Search

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

Background: Manual therapy according to the School of Manual Therapy Utrecht (MTU) is a specific type of passive manual joint mobilization. MTU has not yet been systematically compared to other manual therapies and physical therapy. In this study the effectiveness of MTU is compared to physical therapy, particularly active exercise therapy (PT) in patients with non-specific neck pain. Methods: Patients neck pain, aged between 18-70 years, were included in a pragmatic randomized controlled trial with a one-year follow-up. Primary outcome measures were global perceived effect and functioning (Neck Disability Index), the secondary outcome was pain intensity (Numeric Rating Scale for Pain). Outcomes were measured at 3, 7, 13, 26 and 52 weeks. Multilevel analyses (intention-to-treat) were the primary analyses for overall between-group differences. Additional to the primary and secondary outcomes the number of treatment sessions of the MTU group and PT group was analyzed. Data were collected from September 2008 to February 2011. Results: A total of 181 patients were included. Multilevel analyses showed no statistically significant overall differences at one year between the MTU and PT groups on any of the primary and secondary outcomes. The MTU group showed significantly lower treatment sessions compared to the PT group (respectively 3.1 vs. 5.9 after 7 weeks; 6.1 vs. 10.0 after 52 weeks). Conclusions: Patients with neck pain improved in both groups without statistical significantly or clinically relevant differences between the MTU and PT groups during one-year follow-up. Trial registration: ClinicalTrials.gov Identifier: NCT00713843.

Objective The aim of the Consensus on Interventions Reporting Criteria List for Spinal Manipulative Therapy (CIRCL e SMT) study was to develop a criteria list for reporting spinal manipulative therapy (SMT). Methods A Delphi procedure was conducted from September 2011 to April 2013 and consisted of international experts in the field of SMT. The authors formed a steering committee and invited participants, selected initial items, structured the comments of the participants after each Delphi round, and formulated the feedback. To ensure content validity, a large number of international experts from different SMT-related disciplines were invited to participate. A workshop was organized following the consensus phase, and it was used to discuss and refine the wording of the items. Results In total, 123 experts from 18 countries participated. These experts included clinicians (70%), researchers (93%), and academics working in the area of SMT (27%), as well as journal editors (14%). ( Note: The total is more than 100% because most participants reported 2 jobs.) Three Delphi rounds were necessary to reach a consensus. The criteria list comprised 24 items under 5 domains, including (1) rationale of the therapy, (2) description of the intervention, (3) SMT techniques, (4) additional intervention/techniques, and (5) quantitative data. Conclusions A valid criteria list was constructed with the aim of promoting consistency in reporting SMT intervention in scientific publications.

To evaluate the cost-effectiveness of manual therapy according to the Utrecht School (MTU) in comparison with physiotherapy (PT) in sub-acute and chronic non-specific neck pain patients from a societal perspective. An economic evaluation was conducted alongside a 52-week randomized controlled trial, in which 90 patients were randomized to the MTU group and 91 to the PT group. Clinical outcomes included perceived recovery (yes/no), functional status (continuous and yes/no), and quality-adjusted life-years (QALYs). Costs were measured from a societal perspective using self-reported questionnaires. Missing data were imputed using multiple imputation. To estimate statistical uncertainty, bootstrapping techniques were used. After 52 weeks, there were no significant between-group differences in clinical outcomes. During follow-up, intervention costs (β:€−32; 95 %CI: −54 to −10) and healthcare costs (β:€−126; 95 %CI: −235 to −32) were significantly lower in the MTU group than in the PT group, whereas unpaid productivity costs were significantly higher (β:€186; 95 %CI:19–557). Societal costs did not significantly differ between groups (β:€−96; 95 %CI:−1975–2022). For QALYs and functional status (yes/no), the maximum probability of MTU being cost-effective in comparison with PT was low (≤0.54). For perceived recovery (yes/no) and functional status (continuous), a large amount of money must be paid per additional unit of effect to reach a reasonable probability of cost-effectiveness. From a societal perspective, MTU was not cost-effective in comparison with PT in patients with sub-acute and chronic non-specific neck pain for perceived recovery, functional status, and QALYs. As no clear total societal cost and effect differences were found between MTU and PT, the decision about what intervention to administer, reimburse, and/or implement can be based on the preferences of the patient and the decision-maker at hand. ClinicalTrials.gov Identifier: NCT00713843

BackgroundVarious guidelines for the management of low back pain have been developed to enhance the effectiveness and efficiency of care. Evidence that guideline-adherent care results in better health outcomes, however, is not conclusive.ObjectiveThe main objective of this study was to assess whether a higher percentage of adherence to the Dutch physical and manual therapy guidelines for low back pain is related to improved outcomes. The study further explored whether this relationship differs for the individual steps of the process of care and for distinct subgroups of patients.DesignThis was an observational prospective cohort study (2005–2006) in the Netherlands that included a sample of 61 private practice therapists and 145 patients.MethodsTherapists recorded the process of care and the number of treatment sessions in Web-based patient files. Guideline adherence was assessed using quality indicators. Physical functioning was measured by the Dutch version of the Quebec Back Pain and Disability Scale, and average pain was measured with a visual analog scale. Relationships between the percentage of guideline adherence and outcomes of care were evaluated with regression analyses.ResultsHigher percentages of adherence were associated with fewer functional limitations (β=−0.21, P=.023) and fewer treatment sessions (β=−0.27, P=.005).LimitationsThe relatively small self-selected sample might limit external validity, but it is not expected that the small sample greatly influenced the internal validity of the study. Larger samples are required to enable adequate subgroup analyses.ConclusionsThe results indicate that higher percentages of guideline adherence are related to better improvement of physical functioning and to a lower utilization of care. A proper assessment of the relationship between the process of physical therapy care and outcomes may require a comprehensive set of process indicators to measure guideline adherence.

