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Background Quality indicators (QIs) are measurable elements of practice performance and may relate to context, process, outcome and structure. A valid set of QIs have been developed, reflecting the clinical reasoning used in primary care physiotherapy for patients with whiplash-associated disorders (WAD). Donabedian’s model postulates relationships between the constructs of quality of care, acting in a virtuous circle. Aim To explore the relative strengths of the relationships between context, process, and outcome indicators in the assessment of primary care physiotherapy in patients with WAD. Materials and Methods Data on WAD patients (N=810) were collected over a period of 16 years in primary care physiotherapy practices by means of patients records. This routinely collected dataset (RCD-WAD) was classified in context, process, and outcome variables and analyzed retrospectively. Clinically relevant variables were selected based on expert consensus. Associations were expressed, using zero-order, as Spearman rank correlation coefficients (criterion: rs >0.25 [minimum: fair]; α-value = 0.05). Results In round 1, 62 of 85 (72.9%) variables were selected by an expert panel as relevant for clinical reasoning; in round 2, 34 of 62 (54.8%) (context variables 9 of 18 [50.0%]; process variables 18 of 34 [52.9]; outcome variables 8 of 10 [90.0%]) as highly relevant. Associations between the selected context and process variables ranged from 0.27 to 0.53 (p≤0.00), between selected context and outcome variables from 0.26 to 0.55 (p≤0.00), and between selected process and outcome variables from 0.29 to 0.59 (p≤0.00). Moderate associations (rs >0.50; p≤0.00) were found between “pain coping” and “fear avoidance” as process variables, and “pain intensity” and “functioning” as outcome variables. Conclusion The identified associations between selected context, process, and outcome variables were fair to moderate. Ongoing work may clarify some of these associations and provide guidance to physiotherapists on how best to improve the quality of clinical reasoning in terms of relationships between context, process, and outcome in the management of patients with WAD., Video abstract Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/J5N9cYF3BW4

11 Collins CK, Masaracchio M, Brismee JM. The future of orthopedic manual therapy: what are we missing? J Man Manip Ther. 2017 Sep;25(4):169-171.We would like to comment on the Editorial by Collins...

Quality improvement has become a central tenet of physiotherapy care. Quality indicators (QIs) as measurable elements of care have been used over the past 25 years to analyze and evaluate the quality of physiotherapy care. The aim of this article is to describe the state of the art regarding the development and application of QIs in physiotherapy primary care when embedded in a clinical reasoning process. In contrast to international clinical practice guidelines, Dutch physiotherapy clinical practice guidelines are generally based on the clinical reasoning process in combination with best available evidence. Information required to develop QIs is preferably derived by combining available systematic review-based scientific evidence, guideline-based recommendations, and routinely collected data with clinical evidence, professional expertise and standards, and patient perspectives. A set of QIs (n=28) in patients with whiplash-associated disorders was developed and embedded per step of the clinical reasoning process in physiotherapy care: (a) administration (n=2); (b) history taking (n=7); (c) objectives of examination (n=1); (d) clinical examination (n=4); (e) analysis and conclusion (n=2); (f) treatment plan (n=3); (g) treatment (n=2); (h) evaluation (n=5); and (i) discharge (n=2). The use of QIs represents a useful tool for measuring the (improvement of) quality of physiotherapy primary care, as many evidentiary gaps still exist in terms of diagnostics, prognostics, and treatment, and concerning patient-related outcome measurements in different patient groups such as patients with musculoskeletal pain. The recommended set of QIs embedded in the clinical reasoning process for patients with whiplash-associated disorders can be used as a starting point for the development of a general set of QIs that measure the (improvement of) quality of primary care physiotherapy.

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

We would like to comment on a recent article by Moslem, Alrwaily, and Almarwani (2020) through aLetter to the Editor The study in question focused on adherence to clinical practice guidelines (CPGs...

BACKGROUND: Manual physical therapists (MPTs) working in primary care get limited information about patients courses of (chronic) low back pain (LBP). Identification of kinesiophobia is mostly based on clinical perception. OBJECTIVE: The aim of this study was to evaluate the association between the scores with which manual physical therapists in a primary care setting identify kinesiophobia in patients with low back pain, and the patients self-reported measures of kinesiophobia. METHODS: The cross-sectional study comprised 104 patients with LBP and 17 MPTs. Patients first independently completed the Tampa Scale for Kinesiophobia (TSK-17). The therapists, blinded to the TSK-scores, rated their perception of a patients kinesiophobia using the Visual Analogue Scale-Estimation (VAS-est) and the accuracy of their ratings using the Visual Analogue Scale-Accuracy (VAS-ac). Kendalls tau b was used to determine the level of correlation between scores on the TSK-17 and the VAS-est.

Background and aimsIdentification of psychosocial variables may influence treatment outcome. The objective of this study was to prospectively examine whether psychosocial variables, in addition to clinical variables (pain, functioning, general health, previous neck pain, comorbidity), are predictive factors for treatment outcome (i.e. global perceived effect, functioning and pain) in patients with sub-acute and chronic non-specific neck pain undergoing physical therapy or manual therapy. Psychosocial factors included treatment outcome expectancy and treatment credibility, health locus of control, and fear avoidance beliefs.MethodsThis study reports a secondary analysis of a primary care-based pragmatic randomized controlled trial. Potential predictors were measured at baseline and outcomes, in 181 patients, at 7 weeks and 26 weeks.ResultsHierarchical logistic regression models showed that treatment outcome expectancy predicted outcomeConclusionsBased on the results of this study we conclude that outcome expectancy, in patients with non-specific sub-acute and chronic neck pain, has additional predictive value for treatment success above and beyond clinical and demographic variables.ImplicationsPsychological processes, health perceptions and how these factors relate to clinical variables may be important for treatment decision making regarding therapeutic options for individual patients.

