CANS. The objective of this study is to evaluate the experienced problems of employees with CANS, as a first step in an intervention mapping process aimed at adaptation of an existing self-management program to the characteristics of employees suffering from CANS.MethodsA qualitative study comprising three focus group meetings with 15 employees suffering from CANS. Based on a question guide, participants were asked about experiences in relation to continuing work despite their complaints. Data were analysed using content analysis with an open-coding system. During selective coding, general themes and patterns were identified and relationships between the codes were examined.ResultsParticipants suffering from CANS often have to deal with pain, disability, fatigue, misunderstanding and stress at work. Some needs of the participants were identified, i.e. disease-specific information, exercises, muscle relaxation, working with pain, influence of the work and/or social environment, and personal factors (including workstyle).ConclusionsEmployees suffering from CANS search for ways to deal with their complaints in daily life and at work. This study reveals several recurring problems and the results endorse the multi-factorial origin of CANS. Participants generally experience problems similar to those of employees with other types of complaints or chronic diseases, e.g. related to their illness, insufficient communication, working together with healthcare professionals, colleagues and management, and workplace adaptations. These topics will be addressed in the adaptation of an existing self-management program to the characteristics of employees suffering from CANS.

A self-management program for employees with complaints of the arm, neck, or shoulder (CANS): study protocol for a randomized controlled trial

BackgroundComplaints of the arm, neck, or shoulder (CANS) have a multifactorial origin and cause considerable work problems, including decreased work productivity, sickness absence, and, ultimately, job loss. There is a need for intervention programs for people with CANS. Self-management is an approach used in chronic disease care to improve self-efficacy and wellness behaviors to facilitate participants to make informed choices and carry them out. This study will evaluate the effectiveness of a self-management program (including ehealth) and compare it to usual care among employees with chronic CANS (lasting >3 months).Methods/designThis is a randomized controlled trial in which 142 participants will be recruited and randomized (with pre-stratification) to either the intervention group (IG) or control group (CG). The IG will participate in a self-management program consisting of six group sessions and an ehealth module. The CG is allowed to use all usual care available. The primary outcome of the study is the self-reported disability of arm, shoulder, and hand, measured with the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH). Secondary outcomes include: absenteeism, pain in the previous week, quality of life, catastrophizing pain, self-efficacy, workstyle, presenteeism, fatigue, the use of usual care, and limitations experienced on the job. Data are collected at baseline and at 3, 6, and 12 months follow-up.DiscussionFollowing the process of intervention mapping we developed a self-management program to suit and alleviate the problems and needs of employees with CANS. A strength of the study is that our intervention is specifically tailored to match the needs of employees with CANS. The study also has some potential weaknesses (for example, use of co-interventions, combination of group sessions and ehealth, self-reporting of data and possible contamination, Hawthorne effect, and recall or information bias) which are discussed.Trial registrationThe trial is registered with the Dutch Trial Register (http://www.trialregister.nlNTR3816): (January 2013). The first participant was randomized in September 2012.

Development of a self-management intervention for employees with complaints of the arm, neck and/or shoulder (CANS): a focus group study with experts.

BackgroundMany people suffer from complaints of the arm, neck and/or shoulder (CANS). The complaints are persistent and there is a need for intervention programs for those with longstanding CANS. Studies suggest that a behavioural change is needed in employees with CANS. A self-management program with an add-on eHealth module might be an effective option to achieve the behavioural change needed to manage the complaints in employees with CANS. The aim of this study was to determine the content and strategies of the intervention and to gain insight into possible barriers and facilitators for implementation. Therefore, we examined the views of experts on the problems and characteristics associated with employees with CANS as well as their opinion on a self-management program consisting of self-management sessions and an eHealth module.MethodsA qualitative study was performed consisting of three focus groups involving a total of 17 experts (with experience with CANS, self-management and/or eHealth interventions). Experts were asked their opinion about the content and requirements of a self-management program for employees with CANS, including an eHealth module. Data were analysed using qualitative data analysis. After coding, the emergent themes were used to organise the data into main categories, expressing the ideas and opinions of experts on CANS, self-management and/or eHealth interventions.ResultsThe experts pointed out that the intervention should focus on increasing employees’ self-efficacy and empowerment, and address topics related to the possible risk factors for CANS, symptoms, work environment, social environment and personal factors. The eHealth module should be self-explanatory and attractive, and the information provided should be brief, clear and concise.ConclusionsExperts appeared to see a role for a self-management program for employees with CANS. They indicated that the combination of group sessions and eHealth can work well. Experts provided valuable information with regard to the content of the self-management intervention and the design of the eHealth module.

Development of a self-management program for employees with complaints of the arm, neck, and/or shoulder: an intervention mapping approach.

Purpose To develop a self-management program with an additional eHealth module, using the six steps of the intervention mapping (IM) protocol, to help employees with complaints of the arm, neck, and/or shoulder (CANS) cope with their problems. Methods In Step 1 of the IM protocol, a needs assessment was performed consisting of a review of the Dutch multidisciplinary guidelines on CANS, and of focus group sessions with employees with CANS (n=15) and with relevant experts (n=17). After the needs assessment, the objectives of the intervention and the determinants of self-management at work were formulated (Step 2). Furthermore, theory-based intervention methods and practical strategies were selected (Step 3), and an intervention program (including the eHealth module) was developed (Step 4). Finally, plans for implementation and evaluation of the program were developed (Steps 5 and 6). Results Step 1 of the IM protocol revealed that employees with CANS should be stimulated to search for information about the cause of their complaints, about how to deal with their complaints, and in which manner they can influence their complaints themselves. In Step 2, the overall goal of the intervention was defined as “self-management behavior at work” with the aim to alleviate the perceived disability of the participants. Step 3 described how the intervention methods were translated into practical strategies, and goal setting was introduced as an important method for increasing self-efficacy. The product of Step 4 was the final program plan, consisting of 6-weekly group sessions of 2.5 hours each and an eHealth module. In Step 5, a recruitment plan and course materials were developed, a steering committee was set up, trainers were recruited, and the final program was tested. In Step 6, an evaluation plan was developed, which consists of a randomized controlled trial with a 12-month follow-up period and a qualitative evaluation (interviews) with some of the participants. Conclusion This study resulted in a theory- and practice-based self-management program, based on behavioral change theories, guideline-related evidence, and practice-based knowledge that fits the needs of employees with CANS.

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

Considerations to improve the safety of cervical spine manual therapy

Manipulation and mobilisation of the cervical spine are well established interventions in the management of patients with headache and/or neck pain. However, their benefits are accompanied by potential, yet rare risks in terms of serious adverse events, including neurovascular insult to the brain. A recent international framework for risk assessment and management offers directions in the mitigation of this risk by facilitating sound clinical reasoning. The aim of this article is to critically reflect on and summarize the current knowledge about cervical spine manual therapy and to provide guidance for clinical reasoning for cervical spine manual therapy.

The contribution of physiotherapy to the employment of workers with a chronic musculoskeletal disorder: a focus group study*

The contribution of physiotherapy to the employment of workers with a chronic musculoskeletal disorder: a focus group study N. Hutting, W. Oswald, J. B. Staal, J. A. Engels, E. Nouwens, M. W. G. Nijhuis-van der Sanden and Y. F. Heerkens Research Group Occupation & Health, HAN University of Applied Sciences, Nijmegen, Netherlands; Department of Physiotherapy, HAN University of Applied Sciences, Nijmegen, Netherlands; Faculty of Health and Social Studies, Research Group Musculoskeletal Rehabilitation, HAN University of Applied Sciences, Nijmegen, Netherlands; Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center, Nijmegen, Netherlands