Purpose To evaluate the cost-effectiveness of manual therapy according to the Utrecht School (MTU) in comparison with physiotherapy (PT) in sub-acute and chronic non-specific neck pain patients from a societal perspective.

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.

Contains fulltext : 49973.pdf (Publisher’s version ) (Closed access) Pain-related fear and pain catastrophizing are associated with disability and actual performance in chronic pain patients. In acute low back pain (LBP), little is known about the prediction of actual performance or perceived disability by pain-related fear and pain catastrophizing. This experimental, cross-sectional study aimed at examining whether pain-related fear and pain catastrophizing were associated with actual performance and perceived disability. Ninety six individuals with an episode of acute LBP performed a dynamic lifting task to measure actual performance. Total lifting time was used as outcome measure. The results show that pain-related fear, as measured with the Tampa Scale for Kinesiophobia, was the strongest predictor of this physical task. Using the Roland Disability Questionnaire as a measure of perceived disability, both pain-related fear and pain catastrophizing, as measured with the Pain Catastrophizing Scale, were significantly predictive of perceived disability and more strongly than pain intensity was. The results of the current study suggest that pain-related fear is an important factor influencing daily activities in individuals suffering an episode of acute LBP. The study results have important clinical implications, especially in the development of preventive strategies for chronic LBP.

Contains fulltext : 47629.pdf (Publisher’s version ) (Closed access) STUDY DESIGN: Cluster randomized controlled trial for a multifaceted implementation strategy. OBJECTIVES: To assess the effectiveness of tailored interventions (multifaceted implementation strategy) to implement the Dutch low back pain guideline for general practitioners with regard to adherence to guideline recommendations. SUMMARY OF BACKGROUND DATA: Guidelines for the management of low back pain in primary care have been developed in various countries, but little is known about the optimal implementation strategy. A multifaceted implementation strategy was developed to overcome identified barriers to the implementation of the Dutch low back pain guideline for general practitioners. METHODS: General practitioners were randomized to an intervention or a control group. The general practitioners in the intervention group (n = 21) received tailored interventions consisting of the Dutch low back pain guideline for general practitioners, a 2-hour educational and clinical practice workshop; two scientific articles on low back pain management; the guideline for occupational physicians; a tool for patient education; and a tool for reaching agreement on low back care with physical, exercise, and manual therapists. The control group (n = 20) received no intervention. The participating general practitioners were asked to recruit consecutive patients with a new episode of low back pain as the main reason for consultation. General practitioners completed registration forms of each individual consultation with regard to the main outcome measures: advice and information, referral to other health-care providers, and prescription of medication. RESULTS: Forty-one of the 67 randomized general practitioners reported on a total of 616 consultations for 531 patients with nonspecific low back pain. The advice and explanation provided by the general practitioners, the prescription of paracetamol or nonsteroidal anti-inflammatory drugs, and prescription of pain medication on atime contingent or a pain contingent basis showed no statistically significant differences between the intervention and control groups. There were also no differences in overall referral rate. However, in follow-up consultations fewer patients were referred to a physical or exercise therapist by the general practitioners in the intervention group than in the control group. CONCLUSIONS: The multifaceted intervention strategy modestly improved implementation (for parts of the recommendations in) the Dutch low back pain guideline by general practitioners and produced small concomitant changes in patient management. The implementation strategy produced fewer referrals to therapists during follow-up consultations.

Many guidelines for the management of low back pain in primary care have been published during recent years, but guidelines for physiotherapy do not yet exist. Therefore, physiotherapy guidelines have been developed, reflecting the consequences of the current state of knowledge of effective and appropriate physiotherapy for low back pain. They aim to improve the efficiency and effectiveness of physiotherapeutic care for patients with low back pain. The guidelines were constructed on the basis of the phases of the physiotherapy process, using the Dutch method of developing physiotherapy guidelines. Scientific evidence of systematic reviews was used as the basis for the recommendations. A computerised literature search of Medline, Cinahl, the Cochrane Database of Systematic Reviews and the Database of the Dutch National Institute of Allied Health Professions was conducted to identify relevant systematic reviews. If no evidence was available, consensus between experts was obtained. The guidelines were pilot tested among one hundred physiotherapists and reviewed by an external multidisciplinary panel. The guidelines recommend that the diagnostic process should focus on disability and participation problems resulting from back pain. The treatment should consist of an active approach, in which the patients learn to take control over their back pain. For patients with a normal course, where activities and participation gradually increase, reassurance, adequate information and advice to stay active are the most important recommendations. For patients with an abnormal course, where activities and participation do not increase, exercise therapy should also be provided, with a behavioural approach if necessary. These are the first national physiotherapy guidelines for low back pain. The recommendations are largely in line with other primary care guidelines for low back pain. Implementation will be a major challenge for the near future.