Evidence-based practice is the current undisputed predominant paradigm within medicine and allied health care, particularly in physiotherapy. Despite its potential benefits, over the years various points of criticism have been formulated one of which is the overreliance on randomized clinical trials as the highest level of evidence for treatment effectiveness. In the current era, where the availability of large amounts of clinical data gathered during the course of care delivery is rapidly increasing as well as our ability to access, process, link, and analyze these data in fairly efficient ways, alternative sources to supplement rather than replace evidence from RCTs look promising. In this Editorial, we discuss the opportunities and limitations of these routinely collected data in physiotherapy research and provide several examples from the literature. We conclude that the use of routinely collected data in physiotherapy research has the potential to increasingly contribute to real-world evidence, particularly in musculoskeletal primary care physiotherapy, provided that researchers are aware of methodological limitations and adhere to reporting standards.

Objectives: Biomechanical mechanisms underlying passive joint techniques commonly used in musculoskeletal medicine such as mobilisation and manipulation are largely unknown. We aimed to visualise and measure in vivo time-dependent changes in the volume or distribution of synovial fluid after passive joint movements. Methods: Experiments were conducted in three healthy subjects using magnetic resonance imaging (MRI) and ultrasonography (US) for visualising and measuring synovial fluid volume and distribution in joints of the upper cervical spine, the knee joints, and the metacarpophalangeal joints of the second and third fingers up to 60 minutes before and after passive motion assessment, mobilisation, and/or high-velocity, low-amplitude thrust manipulation. Results: MRI could not detect any fluid in the articular space of the lateral atlanto-axial joints. Using US, the antero-posterior diameter of the suprapatellar recess was decreased from 11.0 to 9.0 millimetres in one subject 30 minutes after mobilisation of the knee. US imaging of the palmar recesses of the metacarpophalangeal joints was found insufficiently reproducible. Conclusions: In our experiments, current techniques for MRI and US were not appropriate for visualisation and measurement of in vivo time-dependent changes, if any, in the volume or distribution of synovial fluid after passive joint movements. As a limitation, we did not estimate any measurement error of US. New, innovative research is needed to generate evidence on the biomechanical effects of passive joint techniques commonly used in musculoskeletal medicine.

Contains fulltext : 168491.pdf (Publisher’s version ) (Closed access) OBJECTIVES: The term 'cephalalgiaphobia' was introduced in the mid-1980s and defined as fear of migraine (attacks). We hypothesized that a specific subtype of cephalalgiaphobia affects patients with cervicogenic headache (CEH). This study aimed to: (1) define the term 'cervico-cephalalgiaphobia'; (2) develop a set of indicators for phobia relevant to patients with CEH; and (3) apply this set to a practice test in order to estimate the frequency of cervico-cephalalgiaphobia in the Dutch primary care practice of manual physical therapy. METHODS: A systematic approach was used to develop a definition and potential indicators for cervico-cephalalgiaphobia. An expert group appraised the definition and the set of indicators (score per indicator: never; sometimes; often/always). An invitation to participate in the practice test was sent to Dutch manual physical therapy practices (n = 56) representing 134 manual physical therapists (MPTs). The cut-off point for percentages of scores for coverage of the indicators was set at >/= 60%. RESULTS: The expert group agreed with the proposed definition of cervico-cephalalgiaphobia. A set of eight indicators for cervico-cephalalgiaphobia was selected from 10 initial indicators. Thirty-six MPTs provided data from 46 patients diagnosed with CEH. The coverage of 'often/always' was substantial for the indicators, 'Short-term positive results in previous manual physical therapeutic treatment', 'Shorter interval between treatment sessions', 'Fear of "locked facet joints" of the neck', 'More frequent manipulation', and 'Fear of increase in headaches'. Coverage was also substantial for 'never' regarding 'Long-term positive results in previous manual physical therapeutic treatment'. 'Confirmation of "locked facet joints" of the cervical spine by MPT as a cause for increase of CEH' scored 'often/always' in all patients. Coverage for 'Increased use of medication with insufficient effect' was substantial, scoring as 'sometimes' in 39 (84.8%) patients. DISCUSSION: Cervico-cephalalgiaphobia was defined and a set of eight indicators formulated based on the literature and clinical expertise. The practice test provides valuable information on the frequency of indicators for cervico-cephalalgiaphobia in the Dutch manual physical therapy practice, suggesting that cervico-cephalalgiaphobia is common in patients with CEH.

Contains fulltext : 168492.pdf (Publisher’s version ) (Closed access) OBJECTIVES: The aim of this study was to evaluate the efficacy of Manual Therapy Utrecht (MTU) plus education in patients with cervicogenic somatosensory tinnitus (CeT). STUDY DESIGN: Pretest-posttest design. METHOD: Five hundred and six patients were referred or referred themselves. A subgroup of patients was identified with CeT, and within this a subgroup with tinnitus sensitization (TS). Two CeT groups were created based on the presence or absence of TS. Both groups underwent manual therapy combined with tinnitus education. Tinnitus intensity (VAS-tin 0-100 mm) was the primary outcome measure. Number of treatments and adverse effects were the secondary outcome measures. RESULTS: A total of 122 patients with CeT (24.1%) were included (average age 53.3 years [+/-9.8], female 38.5% and duration of tinnitus 7.3 years [+/-8.9]). Patients were divided into two groups: 55 patients (45.1%) with TS (CeT + TS group) and 67 patients (54.9%) without TS (CeT - TS group). Pretest to posttest differences on the VAS-tin were statistically significant within both groups (CeT - TS group: difference VAS-tin 5.9 [p = 0.01]; CeT + TS group: difference VAS-tin 18.2 [p = 0.00]), and between the groups in favor of the CeT + TS group (difference VAS-tin 12.3 [p = 0.01]). Pretest to posttest differences were clinically significant for the CeT + TS group (difference VAS-tin 18.2 [MCIC = >/=10 mm VAS-tin]) and between the groups (difference VAS-tin 12.3 in favor of the CeT + TS group). The average number of treatment sessions was 9.6 (+/-2.6) for the CeT - TS group and 10.3 (+/-2.5) for the CeT + TS group, a non-significant difference. There were no adverse effects in either group. CONCLUSIONS: Despite its limitations, this study provides valuable information on both the characteristics of patients with CeT and TS in a Dutch primary care manual therapy practice and on the potential effectiveness of MTU combined with tinnitus education for the subgroup of CeT + TS patients.

