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BackgroundEvidence is lacking to what extent patients with Whiplash-Associated Disorders (WAD), those with non-traumatic neck pain (NTNP), and pain-free individuals differ regarding type and severity of impairments, disability, and psychological factors.Objective To compare clinical characteristics between patients with WAD, with NTNP, and pain-free individuals in primary care physiotherapy. Additionally, differences between patient groups for both acute and chronic symptoms were assessed.MethodA cross-sectional study was conducted including 168 patients with WAD, 336 matched patients with NTNP, and 336 pain-free individuals. Differences and prevalence rates were calculated for pain intensity, pain distribution, cervical range of motion, neck flexor muscle endurance, self-reported disability, and psychological factors.Results Patients with WAD had higher pain intensity (median 6/10 vs. 5/10 p83%) scored in the normal range. No significant differences between the patient groups were observed (p>.16). Both patient groups scored significantly worse than pain-free individuals on all characteristics. Patients with WAD and NTNP experienced different types of activity limitations and participation restrictions.ConclusionWAD is a more severe condition than NTNP and should be considered a separate subgroup. A different approach in clinical practice and research is required for WAD and NTNP.

BACKGROUND: A large proportion of people who sustain a whiplash injury will have persistent pain, disability, and participation problems. Several prognostic factors for functional recovery have been reported in the literature but these factors are often evaluated based on differing implementations in clinical practice. Additionally, physiotherapists also rely on their clinical intuition to estimate the functional prognosis of their patients, but this is seldom measured in experimental research. Furthermore, no study to date has explored the associations between clinical intuition, clinically estimated factors, and objectively measured factors for functional recovery of patients with Whiplash-Associated Disorders (WAD).AIM: The aim of this exploratory study is to evaluate associations between prognostic factors for functional recovery, based on routinely collected data in a specialized primary care physiotherapy practice in a consecutive sample of patients (n = 523) with WAD.METHODS: Three sources of prognostic factors were selected: (1) physiotherapists' synthesis of clinical intuition in terms of high-risk, inconclusive risk, or low-risk for functional recovery, (2) patient-registered factors from history taking, and (3) patient-reported prognostic factors derived from questionnaires. Prognostic factors were selected based on the literature, recommendations in Dutch clinical practice guidelines, and consensus between experts. Spearman's rank correlation coefficients were calculated to explore the associations between sources of prognostic factors, using a cutoff ≥0.25 for acceptable association.RESULTS: Associations between physiotherapists' intuitive synthesis and patient-registered variables were substantial ( r s = 0.86), between patient-registered variables and patient-reported variables fair (ranging from 0.30 to 0.41) to substantial (ranging from 0.69 to 0.73), and between physiotherapists intuitive synthesis and patient-reported variables fair (ranging from 0.30 to 0.37). CONCLUSION: When estimating prognosis for functional recovery using clinical reasoning, physiotherapists should integrate patients' registered experience of their course of recovery, as well as the timeline after an accident, with their own synthesis of clinical intuition regarding prognostic factors in patients with WAD.

Highlights • A previous running-related injury was the strongest risk factor for an injury in long-distance runners. • Previous injuries not attributed to running, was the strongest risk factor in short-distance runners. Higher body mass index, higher age, sex (male), having no previous running experience and lower running volume were strong risk factors for short-distance runners. • Low quality evidence was found for all risk models as predictor for running-related injuries in short- and long-distance runners. • The quality of evidence for risk factors for running-related injurie is limited and running injuries seem to have a multifactorial origin both in short- and long-distance runners., Purpose The aim of this study was to review information about risk factors for lower extremity running injuries in both short-distance (mean running distance ≤20 km/week and ≤10 km/session) and long-distance runners (mean running distance >20 km/week and >10 km/session). Methods Electronic databases were searched for articles published up to February 2019. Prospective cohort studies using multivariable analysis for the assessment of individual risk factors or risk models for the occurrence of lower extremity running injuries were included. Two reviewers independently selected studies for eligibility and assessed risk of bias with the Quality in Prognostic Studies Tool. The GRADE approach was used to assess the quality of the evidence. Results A total of 29 studies were included: 17 studies focused on short-distance runners, 11 studies focused on long-distance runners, and 1 study focused on both types of runners. A previous running-related injury was the strongest risk factor for an injury for long-distance runners, with moderate-quality evidence. Previous injuries not attributed to running was the strongest risk factor for an injury for short-distance runners, with high-quality evidence. Higher body mass index, higher age, sex (male), having no previous running experience, and lower running volume were strong risk factors, with moderate quality evidence, for short-distance runners. Low-quality evidence was found for all risk models as predictors of running-related injuries among short- and long-distance runners. Conclusion Several risk factors for lower extremity injuries have been identified among short- and long-distance runners, but the quality of evidence for these risk factors for running-related injuries is limited. Running injuries seem to have a multifactorial origin both in short- and long-distance runners., Graphical Abstract Image, graphical abstract