Item does not contain fulltext STUDY DESIGN: A clinical practice guideline. OBJECTIVES: To assist physiotherapists in decision making and to improve the efficacy and uniformity of care for patients with whiplash-associated disorders Grades I and II. SUMMARY OF BACKGROUND DATA: Whiplash constitutes a considerable problem in health care. Many interventions are used in physiotherapy practice, despite increasing evidence for the use of active interventions. There is still no clinical practice guideline for the management of patients with whiplash-associated disorders. METHOD OF DEVELOPMENT: A computerized literature search of Medline, Cinahl, Cochrane Controlled Trial Register, Cochrane Database of Systematic Reviews, and the Database of the Dutch National Institute of Allied Health Professions was performed to search for information about the diagnostic process and the therapeutic process in whiplash patients. When no evidence was available, consensus between experts was achieved to develop the guideline. Practicing physiotherapists reviewed the clinical applicability and feasibility of the guideline, and their comments were used to improve it. RECOMMENDATIONS: The diagnostic process consists of systematic history taking and a physical examination supported by reliable and valid assessment tools to document symptoms and functional disabilities. The primary goals of treatment are a quick return to normal activities and the prevention of chronicity. Active interventions such as education, exercise therapy, training of functions, and activities are recommended according to the length of time since the accident and the rate of recovery. The biopsychosocial model is used to address the consequences of whiplash trauma. CONCLUSIONS: Scientific evidence for the diagnosis and physiotherapeutic management of whiplash is sparse; therefore, consensus is used in different parts of the guideline. The guideline reflects the current state of knowledge of the effective and appropriate physiotherapy in whiplash patients. More and better research is necessary to validate this guideline in the future.

Background Manual 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. Methods This 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. Discussion This 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.

Objective. To establish the relationships between the range of joint motion (ROM ) and disability in patients with osteoarthritis (OA) of the knee or hip. Two related issues were addressed: (1) the inter-relationships between ROMs of joint actions, and (2) the relationship between ROM and disability. Methods. Data on 198 patients with OA of the knee or hip were used. The ROM was assessed bilaterally for the hip and knee, using a goniometer. Disability was assessed using a self-reporting method (questionnaire) and an observational method. Correlation and factor analysis were used to establish the inter-relationships between the ROMs of joint actions. Correlation and multiple regression analyses were carried out to establish the relationships between ROM and disability. Results. Close inter-relationships were found between the ROMs of the same joint action of the lateral and contralateral joints; inter-relationships between ROMs of different joint actions were substantially weaker. Low ROMs were associated with high levels of disability, both selfreported and observed. Some 25% of the variation in disability levels could be accounted for by differences in ROM. In both knee and hip OA patients, flexion of the knee and extension and external rotation of the hip were found to be most closely associated with disability. Conclusion. Restricted joint mobility, especially in flexion of the knee and extension and external rotation of the hip, appears to be an important determinant of disability in patients with OA. K : Osteoarthritis, Range of motion, Disability.

Objective: To establish the internal consistency of validity of an observational method for assessing diasbility in mobility in patients with osteoarthritis (OA), Methods: Data were obtained from 198 patients with OA of the hip or knee. Results of the observational method were compared with results of self-report methods (questionnaires) on disability in mobility. Results: Both Cronbach's alpha and Mokken Scale Analysis indicate that the method is internally consistent. Using factor analysis, observed and self-reported disability in mobility were found to be closely associated and could not be differentiated. Conclusions: The observational method is internally consistent and indeed measures disability in mobility (high convergant validity), but observations and self-report seem to yield largely equivalent information (low divergent validity). This raises questions regarding the simultaneous use of both observational and self-report methods in the assessment of disability in mobility in OA patients. (aut.ref.)

Purpose: To examine a process for evaluating physiotherapy (PT) students' knowledge of and adherence to the Ambassador Low Back Pain (LBP) guideline using vignettes. Methods: The study used a cross-sectional survey design. Participants were PT students who had received information related to the guideline as part of their curriculum. Primary measures were responses to questions about the management of four clinical vignettes. Adherence to guideline recommendations was measured by comparing participant scores to a “guideline-based” set of responses from a physiotherapist involved in developing the Ambassador guideline, which was considered a criterion standard. Results: A total of 74 respondents provided complete data, for a response rate of 89%; 65 (88%) reported no knowledge of the guideline. Overall consistency with the criterion standard was high (>70%). Respondents demonstrated high adherence when identifying red flags and deciding whether to refer to another provider. Conclusion: Despite known exposure, knowledge of the guideline was low in this sample of Canadian PT students. Nevertheless, in several key areas, unconscious adherence was high relative to the guideline-based criterion standard. With minor modifications, the vignettes are suitable for evaluating the Ambassador LBP guidelines in a larger study.