Patienten mit (chronischen) Schmerzen befolgen haufig nur unzureichend Anweisungen, die darauf abzielen, dass sie (weiter) ihre Ubungen machen und korperlich aktiv bleiben oder aktiver werden. Dies kann eine negative Wirkung auf die Behandlungseffektivitat haben. Bis heute findet sich in der Fachliteratur keine uberzeugende Erklarung fur dieses unzureichende Befolgen von Behandlungsanweisungen. Dieser Artikel sucht eine mogliche theoretische Erklarung in der kognitiven Dissonanztheorie. Sie zeigt, dass die Kommunikation zwischen Physiotherapeuten und Patienten zu fortbestehenden Beschwerden fuhren kann. Viele Patienten mit chronischen Schmerzen haben Angst vor Schmerzen und neigen dazu, schmerzauslosende Ubungen und Aktivitaten zu vermeiden. Das bedeutet, sie vernachlassigen auch schmerzauslosende Anweisungen zu Ubungen, die sie auserhalb der Behandlungssitzungen durchfuhren sollen. Im Kontakt mit den Physiotherapeuten suchen sie nach Signalen, die es ihnen erlauben, das Vermeiden von Ubungen und korperlichen Aktivitaten zu legitimieren. Physiotherapeuten haben haufig selbst mehr oder weniger Angst davor, bei ihren Patienten Schmerzen auszulosen. Daher geben sie in der Kommunikation mit den Patienten – oft unbewusst – ihre Angstkognitionen in Form von verbalen, para- und nonverbalen Signalen an diese weiter. Die Patienten interpretieren sie dann wiederum als Legitimierung fur ihr Vermeidungsverhalten. Dies geschieht z. B., indem die Physiotherapeuten einfuhlend auf eine Schmerzzunahme reagieren und diese Reaktionen als empathisch und damit therapeutisch sinnvoll und gerechtfertigt interpretieren. Die Patienten dagegen sehen in ihnen eine Bestatigung ihrer eigenen Angst vor Schmerzen und damit eine Rechtfertigung fur ihr Vermeidungsverhalten. Das Zusammenwirken und Verstarken der Angstkognitionen von Therapeuten und Patienten wird als iatrogene Symbiose bezeichnet. Die Vermeidung einer solchen iatrogenen Symbiose und damit einhergehend die Verbesserung der Bereitschaft der Patienten, sich an Anweisungen zu halten, lasst sich durch konsequentes verbales als auch para- und/oder nonverbales Ignorieren von Schmerzsignalen der Patienten vermeiden. Im Kontext des Verhaltnisses zwischen Therapeuten und Patienten muss „empathisches Handeln“ deshalb als professionelle Fahigkeit zu handeln im Einklang mit langfristigen Behandlungszielen definiert werden. Auf diese Weise kann das Erkennen einer moglichen iatrogenen Symbiose als „Sprungbrett“ zu einem optimalen Behandlungsergebnis dienen.

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.

Dear Editor,With interest, we have read the article on clinical biopsychosocial physiotherapy assessment of patients with chronic pain (Wijma, van Wilgen, Meeus, and Nijs, 2016). We would like to c...

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.

RATIONALE, AIMS AND OBJECTIVES: Little is currently known about the quality of physiotherapy care for patients with musculoskeletal pain. Neck pain was used as an example. The aim is to develop a set of quality indicators, including a practice test. METHODS: A systematic method is used to develop potential process and outcome indicators. An expert and user panel is used to appraise the potential quality indicators regarding clarity, relevancy, feasibility, acceptability and improvement potential. An invitation to participate in the practice test was sent to physiotherapy practices. The resulting algorithm is used to calculate the degree to which physiotherapists met these indicators (0-100%). Differences in valid outcomes are tested for significance (Student's t-test; alpha = 0.05) and compared with established values for clinical relevance [minimal clinically important change (MCIC)]. RESULTS: A representative set of 40 quality indicators (28 process indicators and 12 outcome indicators) is selected from 44 initial guidelines and literature-based recommendations. The process indicators (n = 28) are classified per step of the clinical reasoning process of physiotherapy care. Of the 106 potential participants from 27 practices, 38 physiotherapists (35.8%) submitted data on 96 patients with non-specific neck pain. On average, the participating physiotherapists showed a 55.6% adherence to process indicators with a great variation in scores per step of the clinical reasoning process. The outcomes for 'pain', 'headache' and 'daily functioning' were significantly better compared with baseline, and the mean differences exceeded established values for MCICs. CONCLUSION: Guardedly, we can conclude that a systematic approach is a valuable means to develop a preliminary set of process and outcome indicators for physiotherapy care for patients with non-specific neck pain, and a practice test should be an intrinsic part of such a systematic approach as it provides valuable information on the key attributes of the set indicators.