To determine the diagnostic accuracy of patient interview items and clinical tests to diagnose cervical radiculopathy. Design A prospective diagnostic accuracy study. Participants Consecutive patients (N = 134) with a suspicion of cervical radiculopathy were included. A medical specialist made the diagnosis of cervical radiculopathy based on the patient's clinical presentation and corresponding Magnetic Resonance Imaging findings. Participants completed a list of patient interview items and the clinical tests were performed by a physiotherapist. Main outcome measures Diagnostic accuracy was determined in terms of sensitivity, specificity, and positive (+LR) and negative likelihood ratios (-LR). Sensitivity and specificity values >= 0.80 were considered high. We considered +LR >= 5 and -LR = 10and -LR

Supplemental Digital Content is Available in the Text. Through a Delphi study, consensus was reached regarding recommended self-administered questionnaires to assess fear of movement, coping, self-efficacy, and catastrophizing in patients with musculoskeletal pain., The way people with musculoskeletal disorders deal with pain influences their prognosis. Psychosocial factors that influence outcomes include fear of movement, coping, self-efficacy, and catastrophizing. A 3-round modified Delphi study was conducted with the aim to reach consensus on the most appropriate questionnaires to assess these 4 psychosocial factors in patients at risk of developing persistent musculoskeletal pain. The panel consisted of 36 experts, with track records in medicine, psychology, and allied health. To be considered an expert, a minimum number of authorships were required on research articles using self-administered questionnaires to assess these psychosocial factors in relevant patient populations. In round 1, the experts proposed 30 questionnaires to assess the 4 factors. In round 2, experts rated the questionnaires on suitability, considering clinimetric properties, content, feasibility, personal experiences, and expertise. The highest ranked questionnaires (maximally 5 per factor) were retained for round 3, in which the experts made a final assessment of the questionnaires and provided their positive and negative experiences with the questionnaires. Consensus was reached for the following questionnaires to assess (1) fear of movement: Fear Avoidance Beliefs Questionnaire and Tampa Scale (full version or 11-item version); (2) coping: Coping Strategies Questionnaire (initial or revised version) and Chronic Pain Coping Index; (3) self-efficacy: Pain Self-Efficacy Questionnaire (full version or 2-item version); and (4) catastrophizing: Pain Catastrophizing Scale and the revised version of the Coping Strategies Questionnaire. Although other questionnaires can be considered in specific circumstances, these questionnaires are recommended in people with musculoskeletal pain.

Background: It is unknown whether the treatment effects of partial meniscectomy and physical therapy differ when focusing on activities most valued by patients with degenerative meniscal tears. Purpose: To compare partial meniscectomy with physical therapy in patients with a degenerative meniscal tear, focusing on patients’ most important functional limitations as the outcome. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: This study is part of the Cost-effectiveness of Early Surgery versus Conservative Treatment with Optional Delayed Meniscectomy for Patients over 45 years with non-obstructive meniscal tears (ESCAPE) trial, a multicenter noninferiority randomized controlled trial conducted in 9 orthopaedic hospital departments in the Netherlands. The ESCAPE trial included 321 patients aged between 45 and 70 years with a symptomatic, magnetic resonance imaging–confirmed meniscal tear. Exclusion criteria were severe osteoarthritis, body mass index >35 kg/m2, locking of the knee, and prior knee surgery or knee instability due to an anterior or posterior cruciate ligament rupture. This study compared partial meniscectomy with physical therapy consisting of a supervised incremental exercise protocol of 16 sessions over 8 weeks. The main outcome measure was the Dutch-language equivalent of the Patient-Specific Functional Scale (PSFS), a secondary outcome measure of the ESCAPE trial. We used crude and adjusted linear mixed-model analyses to reveal the between-group differences over 24 months. We calculated the minimal important change for the PSFS using an anchor-based method. Results: After 24 months, 286 patients completed the follow-up. The partial meniscectomy group (n = 139) improved on the PSFS by a mean of 4.8 ± 2.6 points (from 6.8 ± 1.9 to 2.0 ± 2.2), and the physical therapy group (n = 147) improved by a mean of 4.0 ± 3.1 points (from 6.7 ± 2.0 to 2.7 ± 2.5). The crude overall between-group difference showed a –0.6-point difference (95% CI, –1.0 to –0.2; P = .004) in favor of the partial meniscectomy group. This improvement was statistically significant but not clinically meaningful, as the calculated minimal important change was 2.5 points on an 11-point scale. Conclusion: Both interventions were associated with a clinically meaningful improvement regarding patients’ most important functional limitations. Although partial meniscectomy was associated with a statistically larger improvement at some follow-up time points, the difference compared with physical therapy was small and clinically not meaningful at any follow-up time point. Registration: NCT01850719 ( ClinicalTrials.gov identifier) and NTR3908 (the Netherlands Trial Register).