Background Shoulder pain is reported to be highly prevalent and tends to be recurrent or persistent despite medical treatment. The pathophysiological mechanisms of shoulder pain are poorly understood. Furthermore, there is little evidence supporting the effectiveness of current treatment protocols. Although myofascial trigger points (MTrPs) are rarely mentioned in relation to shoulder pain, they may present an alternative underlying mechanism, which would provide new treatment targets through MTrP inactivation. While previous research has demonstrated that trained physiotherapists can reliably identify MTrPs in patients with shoulder pain, the percentage of patients who actually have MTrPs remains unclear. The aim of this observational study was to assess the prevalence of muscles with MTrPs and the association between MTrPs and the severity of pain and functioning in patients with chronic non-traumatic unilateral shoulder pain. Methods An observational study was conducted. Subjects were recruited from patients participating in a controlled trial studying the effectiveness of physical therapy on patients with unilateral non-traumatic shoulder pain. Sociodemographic and patient-reported symptom scores, including the Disabilities of the Arm, Shoulder, and Hand (DASH) Questionnaire, and Visual Analogue Scales for Pain were compared with other studies. To test for differences in age, gender distribution, and education level between the current study population and the populations from Dutch shoulder studies, the one sample T-test was used. One observer examined all subjects (n = 72) for the presence of MTrPs. Frequency distributions, means, medians, standard deviations, and 95% confidence intervals were calculated for descriptive purposes. The Spearman's rank-order correlation (ρ) was used to test for association between variables. Results MTrPs were identified in all subjects. The median number of muscles with MTrPs per subject was 6 (active MTrPs) and 4 (latent MTrPs). Active MTrPs were most prevalent in the infraspinatus (77%) and the upper trapezius muscles (58%), whereas latent MTrPs were most prevalent in the teres major (49%) and anterior deltoid muscles (38%). The number of muscles with active MTrPs was only moderately correlated with the DASH score. Conclusion The prevalence of muscles containing active and latent MTrPs in a sample of patients with chronic non-traumatic shoulder pain was high.

Low back pain (LBP) is a problem with significant personal and societal impacts. Although it is often suggested that LBP spontaneously resolves within 1 month in 90% of patients, epidemiological research into the natural history of LBP has in fact reported continued pain in 42%–75% of patients at 1 year and recurrence in 44%–78% of patients.1 Research into functional recovery is plagued by the use of diverse endpoints, including return to work, cessation of care seeking, and pre-set improvements on functional outcome measures. Estimates of the economic costs of LBP also differ widely based on study methodology; however, we do know that the financial impact is substantial and that indirect costs associated with lost wages and reduced productivity greatly exceed direct costs, including medical costs. A systematic review of LBP cost of illness in the United States and internationally found that the costs of physiotherapy are equal to inpatient costs (17%) and exceed all other direct health care–related costs, including—perhaps surprisingly to some—pharmaceutical expenses (13%).2 Yet physical therapy assessment and management of patients with LBP are characterized by notable practice variations and include a great number of interventions not supported by research evidence.3 In part, this is likely a result of the various and often contradictory—or, at best, non-complementary—paradigms of LBP and diagnostic classification models in use in clinical practice today.4–12

To identify the evidence for the effectiveness of behaviour change techniques, when used by health-care professionals, in accomplishing health-promoting behaviours in patients. Reviews were used to extract data at a study level. A taxonomy was used to classify behaviour change techniques. We included 23 systematic reviews: 14 on smoking cessation, 6 on physical exercise, and 2 on healthy diets and 1 on both exercise and diets. None of the behaviour change techniques demonstrated clear effects in a convincing majority of the studies in which they were evaluated. Techniques targeting knowledge (n = 210 studies) and facilitation of behaviour (n = 172) were evaluated most frequently. However, self-monitoring of behaviour (positive effects in 56% of the studies), risk communication (52%) and use of social support (50%) were most often identified as effective. Insufficient insight into appropriateness of technique choice and quality of technique delivery hinder precise conclusions. Relatively, however, self-monitoring of behaviour, risk communication and use of social support are most effective. Health professionals should avoid thinking that providing knowledge, materials and professional support will be sufficient for patients to accomplish change and consider alternative strategies which may be more effective. ispartof: Health Promotion International vol:26 issue:2 pages:148-162 ispartof: location:England status: published

Passive intervertebral motion (PIVM) assessment is a characterizing skill of manual physical therapists (MPTs) and is important for judgments about impairments in spinal joint function. It is unknown as to why and how MPTs use this mobility testing of spinal motion segments within their clinical reasoning and decision-making. This qualitative study aimed to explore and understand the role and position of PIVM assessment within the manual diagnostic process. Eight semistructured individual interviews with expert MPTs and three subsequent group interviews using manual physical therapy consultation platforms were conducted. Line-by-line coding was performed on the transcribed data, and final main themes were identified from subcategories. Three researchers were involved in the analysis process. Four themes emerged from the data: contextuality, consistency, impairment orientedness, and subjectivity. These themes were interrelated and linked to concepts of professionalism and clinical reasoning. MPTs used PIVM assessment within a multidimensional, biopsychosocial framework incorporating clinical data relating to mechanical dysfunction as well as to personal factors while applying various clinical reasoning strategies. Interpretation of PIVM assessment and subsequent decisions on manipulative treatment were strongly rooted within practitioners’ practical knowledge. This study has identified the specific role and position of PIVM assessment as related to other clinical findings within clinical reasoning and decision-making in manual physical therapy in The Netherlands. We recommend future research in manual diagnostics to account for the multivariable character of physical examination of the spine.