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

Item does not contain fulltext AIM: To determine longitudinal motor performance in very preterm (VPT) infants from 6 months to 5 years of age for the entire cohort of infants, according to gender and gestational age and at the individual level. METHOD: Single-center, prospective longitudinal study of 201 VPT infants (106 boys) without severe impairments. OUTCOMES: Motor performance was assessed with the Bayley Scales of Infant Development (BSID-II-MS: 6, 12, 24 months) and the Movement Assessment Battery for Children (MABC-2-NL: 5 years). RESULTS: At 6, 12, and 24 months and then at 5 years, 77%, 80%, 48%, and 22% of the infants, respectively, showed delayed motor performance (

Contains fulltext : 168493.pdf (Publisher’s version ) (Closed access) Tinnitus can be evoked or modulated by input from the somatosensory and somatomotor systems. This means that the loudness or intensity of tinnitus can be changed by sensory or motor stimuli such as muscle contractions, mechanical pressure on myofascial trigger points, transcutaneous electrical stimulation or joint movements. The neural connections and integration of the auditory and somatosensory systems of the upper cervical region and head have been confirmed by many studies. These connections can give rise to a form of tinnitus known as somatosensory tinnitus. To date only a handful of publications have focussed on (cervicogenic) somatosensory tinnitus and manual therapy. Broadening the current understanding of somatosensory tinnitus would represent a first step towards providing therapeutic approaches relevant to manual therapists. Treatment modalities involving the somatosensory systems, and particularly manual therapy, should now be re-assessed in the subgroup of patients with cervicogenic somatosensory tinnitus. The conceptual phase of this study aims to uncover underlying mechanisms linking the auditory and somatosensory systems in relation to subjective tinnitus through (i) review of the literature (part 1) and (ii) through design of a pilot study that will explore characteristics of the study population and identify relevant components and outcomes of manual therapy in patients with cervicogenic somatosensory tinnitus (part 2). This manuscript focusses the theoretical concept of (cervicogenic) somatosensory tinnitus, either with or without secondary central tinnitus or tinnitus sensitization.

Background: Transcutaneous electrical nerve stimulation (TENS) is an easy to use analgesic intervention. However, long-term randomized placebo-controlled studies with treatment periods of more than 3 months have not been executed to date. The aim of our study is to explore the long-term (1 year) time course of the treatment effects of TENS compared to placebo (sham TENS). Method: We performed a randomized placebo-controlled trial in patients with chronic pain (165), referred to a multidisciplinary pain center of a university hospital. Main outcome measures are the proportion of patients satisfied with treatment result and willing to continue treatment, pain intensity, pain disability, and perceived health status. Results: Survival analysis of time courses of proportions of satisfied patients revealed no significant differences (P = 0.79; log-rank test) for TENS treatment compared to sham TENS. After 1 year, 30% (24/81) of the patients of the TENS group and 23% (19/82) of the sham TENS group were satisfied with treatment result. These patients experienced a mean overall improvement of 62.7% (n = 43). This effect was not significantly different between both groups. For satisfied patients, there were no differences in pain intensity or disability and perceived health status between the TENS and sham TENS group. Conclusions: Transcutaneous electrical nerve stimulation and sham TENS show similar effects in patients with chronic pain over a period of 1 year. We found support for a long sustained placebo effect.

Item does not contain fulltext BACKGROUND: Pediatric physical therapists assess the quantity and quality of children's motor skills. Several quantitative motor tests are currently available, but a concise measurement tool of observable movement quality (OMQ) is lacking. OBJECTIVE: The purpose of this study was to develop an OMQ measurement tool for children from the perspective of pediatric physical therapists. DESIGN: A qualitative, 3-phase study involving pediatric physical therapists was conducted. METHODS: The first phase consisted of 7 semistructured interviews. The second phase comprised a structured meeting using a nominal group technique, with the interviewees required to identify the most relevant OMQ aspects. The third phase comprised a Delphi technique involving 61 pediatric physical therapy experts with the aim of achieving at least 80% agreement on relevance, terminology, and definitions of OMQ aspects. RESULTS: Across all 3 phases, 32 aspects based on different theoretical constructs were considered. Fifteen aspects were included in the measurement. The pediatric physical therapy experts achieved at least 80% agreement on the definitions of 14 OMQ aspects: automated movements, asymmetry in movements, variation in movements, appropriate gross motor movements, fluency of movements, reduced muscle tone, increased muscle tone, involuntary movements, accuracy, slow/delayed movements, accelerated/abrupt movements, tremors, strength regulation, and stereotyped movements. The definition of appropriate fine motor movements achieved 75% agreement. This aspect was included because gross and fine motor movements are complementary. The aspects were scored using a 5-point Likert scale, with a total score ranging from 15 to 75 and with a higher score indicating a better OMQ. CONCLUSION: The OMQ scale, a concise measurement tool with 15 defined aspects, was developed. Content validity was obtained, but before the OMQ scale can be used in clinical practice, studies on reliability, construct validity, and responsiveness are needed. 01 april 2012

Contains fulltext : 89481.pdf (Publisher’s version ) (Closed access) Central sensitization plays an important role in the pathophysiology of numerous musculoskeletal pain disorders, yet it remains unclear how manual therapists can recognize this condition. Therefore, mechanism based clinical guidelines for the recognition of central sensitization in patients with musculoskeletal pain are provided. By using our current understanding of central sensitization during the clinical assessment of patients with musculoskeletal pain, manual therapists can apply the science of nociceptive and pain processing neurophysiology to the practice of manual therapy. The diagnosis/assessment of central sensitization in individual patients with musculoskeletal pain is not straightforward, however manual therapists can use information obtained from the medical diagnosis, combined with the medical history of the patient, as well as the clinical examination and the analysis of the treatment response in order to recognize central sensitization. The clinical examination used to recognize central sensitization entails the distinction between primary and secondary hyperalgesia. 01 april 2010