Rob AB Oostendorp,1– 4 JW Hans Elvers,5,6 Emiel van Trijffel,7,8 Geert M Rutten,9,10 Gwendolyne GM Scholten-Peeters,11 Marcel Heijmans,4 Erik Hendriks,12,13 Emilia Mikolajewska,14,15 Margot De Kooning,3,16 Marjan Laekeman,17,18 Jo Nijs,3,16,19 Nathalie Roussel,20 Han Samwel21 1Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands; 2Department of Manual Therapy, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium; 3Pain in Motion International Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; 4Practice Physiotherapy and Manual Therapy, Heeswijk-Dinther, the Netherlands; 5Department of Public Health and Research, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands; 6Department of Allied Health Care, Methodological Health-Skilled Institute, Beuningen, the Netherlands; 7Department of Master Education, SOMT University of Physiotherapy, Amersfoort, the Netherlands; 8Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; 9Institute of Health Studies, Faculty of Health and Social Studies, HAN University of Applied Science, Nijmegen, the Netherlands; 10Campus Venlo, Faculty of Science and Engineering, Maastricht University, Maastricht, the Netherlands; 11Department of Human Movement Sciences, Faculty of Behavioral and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands; 12Department of Epidemiology, Center of Evidence Based Physiotherapy, Maastricht University, Maastricht, the Netherlands; 13Practice Physiotherapy ‘Maasstaete, Druten, the Netherlands; 14Department of Physiotherapy, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland; 15Neurocognitive Laboratory, Centre for Modern Interdisciplinary Technologies, Nicolaus Copernicus University, Toruń, Poland; 16Department of Physical Medicine and Physiotherapy, University Hospital Brussels, Brussels, Belgium; 17Department of Nursing Sciences, Ph.D.-Kolleg, Faculty of Health, University Witten/Herdecke, Witten, Germany; 18Department of Physiological Psychology, University of Bamberg, Bamberg, Germany; 19Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden; 20Department of Physiotherapy and Rehabilitation Sciences (MOVANT), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; 21Revalis Pain Rehabilitation Centre, S Hertogenbosch, the NetherlandsCorrespondence: Rob AB OostendorpScientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, p/a Oude Kleefsebaan 325, AT Berg En Dal 6572, Nijmegen, the NetherlandsTel +31 246423419Email oostendorp.rob@gmail.comBackground: Whiplash-associated disorders (WADs) constitute a state of health characterized by a wide diversity of symptoms as a result of impairments of functions, activity limitations, and participation restrictions. Patient-reported outcome measurements (PROMs) and patient-reported outcomes (PROs) seem appropriate when describing and evaluating the health status of patients with WAD.Aim: To measure the use of PROMs and PROs as quality indicators in clinical reasoning, and to analyze and evaluate pre- and post-treatment ‘pain intensity’ and ‘functioning’, and for ‘perceived improvement’ in patients with WAD in primary care physiotherapy practice by year of referral, with the phase after accident and prognostic health profile embedded in the clinical reasoning process.Materials and Methods: Data were collected over a period of 10 years. Pain intensity, functioning, and perceived improvement were measured using the Visual Analogue Scale for Pain (VAS-P), the Neck Disability Index (NDI) and the Global Perceived Effect scale (GPE). Pre- and post-treatment mean differences were tested for statistical significance and compared to minimal clinically important differences (MCID). Effect sizes were expressed as Cohen’s d. Multivariable regression analysis was performed to explore independent associations of year of referral, phase after the accident, and the patient’s prognostic health profile with post-treatment pain intensity and functioning.Results: A consecutive sample of 523 patients was included. Pre- and post-treatment mean differences on VAS-P and NDI were statistically significant (P< 0.000) and clinically relevant, with ‘large’ effect sizes for pain intensity and functioning. MCIDs were achieved by 80% for VAS-P and for 60% for NDI. Year of referral and phase after the accident were independently associated with worse post-treatment functioning. About half of the patients (n=241 [46.1%]) perceived themselves as improved.Conclusion: The PROMs and PROs pain intensity, functioning and perceived improvement were integrated as quality indicators in the physiotherapy clinical reasoning process for patients with WAD. Significant differences in pain intensity and functioning were found but were unrelated to year of referral, phase after whiplash-related injury or prognostic health profile. The MCID VAS-P scores did not differ depending on experienced pain.Keywords: whiplash-Associated Disorders, neck pain, physiotherapy, patient-reported outcomes measures, routinely collected data