Background Many patients suffer from severe shoulder complaints after breast cancer surgery and axillary lymph node dissection. Physiotherapy has been clinically observed to improve treatment of these patients. However, it is not a standard treatment regime. The purpose of this study is to investigate the efficacy of physiotherapy treatment of shoulder function, pain and quality of life in patients who have undergone breast cancer surgery and axillary lymph node dissection. Methods Thirty patients following breast cancer surgery and axillary lymph node dissection were included in a randomised controlled study. Assessments were made at baseline and after three and six months. The treatment group received standardised physiotherapy treatment of advice and exercises for the arm and shoulder for three months; the control group received a leaflet containing advice and exercises. If necessary soft tissue massage to the surgical scar was applied. Primary outcome variables were amount of pain in the shoulder/arm recorded on the Visual Analogue Scale, and shoulder mobility (flexion, abduction) measured using a digital inclinometer under standardized conditions. Secondary outcome measures were shoulder disabilities during daily activities, edema, grip strength of both hands and quality of life. The researcher was blinded to treatment allocation. Results All thirty patients completed the trial. After three and six months the treatment group showed a significant improvement in shoulder mobility and had significantly less pain than the control group. Quality of life improved significantly, however, handgrip strength and arm volume did not alter significantly. Conclusion Physiotherapy reduces pain and improves shoulder function and quality of life following axillary dissection after breast cancer. Trial registration ISRCTN31186536

Contains fulltext : 53212.pdf (Publisher’s version ) (Closed access) Our objective was to investigate whether behavioral graded activity (BGA) has particular benefit in specific subgroups of osteoarthritis (OA) patients. Two hundred participants with OA of hip or knee, or both (clinical American College of Rheumatology, ACR, criteria) participated in a randomized clinical trial on the efficacy of BGA compared to treatment according to the Dutch physiotherapy guideline (usual care; UC). Changes in pain (Visual Analog Scale, VAS), physical functioning (Western Ontario and McMaster Universities Osteoarthritis Index, WOMAC, and McMaster Toronto Arthritis Questionnaire, MACTAR), and patient global assessment were compared for specific subgroups. Subgroups were assigned by the median split method and were analyzed using analysis of covariance. Beneficial effects of BGA were found for patients with a relatively low level of physical functioning (p?0.03). Furthermore, beneficial effects of BGA in patients with a low level of internal locus of control were marginally significant (p = .05). Patients with a relatively low level of physical functioning benefit more from BGA compared to UC. Compared to UC, BGA is the preferred treatment option in patients with a low level of physical functioning.

This study compared socio-demographic characteristics, health problem characteristics, and primary process data between database samples of patients referred to physical therapy (PT) versus a sample of patients referred to manual physical therapy (MPT) in the Netherlands. Statistical analysis indicated that that the MPT sample was significantly (P

Contains fulltext : 47398.pdf (Publisher’s version ) (Closed access) The objective of our prospective inception cohort study was to identify prognostic factors for poor recovery in patients with whiplash-associated disorders grade 1 or 2 who still had neck pain and accompanying complaints 2 weeks after the accident. The study was carried out in a primary health care setting in The Netherlands and included 125 patients. The primary outcome measure was functional recovery defined in terms of neck pain intensity or work disability without medication use. The secondary outcome measures included neck pain intensity, work disability and sick leave. The outcomes were assessed at 4, 12 and 52 weeks after the accident. Prognostic factors were identified by logistic regression analyses. One year after the injury, 64% of the patients were recovered. Factors related to poor recovery were female gender, a low level of education, high initial neck pain, more severe disability, higher levels of somatisation and sleep difficulties. Neck pain intensity and work disability proved to be the most consistent predictors for poor recovery. The accuracy of the predictions of the prognostic models was high, meaning that the models adequately distinguished patients with poor recovery from those regarded as recovered. These findings add to the growing body of evidence, indicating that socio-demographic, physical and psychological factors affect short- and long-term outcome after whiplash injury. Our findings also indicate that care providers can easily identify patients at risk for poor recovery with a visual analogue scale for initial pain intensity and work-related activities.

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.

Background and Purpose. One-time physical therapist consultation, prior to possible referral for physical therapy intervention, may enhance the quality of patient care, particularly if the referring physician is uncertain as to whether intervention by a physical therapist will be beneficial. The purpose of this study was to describe the use of consultation by a group of primary care physicians (PCPs) who could refer patients for a one-time consultation. Subjects and Methods. A 7-month observational study was conducted in the Netherlands with 59 pairs of randomly selected PCPs and physical therapists practicing in primary health care. Data were collected for the PCPs, the physical therapists, and the patients. Self-administered questionnaires (completed at the start and at the completion of the study), consultation request and report forms, and treatment referral records from health insurance agencies were used to obtain data. National reference data on patients referred by PCPs for intervention by a physical therapist were used to compare the data of patients referred by PCPs for a one-time consultation. The number and nature of consultation requests were determined as well as patient characteristics. The PCPs' satisfaction with the outcome and process of a one-time consultation and its impact on PCPs' management decisions also were described. Results. The number of referrals for a one-time consultation was 352 (X̄=5.9 per PCP, SD=5.4, range=0-20), resulting in a mean referral rate of 4.7 per 1,000 patients (SD=4.6). Characteristics of patients referred for a one-time consultation differed from national reference data of patients referred by their PCP for intervention by a physical therapist. Discussion and Conclusion. The results show that PCPs used the opportunity for a one-time physical therapist consultation and were satisfied with the outcome and process of consultation. The findings suggest that a one-time consultation is an appropriate and beneficial component of PCPs' patient management process. [Hendriks EJM, Kerssens JJ, Dekker J, et al. One-time physical therapist consultation in primary health care.