Question: What is the inter-rater reliability for measurements of passive physiological or accessory movements in lower extremity joints? Design: Systematic review of studies of inter-rater reliability. Participants: Individuals with and without lower extremity disorders. Outcome measures: Range of motion and end-feel using methods feasible in daily practice. Results: 17 studies were included of which 5 demonstrated acceptable inter-rater reliability. Reliability of measurements of physiological range of motion ranged from Kappa -0.02 for measuring knee extension using a goniometer to ICC 0.97 for measuring knee flexion using vision. Measuring range of knee flexion consistently yielded acceptable reliability using either vision or instruments. Measurements of end-feel were unreliable for all hip and knee movements. Two studies satisfied all criteria for internal validity while reporting acceptable reliability for measuring physiological range of knee flexion and extension. Overall, however, methodological quality of included studies was poor. Conclusion: Inter-rater reliability of measurement of passive movements in lower extremity joints is generally low. We provide specific recommendations for the conduct and reporting of future research. Awaiting new evidence, clinicians should be cautious when relying on results from measurements of passive movements in joints for making decisions about patients with lower extremity disorders. [van Trijffel E, van de Pol RJ, Oostendorp RAB, Lucas C (2010) Inter-rater reliability for measurement of passive physiological movements in lower extremity joints is generally low: a systematic review. Journal of Physiotherapy 56: 223-235]

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.

Background: This article investigated a Dutch scientific study on the evaluation of the quality of physiotherapy patient documentation and its implementation in daily practise of physiothera- pists in Switzerland. Objective: To find a standardised procedure within the scope of a quality-circle in order to as- sess and identify flaws and improve the actual state of physiotherapeutic patient documenta- tion, then test the procedure and advance an opinion about it. Method: The quality evaluation instrument in- cluding the corresponding article's summary and quintessence were translated into German. A non-member's back-translation ensured the indi- cators' analogous rendition in German. After- wards all members evaluated several patient charts by means of this instrument. The applica- tion served as a basis for the discussion about the quality evaluation instrument and all the item- ized indicators. Results: All indicators can be transferred to Swiss conditions. The instrument is well suited for qual- ity survey of the physiotherapy patient documen- tation within the scope of a quality-circle. It offers the opportunity to implement specific desirable or necessary corrections in relevant clinical de- tails. As an individual aim 2 or 3 indicators can offhand be identified. Conclusion: The quality evaluation instrument should also be available to other physiotherapists, moderators and their quality-circles. With the authors' consent it was decided to offer the origi- nal article as well as the manual and score-form as download on the Swiss Association of Physio- therapy website (www.physioswiss.ch).

Item does not contain fulltext PURPOSE: To investigate the feasibility and effect of a functional physical training program on aerobic endurance and walking ability of children with cerebral palsy. METHODS: Thirteen children (8-13 years, Gross Motor Function Classification System level I or II, with normal intelligence or mild retardation) participated in this study. A functional physical training program addressing aerobic endurance, walking distance, walking velocity, and ambulation, consisted of a circuit with 4 stations and lasted 30 minutes twice weekly for 9 weeks. The Bruce, 6-minute-run test, Timed Up and Down Stairs Test, and Ambulation Questionnaire were administered 2 weeks before the start, immediately after, and 11 weeks after the intervention. RESULTS: Significant improvement in aerobic endurance, walking distance, and ambulation were observed immediately after the intervention. Maximum treadmill time had improved significantly at 11 weeks. CONCLUSION: A functional physical training improves the aerobic endurance and the functional walking ability of children with cerebral palsy.

Contains fulltext : 79851.pdf (Publisher’s version ) (Closed access) PURPOSE: A systematic evaluation of the literature to identify health and contextual factors associated with employment in patients with neuromuscular diseases (NMD) and to perform a best evidence synthesis, taking into account the design of studies, methodological quality and the statistical significance of findings. METHOD: Publications were retrieved by a computerised search in medical and psychological databases. Two reviewers assessed titles and abstracts first and assessed the quality of the remaining full text publications independently as well. Of the residual publications, health and contextual factors associated with employment in patients with NMD were extracted. The factors found were included in a recently developed expanded International Classification of Functioning, Disability and Health scheme. RESULTS: Six hundred and sixty-two titles and abstracts were screened. The main reason to exclude a title and/or abstract was the absence of the study population selected: Facioscapulohumeral Muscular Dystrophy (FSHD), Hereditary Motor and Sensory Neuropathy (HMSN) & Myotonic Dystrophy (MD). Of the remaining 20 full-text publications, eight publications fulfilled the inclusion criteria: two repeated survey designs and six cross-sectional studies. Factor extraction resulted in 94 factors related to employment. Ten factors in five publications were indicative for an association with employment status: Disease related factors HMSN, MD & NMD in general), factors related to functions (physical functions, muscle power functions), general personal factors (age, gender and education), work related personal factors (type of occupation, and expressed interest in employment by patients with NMD). CONCLUSION: In the best evidence synthesis ten factors were indicative for an association with employment status in patients with NMD in five publications with good to excellent methodological quality.

There is evidence for the efficacy of allied health care in Parkinson's disease (PD). However, barriers exist that hamper implementation of evidence into daily practice. We conducted a survey to investigate: (1) to what extent PD patients currently utilize allied health care for relevant problems in the core areas of allied health care and (2) the level of PD-specific expertise among allied health professionals. Questionnaires were sent to 260 patients and 297 allied health professionals. Referral rates were 63% for physical therapy, 9% for occupational therapy, and 14% for speech therapy. PD patients with problems that can potentially be alleviated by input from allied health professionals are often not being referred. Furthermore, most patients were treated by allied health professionals who lacked PD-specific expertise. Current referral to and delivery of allied health care in PD are suboptimal. Evidence-based guidelines for allied health care in PD and active implementation of these guidelines are needed.