Supplemental Digital Content is available in the text Prognostic models for recovery, pain, and disability following lumbar microdiscectomy and postoperative physiotherapy were developed and internally validated. The models performed poorly. Currently gathered data do not enable surgeons and clinicians to predict the outcome., Study Design. Prospective cohort study. Objective. To develop and internally validate prognostic models based on commonly collected preoperative data for good and poor outcomes of lumbar microdiscectomy followed by physiotherapy. Summary of Background Data. Lumbar microdiscectomy followed by physiotherapy is a common intervention for lumbar radiculopathy. Postoperatively, a considerable percentage of people continues to experience pain and disability. Prognostic models for recovery are scarce. Methods. We included 298 patients with lumbar radiculopathy who underwent microdiscectomy followed by physiotherapy. Primary outcomes were recovery and secondary outcomes were pain and disability at 12 months follow-up. Potential prognostic factors were selected from sociodemographic and biomedical data commonly captured preoperatively. The association between baseline characteristics and outcomes was evaluated using multivariable logistic regression analyses. Results. At 12 months follow-up, 75.8% of the participants met the criterion for recovery. Variables in the model for good recovery included: younger age, leg pain greater than back pain, high level of disability, and a disc herniation at another level than L3–L4. The model for poor recovery included: lower educational level, prior back surgery, and disc herniation at L3–L4. Following internal validation, the explained variance (Nagelkerke R 2) and area under the curve for both models were poor (≤0.02 and ≤0.60, respectively). The discriminative ability of the models for disability and pain were also poor. Conclusion. The outcome of microdiscectomy followed by postoperative physiotherapy cannot be predicted accurately by commonly captured preoperative sociodemographic and biomedical factors. The potential value of other biomedical, personal, and external factors should be further investigated. Level of Evidence: 3

We wholeheartedly agree with Klyne and Hodges [1] who emphasized in response to our Perspective [2] that the association between systemic inflammation and musculoskeletal pain is complex. In our Perspective, we called for a prudent interpretation of the literature because multiple confounders influence the association between low-grade systemic inflammation and musculoskeletal pain. A recent systematic review reiterated our viewpoint (“The potential role of confounding factors on the association between (pro)inflammatory biomarkers and nonspecific low back pain needs to be better controlled for and/or evaluated in future research”) [3]. Furthermore, we proposed to create a core set of potentially important confounders to assist researchers with their selection of factors. This was also echoed by the authors of another recent systematic review who “did not find relevant information in the literature to decide a-priori which confounders would be the most relevant in this field” [4]. Although we focussed on confounders in our Perspective, Klyne and Hodges [1] appropriately expanded on the topic and highlighted the distinction between confounders and mediators in their Letter-to-the-Editor.

Clinical practice in physical and manual therapy is experiencing a paradigm shift from an experience- and authority-based model to a more evidence-based model. National Practice Guidelines (NPG) are examples of this shift towards research-based knowledge. This article discusses the five steps in the development of NPGs. These steps are illustrated by a discussion of development and content of two NPGs produced recently in the Netherlands for the treatment of patients with non-specific low back pain.