Item does not contain fulltext In the Netherlands, clinical practice physiotherapy guidelines are mainly implemented by using passive implementation strategies. It is well known that these strategies are not effective in establishing changes in behaviour of health care professionals. Therefore, a new implementation strategy was developed for the physiotherapy guidelines on low back pain. This paper describes the method for the design of this strategy. A survey was conducted of 100 physiotherapy practices to identify perceived barriers to implementation of the guidelines and the most important discrepancies between current practice and recommendations of the guidelines. The strategy was further developed using a model for changing professionals' behaviour and systematic reviews on the effectiveness of implementation interventions. The most frequently reported barriers for implementation of the guidelines are related to a lack of knowledge or skills of physiotherapists. The most frequently reported discrepancies between physiotherapy practice and guidelines recommendations were related to the focus of the diagnostic process on impairments, the common use of passive physiotherapeutic interventions, the frequent use of a pain-contingent approach, and the expectations of the patient. The new implementation strategy consisted of multiple interventions, namely education, discussion, role-playing, feedback and reminders.The strategy addressed perceived barriers and discrepancies between current practice and the recommendations of the guidelines.

Objective: Reduced muscle strength is regarded as a risk factor for pain and disability in osteoarthritis (OA). Currently, various indices for muscle strength are used when assessing determinants of pain and disability. The goal of the present study was to evaluate these indices of muscle strength. Design: Isometric muscle strength was measured for 16 muscle actions around the knees and hips in 52 patients with OA of the hip and 70 patients with OA of the knee. Various indices of muscle strength were derived from these measurements, applying five alternative approaches. These approaches ranged from a single overall index to a set of 16 separate indices. The internal consistency of these indices was determined (Cronbach's α), and it was determined to what extent they could reveal the association between reduced muscle strength on the one hand and pain and disability on the other hand. Results: Internal consistency was satisfactory for all indices (Cronbach's α >0.74). As expected, reduced muscle strength was associated with increased disability, but no clear relationship could be established between muscle weakness and pain. The strength of these associations did not depend on the approach used to derive the indices for muscle strength. Conclusions: The indices did not show major differences with regard to internal consistency or the extent to which the association with pain and disability could be revealed. For reasons of parsimony, approaches resulting in few indices appear to be most useful. However, muscle strength was found to be significantly reduced around affected joints, compared with muscle strength around unaffected joints. Therefore, the most suitable approach for reducing muscle strength data into indices is one that results in as few indices as possible, but with separate indices for muscle strength around affected and unaffected joints.

Item does not contain fulltext OBJECTIVE: To determine whether the effects of an exercise programme in patients with osteoarthritis of hip or knee are sustained at six and nine months' follow up. METHODS: A randomised, single blind, clinical trial was conducted in a primary care setting. Patients with osteoarthritis of hip or knee (ACR criteria) were selected. Two intervention groups were compared. Both groups received treatment from their general practitioner, including patient education and drug treatment if necessary. The experimental group also received exercise treatment from a physiotherapist in primary care. The treatment period was 12 weeks, with an ensuing 24 week follow up. The main outcome measures were pain, drug use (non-steroidal anti-inflammatory drugs), and observed disability. RESULTS: 201 patients were randomly allocated to the exercise or control group, and 183 patients completed the trial. At 24 weeks exercise treatment was associated with a small to moderate effect on pain during the past week (difference in change between the two groups -11.5 (95% CI -19.7 to -3.3). At 36 weeks no differences were found between the groups. CONCLUSIONS: Beneficial effects of exercise decline over time and finally disappear.

Objective: To review the effectiveness of exercise therapy in patients with osteoarthritis (OA) of the hip or knee. Methods: A computerized literature search of Medline, Embase, and Cinahl was carried out. Randomized clinical trials on exercise therapy for OA of the hip or knee were selected if treatment had been randomly allocated and if pain, self-reported disability, observed disability, or patient's global assessment of effect had been used as outcome measures. The validity of trials was systematically assessed by independent reviewers. Effect sizes and power estimates were calculated. A best evidence synthesis was conducted, weighting the studies with respect to their validity and power. Results: Six of the 11 assessed trials satisfied at least 50% of the validity criteria. Two trials had sufficient power to detect medium-sized effects. Effect sizes indicated small-to-moderate beneficial effects of exercise therapy on pain, small beneficial effects on both disability outcome measures, and moderate-to-great beneficial effects according to patient's global assessment of effect. Conclusion: There is evidence of beneficial effects of exercise therapy in patients with OA of the hip or knee. However, the small number of good studies restricts drawing firm conclusions.