Contains fulltext : 71413.pdf (Publisher’s version ) (Closed access) Transcutaneous electrical nerve stimulation (TENS) is an easy to use non-invasive analgesic intervention applied for diverse pain states. However, effects in man are still inconclusive, especially for chronic pain. Therefore, to explore the factors predicting result of TENS treatment in chronic pain we conducted a prospective, randomized, placebo-controlled trial (n=163), comparing high frequency TENS (n=81) with sham TENS (n=82). Patients' satisfaction (willingness to continue treatment; yes or no) and pain intensity (VAS) were used as outcome measures. The origin of pain and cognitive coping strategies were evaluated as possible predictors for result of TENS treatment. Results: Fifty-eight percent of the patients in the TENS group and 42.7% of the sham-TENS group were satisfied with treatment result (chi square=3.8, p=0.05). No differences were found for pain intensity. Patients diagnosed with osteoarthritis and related disorders (especially of the vertebral column) or peripheral neuropathic pain were less satisfied with high frequency TENS (OR=0.12 (95% CI 0.04-0.43) and 0.06 (95% CI 0.006-0.67), respectively). Injury of bone and soft tissue (especially postsurgical pain disorder) provided the best results. Treatment modality or interactions with treatment modality did not predict intensity of pain as a result of treatment. We conclude, that predicting the effect of high frequency TENS in chronic pain depends on the choice of outcome measure. Predicting patients' satisfaction with treatment result is related to the origin of pain. Predicting pain intensity reflects mechanisms of pain behavior and perceived control of pain, independent of treatment modality. Pain catastrophizing did not predict TENS treatment outcome.

Contains fulltext : 69726.pdf (Publisher’s version ) (Closed access) The aim of this cross-sectional study was to determine the influence of test-taking behaviour and risk factors for delayed motor performance in 437 preterm infants (244 males, 193 females; < or = 32 weeks of gestation) at the corrected age of 2 to 3 years (mean 29mo [SD 3.3]). Other mean (SD) sample demographics were: postmenstrual age 29(+5) weeks (1(+5)), range 25(+0)-32(+0); birthweight 1213.7g (331.7), range 468-2350; and days in the neonatal intensive care unit 21.1 (21.3), range 1-165. Children (n=23) with a severe disability were excluded. We assessed motor performance and behaviour during testing with the Motor Scale and the Behaviour Rating Scale (BRS) of the Bayley Scales of Infant Development, 2nd edition (BSID-II). Risk factors were tested against delayed motor performance as the dependent variable in binary logistic regression analysis. Median score on the Motor Scale in terms of the BSID-II Psychomotor Developmental Index (PDI) was 86. 'Delayed' motor performance was observed in 46.5% of the children tested, and behaviour was 'not-optimal' in 31.4%. The Motor Scale and BRS scores were significantly correlated (r(s)=0.62, p

A systematic review was conducted to assess the evidence base of occupational therapy for adults with neuromuscular diseases. A comprehensive search for controlled and uncontrolled studies was performed in the Cochrane, MEDLINE, CINHAL, and EMBASE databases. After screening 3,534 titles and abstracts, six articles were retrieved for more detailed evaluation. Only two studies met all of the predefined criteria and were subjected to methodological assessment. These studies provide indications for the efficacy of hand training in muscle diseases. There is a lack of scientific evidence regarding the question of whether patients with neuromuscular diseases are better capable of participating in meaningful activities and roles through occupational therapy. Recommendations for future research are given.

This observational study included both asymptomatic subjects (n=8) and patients with unilateral or bilateral shoulder pain (n=32). Patient diagnoses provided by the referring medical physicians included subacromial impingement, rotator cuff disease, tendonitis, tendinopathy, and chronic subdeltoid-subacromial bursitis. Three raters bilaterally palpated the infraspinatus, the anterior deltoid, and the biceps brachii muscles for clinical characteristics of a total of 12 myofascial trigger points (MTrPs) as described by Simons et al. The raters were blinded to whether the shoulder of the subject was painful. In this study, the most reliable features of trigger points were the referred pain sensation and the jump sign. Percentage of pair-wise agreement (PA) was >/= 70% (range 63-93%) in all but 3 instances for the referred pain sensation. For the jump sign, PA was >/= 70% (range 67-77%) in 21 instances. Finding a nodule in a taut band (PA = 45-90%) and eliciting a local twitch response (PA = 33-100%) were shown to be least reliable. The best agreement about the presence or absence of MTrPs was found for the infraspinatus muscle (PA = 69-80%). This study provides preliminary evidence that MTrP palpation is a reliable and, therefore, potentially useful diagnostic tool in the diagnosis of myofascial pain in patients with non-traumatic shoulder pain.

In 2006 is de multiprofessionele Richtlijn Complex Regionaal Pijnsyndroom type I (CRPS I) gepresenteerd over de diagnostiek en behandeling van dit syndroom, ook wel posttraumatische dystrofie (PD) of sympathische reflexdystrofie (SRD) genaamd (Richtlijn Complex Regionaal Pijn Syndroom type I, 2006).