Using a pressure algometer pain threshold (PT) measurements were carried out in the paraspinal area as well as at the knee and ankle joints in 30 adults with active rheumatoid arthritis (RA) and in 30 healthy adults. The group of RA patients was then randomly divided in two. In 15 RA patients a manual oscillation technique was applied at T12 and L4 for 12 minutes. The 15 other patients were resting. Immediately after the experimental procedure the PT was measured again at the same points in all patients. The RA patients showed a significantly (p < 0.05) lower PT than the healthy adults at all investigated points, which suggests that in RA certain changes arise in the peripheral and central nociceptive processing system, as mentioned in the literature. In the second measurement session for the RA patients the PT was significantly higher (p

Summary: The abductor pollicis longus (APL) has to be viewed as an important muscle for moving and stabilizing the human thumblo. This muscle has two divisions, a distal superficial division and a more proximal deep one. The electromyographic (EMG) signals from these divisions were measured for several motor tasks in order to investigate differences in activation and function. EMG signals were recorded with intramuscular wire electrodes in isometric as well as in dynamic contractions in different directions, both for the thumb and for the hand. The EMG signals of the right hand of eight subjects were scaled relative to the mean EMG value at the maximum voluntary isometric contraction (MVC) in order to compare relative muscle activity in various directions for different subjects. In 18 out of the 22 directions the EMG activity in the two divisions of the APL was modulated differently, indicating a different activation. The differences were most prominent in dorsal and palmar flexion of the hand. The results suggested that the APLdeep is activated to stabilize the carpal joint. The APLdeep is a direct mover of the carpal joint in dorsal flexion of the hand.

Background Shoulder disorders are a common health problem in western societies. Several treatment protocols have been developed for the clinical management of persons with shoulder pain. However available evidence does not support any protocol as being superior over others. Systematic reviews provide some evidence that certain physical therapy interventions (i.e. supervised exercises and mobilisation) are effective in particular shoulder disorders (i.e. rotator cuff disorders, mixed shoulder disorders and adhesive capsulitis), but there is an ongoing need for high quality trials of physical therapy interventions. Usually, physical therapy consists of active exercises intended to strengthen the shoulder muscles as stabilizers of the glenohumeral joint or perform mobilisations to improve restricted mobility of the glenohumeral or adjacent joints (shoulder girdle). It is generally accepted that a-traumatic shoulder problems are the result of impingement of the subacromial structures, such as the bursa or rotator cuff tendons. Myofascial trigger points (MTrPs) in shoulder muscles may also lead to a complex of symptoms that are often seen in patients diagnosed with subacromial impingement or rotator cuff tendinopathy. Little is known about the treatment of MTrPs in patients with shoulder disorders. The primary aim of this study is to investigate whether physical therapy modalities to inactivate MTrPs can reduce symptoms and improve shoulder function in daily activities in a population of chronic a-traumatic shoulder patients when compared to a wait-and-see strategy. In addition we investigate the recurrence rate during a one-year-follow-up period. Methods/Design This paper presents the design for a randomized controlled trial to be conducted between September 2007 – September 2008, evaluating the effectiveness of a physical therapy treatment for non-traumatic shoulder complaints. One hundred subjects are included in this study. All subjects have unilateral shoulder pain for at least six months and are referred to a physical therapy practice specialized in musculoskeletal disorders of the neck-, shoulder-, and arm. After the initial assessment patients are randomly assigned to either an intervention group or a control-group (wait and see). The primary outcome measure is the overall score of the Dutch language version of the DASH (Disabilities of Arm, Shoulder and Hand) questionnaire. Discussion Since there is only little evidence for the efficacy of physical therapy interventions in certain shoulder disorders, there is a need for further research. We found only a few studies examining the efficacy of MTrP therapy for shoulder disorders. Therefore we will perform a randomised clinical trial of the effect of physical therapy interventions aimed to inactivate MTrPs, on pain and impairment in shoulder function in a population of chronic a-traumatic shoulder patients. We opted for an intervention strategy that best reflects daily practice. Manual high velocity thrust techniques and dry-needling are excluded. Because in most physical therapy interventions, blinding of the patient and the therapist is not possible, we will perform a randomised, controlled and observer-blinded study. Trial Registration This randomized clinical trial is registered at current controlled trials ISRCTN75722066.

Objective: To establish the effect of exercise therapy in patients with intermittent claudication and to identifiy outcome predictors for exercise training. Design: A methodological study of randomised clinical trials. Methods: A quality assessment of all eligible studies was petformed, using a list of methodological criteria. A weighing scale for the criteria was developed, based on four main categories: study population, intervention, outcome variables and data presentation~analysis. Results: Ten studies were included in the analysis. Seven randomised clinical trials had a methodological score of 60 or more points (maximum 100), and were considered to be of good quality. The mean of the methodological score was 62.5 (s.D. 8.5). hnprovement in pain-free~maximum distance~time ranged from 28-210% (Yc 105, s.D. 55.8). Only one study evaluated outcome predictors for exercise therapy. Conclusions: All studies reported a positive effect of exercise therapy on walking distance in patients with intermittent claudication, but no predictive factors were clearly identified. Future research efforts should focus on improving the quality of clinical research for patients with intermittent claudication and developing optimal rehabilitation programs.