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 : 50069.pdf (Publisher’s version ) (Closed access) OBJECTIVE: To assess the stability of benefits of mime therapy, a modality of physiotherapy for patients with facial nerve paresis, during a period of 1 year. STUDY DESIGN: A prospective follow-up build on a randomized clinical trial in which a treatment group is compared with a control group. SETTING: Physiotherapy outpatient department. PATIENTS: Forty-eight patients with a history of a facial nerve paresis of 9 months or more. INTERVENTION: Mime therapy. METHOD: Sequelae of facial nerve paresis were measured using the same measurement instruments as in the randomized clinical trial--the Sunnybrook and the House-Brackmann (HB) Facial Grading Systems, the lip length and pout indices, a stiffness scale, and the Facial Disability Index. Stability of outcome level and of interpatient differences is analyzed. RESULTS: Of the 46 patients who completed the follow-ups, repeated-measures analyses of covariance revealed no significant differences in the average scores nor significant trends of the posttherapy measurements, except for the pout index and the Facial Disability Index-social. For six sequelae (except HB), 95% of patient-sequel combinations showed immediate improvement after mime therapy, for HB grades this was 74%. Where sequelae improved, the posttherapy individual courses (T2-T3-T4) showed, also for HB, in majority absence of deterioration; benefits obtained were stable. CONCLUSION: Mime therapy is effective in patients with facial nerve paresis and benefits are stable 1 year after therapy.

A previous study compared socio-demographic characteristics, health problem characteristics, and primary process data between a database sample of patients referred to physical therapy (PT) versus a sample of patients referred for specific manual physical therapy (MPT) diagnosis and management. This study did not differentiate between patients based on affected body region or diagnosis. The present study is a secondary analysis of these data for patients with non-specific low-back pain (LBP). Statistical analysis indicated that the MPT patient sample was significantly (P

Contains fulltext : 49338.pdf (Publisher’s version ) (Closed access) STUDY DESIGN: Prospective inception cohort study. OBJECTIVE: To investigate prospectively whether pain-related fear predicts future perceived disability and participation in patients with acute low back pain (LBP). SUMMARY OF BACKGROUND DATA: There are indications that fear of movement/(re)injury, as measured by the Tampa Scale for Kinesiophobia, is present early in an episode of LBP, and that it might be a predictor of future perceived disability and participation. METHODS: A cohort of 555 patients with acute LBP included by general practitioners and physical therapists in primary care settings was followed for 6 months. RESULTS: Results indicate that baseline fear of movement/(re)injury was predictive of future perceived disability and, to a lesser extent (and together with duration and radiation), of participation. CONCLUSIONS: The results suggest that interventions aimed at reducing pain-related fear in the acute stage of LBP might prevent restrictions of activity and participation because of pain, and might be a way of preventing the transition from acute to chronic LBP.

Contains fulltext : 51217.pdf (Publisher’s version ) (Open Access) The aim of this study was to test the efficacy of shortterm transcutaneous electrical nerve stimulation (TENS) treatment in chronic pain with respect to pain intensity and patients' satisfaction with treatment results. We therefore performed a randomised controlled trial comparing TENS and sham TENS. Patients, researchers and therapists were blinded for treatment allocation. One hundred and sixty-three patients with chronic pain referred to the Pain Centre entered the study. Conventional TENS and sham TENS were applied in the segments of pain, for a period of ten days. Outcome measures were pain intensity (visual analogue scale) and patients' satisfaction with treatment result (yes or no). The proportions of patients satisfied with treatment result differed significantly for TENS compared to sham TENS (58 and 42.7% respectively, chi(2)=3.8, p=0.05). However, no differences in pain intensity were found for patients treated with TENS or sham TENS. Only for patients satisfied with treatment results pain intensity gradually decrease equally both for TENS and sham TENS with repeated treatment application.

Contains fulltext : 50239.pdf (Publisher’s version ) (Closed access) OBJECTIVE: To determine the effectiveness of a behavioral graded activity program (BGA) compared with usual care (UC; exercise therapy and advice) according to the Dutch guidelines for physiotherapy in patients with osteoarthritis (OA) of the hip and/or knee. The BGA intervention is intended to increase activity in the long term and consists of an exercise program with booster sessions, using operant treatment principles. METHODS: We conducted a cluster randomized trial involving 200 patients with hip and/or knee OA. Primary outcome measures were pain (visual analog scale [VAS] and Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]), physical function (WOMAC), and patient global assessment, assessed at weeks 0, 13, 39, and 65. Secondary outcome measures comprised tiredness (VAS), patient-oriented physical function (McMaster Toronto Arthritis Patient Preference Disability Questionnaire [MACTAR]), 5-meter walking time, muscle strength, and range of motion. Data were analyzed according to intent-to-treat principle. RESULTS: Both treatments showed short-term and long-term beneficial within-group effects. The mean differences between the 2 groups for pain and functional status were not statistically significant. Significant differences in favor of BGA were found for the MACTAR functional scale and 5-meter walking test at week 65. CONCLUSION: Because both interventions resulted in beneficial long-term effects, the superiority of BGA over UC has not been demonstrated. Therefore, BGA seems to be an acceptable method to treat patients with hip and/or knee OA, with equivalent results compared with UC.

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 : 47397.pdf (Publisher’s version ) (Closed access) STUDY DESIGN: Data were derived from a randomized controlled trial on the (cost-) effectiveness of the implementation of the clinical guidelines on physiotherapy for low back pain in primary care. OBJECTIVES: To describe the course of low back pain in patients who are referred to physiotherapy, to identify clinically important prognostic factors on different outcomes, and to evaluate the influence of different statistical techniques in developing a prognostic model. SUMMARY OF BACKGROUND DATA: Several studies have aimed to identify prognostic factors for low back pain in primary care. These studies focused on different outcome measures and used various statistical techniques. METHODS: Primary outcomes were perceived recovery, improvement in pain, improvement in functioning, and presence of disabling low back pain at 3 and 12 months follow-up. Multivariate logistic regression analyses were performed for each outcome variable. Two cut-off points were used to determine significance with respect to the univariate analysis, and two selection methods were used to build the final multivariate models. The resulting prognostic models were compared. RESULTS: A total of 500 patients were included. Pain and disability reduced considerably in the first 3 months, but further reduction was only modest. Prognostic factors varied for different outcomes, but the duration of the current episode was included in all models generated. Varying the statistical techniques also resulted in a different prognostic model with some change to the amount of variance explained. CONCLUSIONS: A substantial proportion of patients still experienced some pain and disability at 12 months follow-up. The most stable predictor of prognosis in low back pain was the duration of the current episode. The choice of statistical method influenced the final model; however, changes in the explained variance were small.

Het is mogelijk in grote lijnen te voorspellen wie een chronische whiplash zal ontwikkelen en wie niet. Whiplashklachten worden vooral chronisch bij vrouwelijke patienten met een relatief laag opleidingsniveau, die in de periode direct na het ongeval veel nekpijn hebben, niet aan het werk kunnen en somatiseren. De arts zou in het bijzonder de patienten die aan dit beeld voldoen, een behandeling moeten aanbieden. Dit vermindert mogelijk het percentage chronische klachten bij een whiplash.

Background and Purpose. An active strategy was developed for the implementation of the clinical guidelines on physical therapy for patients with low back pain. The effect of this strategy on patients' physical functioning, coping strategy, and beliefs regarding their low back pain was studied. Subjects. One hundred thirteen primary care physical therapists treated a total of 500 patients. Methods. The physical therapists were randomly assigned to 1 of 2 groups. The control group received the guidelines by mail (standard passive method of dissemination). The intervention group, in contrast, received an additional active training strategy consisting of 2 sessions with education, group discussion, role playing, feedback, and reminders. Patients with low back pain, treated by the participating therapists, completed questionnaires on physical functioning, pain, sick leave, coping, and beliefs. Results. Physical functioning and pain in the 2 groups improved substantially in the first 12 weeks. Multilevel longitudinal analysis showed no differences between the 2 groups on any outcome measure during follow-up. Discussion and Conclusion. The authors found no additional benefit to applying an active strategy to implement the physical therapy guidelines for patients with low back pain. Active implementation strategies are not recommended if patient outcomes are to be improved.

Contains fulltext : 49588.pdf (Publisher’s version ) (Closed access) The objective of this systematic review is to summarize scientific evidence concerning the predictive value of bio-psychosocial risk factors with regard to the outcome after lumbar disc surgery. Medical and psychological databases were used to locate potentially relevant articles, which resulted in the selection of 11 studies. Each of these studies has a prospective design that examined the predictive value of preoperative variables for the outcome of lumbar disc surgery. Results indicated that socio-demographic, clinical, work-related as well as psychological factors predict lumbar disc surgery outcome. Findings showed relatively consistently that a lower level of education, a higher level of preoperative pain, less work satisfaction, a longer duration of sick leave, higher levels of psychological complaints and more passive avoidance coping function as predictors of an unfavourable outcome in terms of pain, disability, work capacity, or a combination of these outcome measures. The results of this review provide preliminary opportunities to select patients at risk for an unfavourable outcome. However, further systematic and methodologically high quality research is required, particularly for those predictors that can be positively influenced by multidisciplinary interventions.

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.

Contains fulltext : 48070.pdf (Publisher’s version ) (Closed access) OBJECTIVES: To evaluate the effect on the process of care of an active strategy to implement clinical guidelines on physiotherapy for low back pain. DESIGN: A cluster randomised controlled trial comparing an active strategy with standard dissemination. SETTING: Primary care physiotherapy practices. PARTICIPANTS: 113 physiotherapists were randomly allocated to receive the guidelines by mail (control group) or to receive an additional active strategy (intervention group) which consisted of a multifaceted programme including education, discussion, role playing, feedback, and reminders. MAIN OUTCOME MEASURES: Adherence to the guidelines was measured by means of individual patients' forms recording the treatment completed by the physiotherapist. The forms were assessed using an algorithm based on the number of treatment sessions, treatment goals, interventions, and patient education. RESULTS: Physiotherapists in the intervention group more often correctly limited the number of treatment sessions for patients with a normal course of back pain (OR 2.39; 95% CI 1.12 to 5.12), more often set functional treatment goals (OR 1.99; 95% CI 1.06 to 3.72), more often used mainly active interventions (OR 2.79; 95% CI 1.19 to 6.55), and more often gave adequate patient education (OR 3.59; 95% CI 1.35 to 9.55). They also adhered more to all four criteria (OR 2.05; 95% CI 1.15 to 3.65). CONCLUSIONS: The active strategy moderately improved adherence to the guidelines. Active strategies are recommended to implement the clinical guidelines on physiotherapy for low back pain.

Since 1980, patients with sequelae of peripheral facial nerve paresis have been treated with mime therapy at the physiotherapy department of the University Medical Centre in Nijmegen, which aims to rehabilitate facial expression. Mime therapy was developed by Jan Bronk (a mime actor) and Pieter Devriese (an otolaryngologist) in the 1970s, using the principles of mime for patients suffering from either lack of facial movement or uncontrolled movements. Both therapists and patients reported benefits of mime therapy; most importantly, an improved symmetry of the face. There is a belief within the profession that evidence-based treatment is required to scientifically substantiate physiotherapy. A detailed description of the mime therapy treatment is essential for performing a randomized controlled trial, which is currently underway. This article aims to comprehensively describe the historical development and clinical characteristics of mime therapy and to give insight into its usefulness as a tool in the treatment of patients with facial nerve paresis.

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.