Introduction: Pain is an individual experience influenced by multiple interacting factors. The “biopsychosocial” care model has gained popularity in response to growing research evidence indicating the influence of biological, psychological, and social factors on the pain experience. The implementation of this model is a challenge in the practice of the health professional. Objective: To perform the transcultural adaptation of the SCEBS method into Brazilian Portuguese. Methods: The instrument was translated and applied to 50 healthy subjects and 50 participants with non-specific chronic pain in the spine. The process of cross-cultural adaptation included the following steps: transcultural adaptation, content analysis of the scale, pre-test, revision, back-translation review, cross-cultural adaptation, revised text correction and final report. Results: The translated and adapted 51-item Portuguese version of the SCEBS method produced an instrument called SCEBS-BR. In the assessment by the target population, 50 adult users of the Brazilian Unified Health System answered the questionnaire and showed good understanding of the instrument on the verbal rating scale. Conclusion: The SCEBS-BR was proved to be easily understandable, showing good semantic validation regardless of schooling level or age, and can be considered adequate for clinical use. Resumo Introdução: A dor é uma experiência individual influenciada por aspectos multifatoriais. O modelo de cuidado “biopsicossocial” adquiriu popularidade em resposta à crescente evidência de pesquisas indicando a influência de fatores biológicos, psicológicos e sociais na experiência de dor. A implantação deste modelo é um desafio na prática do profissional de saúde. Objetivo: Realizar a adaptação transcultural do Método SCEBS para o português do Brasil. Métodos: O instrumento foi traduzido e aplicado a 50 indivíduos saudáveis e 50 pacientes com dor crônica não específica na coluna. O processo de adaptação transcultural incluiu as seguintes etapas: adaptação transcultural, análise de conteúdo da escala, pré-teste, revisão, revisão de back-translation, adaptação transcultural, correção de texto revisada e relatório final. Resultados: A versão portuguesa traduzida e adaptada de 51 itens do método SCEBS produziu um instrumento denominado SCEBS-BR. Na avaliação da população-alvo, 50 usuários adultos do Sistema Único de Saúde responderam ao questionário e mostraram boa compreensão do instrumento na escala de classificação verbal. Conclusão: O SCEBS-BR demonstrou ser facilmente compreensível, mostrando boa validação semântica independentemente do nível de escolaridade ou idade e considerado adequado para o uso clínico.

Contains fulltext : 186499.pdf (Publisher’s version ) (Open Access) BACKGROUND: Guideline adherence in physical therapy is far from optimal, which has consequences for the effectiveness and efficiency of physical therapy care. Programmes to enhance guideline adherence have, so far, been relatively ineffective. We systematically developed a theory-based Quality Improvement in Physical Therapy (QUIP) programme aimed at the individual performance level (practicing physiotherapists; PTs) and the practice organization level (practice quality manager; PQM). The aim of the study was to pilot test the multilevel QUIP programme's effectiveness and the fidelity, acceptability and feasibility of its implementation. METHODS: A one-group, pre-test, post-test pilot study (N = 8 practices; N = 32 PTs, 8 of whom were also PQMs) done between September and December 2009. Guideline adherence was measured using clinical vignettes that addressed 12 quality indicators reflecting the guidelines' main recommendations. Determinants of adherence were measured using quantitative methods (questionnaires). Delivery of the programme and management changes were assessed using qualitative methods (observations, group interviews, and document analyses). Changes in adherence and determinants were tested in the paired samples T-tests and expressed in effect sizes (Cohen's d). RESULTS: Overall adherence did not change (3.1%; p = .138). Adherence to three quality indicators improved (8%, 24%, 43%; .000

Contains fulltext : 51576.pdf (Publisher’s version ) (Open Access) BACKGROUND: Treatment of headache disorders is not always optimal. Patients are treated in multiple ways, and the lack of scientific arguments for referral and the insufficient implementation of guidelines result in unclear treatment strategies. The coexistence of headache and neck pain can lead to the referral to a musculoskeletal physiotherapist. This treatment can only be successful if an underlying cervical segmental dysfunction is present. In such cases a physical treatment can be a valuable option that should be considered. The aim of this study is to identify prognostic therapeutic patient characteristics and to increase the number of correct physiotherapy referrals. METHODS/DESIGN: This trial is designed to identify patient characteristics which can influence the prognosis of the patient. Patients with recurrent headache and co-existent neck pain are recruited via a multicenter setup. After screening for eligibility, subjects are tested at baseline and randomly allocated to one of two treatment groups. Testing includes the administering of questionnaires (a Headache Diagnosis Questionnaire, Headache Inventory List and the Headache Impact Test (HIT-6)) and physical tests (Thermal Stimuli, Manual Cervical Spine Examination and Pressure Algometry). Treatment groups are a usual care group (UC) administered by the General Practitioner (GP) and a usual care plus musculoskeletal physiotherapy treatment group (UCMT). UC is based on the Dutch GP Guideline for Headache. UCMT consists of the UC plus a combination of exercises and spinal cervical mobilisations. Follow-up measurements consist of the completion of the Headache Inventory List, the HIT-6 and scoring of the global perceived effect (GPE). The latter allowing the distinction between responders (positive effect) and non-responders (no effect or worse). Logistic regression analysis will be used to identify the specific patient characteristics of the responders and the non-responders. The additional value of the musculoskeletal physiotherapy will be examined. Follow-up measurements up to 52 weeks are scheduled. DISCUSSION: This trial aims to identify prognostic patient characteristics, in order to supply a useful diagnostic tool for all health care workers, dealing with headache sufferers.