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Background: Improved techniques of measuring sitting posture have not led to a more comprehensive understanding of poor posture, nor its association with pain. There is also an evidence gap regarding critical thresholds of sitting postural change over time related to pain production. This paper describes postural angle changes over a 12-month period, and describes the process of placing defensible cut-points in the angle change data, to better understand associations between posture change over time, and onset of upper quadrant musculoskeletal pain (UQMP). Methods: This paper reports on data captured at baseline and 12-month follow-up, in adolescents in school using computers. Four sitting postural angles, head flexion (HF), neck flexion (NF), craniocervical angle (CCA) and trunk flexion (TF), and self-reported seated UQMP in the previous month were captured at each time-point. Research questions were: 1) What is the magnitude and direction of change in each postural angle over 12 months? 2) What are best cut-points in the continuous posture change distribution to most sensitively test the association between posture change and UQMP? 3) Is gender-specific cut-points required? The 12-month posture angle change data was divided into quintiles (0-20th%; 21-40 th %, 41-60 th %, 61-80 th %, > 80 th %), and the odds of UQMP occurring in each posture change quintile were calculated using logistic regression models. Results: Two hundred and eleven students participated at baseline, of which 153 were followed-up at one year. Both males and females with postural change into extension (which represents lesser flexion range) were more at risk for the development of UQMP, than any other group. The best cut-point for HF was 40 th % (≤-3.9°), NF was 20th% (≤-2.9°) and TF was 40 th % (≤-1.1°). For CCA however, change at or beyond 40 th % for extension or beyond 60% for flexion was associated with UQMP. Conclusions: Identification of critical postural angle change cut-points assists in considering the pain-producing mechanisms for adolescents using desk top computers. Refereed/Peer-reviewed

Background: There is evidence that consistent sitting for prolonged periods is associated with upper quadrant musculoskeletal pain (UQMP). It is unclear whether postural alignment is a significant risk factor. Objective and design: The aim of the prospective study (2010-2011) was to ascertain if three-dimensional sitting postural angles, measured in a real-life school computer classroom setting, predict seated-related UQMP. Method: Asymptomatic Grade 10 high-school students, aged 15-17 years, undertaking Computer Application Technology, were eligible to participate. Using the 3D Posture Analysis Tool, sitting posture was measured while students used desk-top computers. Posture was reported as five upper quadrant angles (Head flexion, Neck flexion; Craniocervical angle, Trunk flexion and Head lateral bending). The Computer Usage Questionnaire measured seated-related UQMP and hours of computer use. The Beck Depression Inventory and the Multidimensional Anxiety Scale for Children assessed psychosocial factors. Sitting posture, computer use and psychosocial factors were measured at baseline. UQMP was measured at six months and one-year follow-up. Results: 211, 190 and 153 students participated at baseline, six months and one-year follow-up respectively. 34.2% students complained of seated-related UQMP during the follow-up period. Increased head flexion (HF) predicted seated-related UQMP developing over time for a small group of students with pain scores greater than the 90th pain percentile, adjusted for age, gender, BMI, computer use and psychosocial factors (p = 0.003). The pain score increased 0.22 points per 1° increase in HF. Conclusions: Classroom ergonomics and postural hygiene should therefore focus on reducing large HF angles among computing adolescents. Refereed/Peer-reviewed

BACKGROUND: Prolonged sitting, such as when computing, has been linked to adolescent spinal pain. A chair should fit the user's body dimensions and aid the user in frequently changing sitting posture, rather than support one 'ideal' posture. Such a chair is not currently available to high school learners. OBJECTIVES: To develop a novel experimental school chair. To determine whether the experimental chair encourages regular small range movement in all directions whilst students work at computers in class. To compare the number of postural changes between the normal static school chair and the experimental chair, whilst students do computing work. METHODS: A development and validation study was conducted. Twelve high school students were randomly selected from a conveniently selected school. Fifteen minutes of 3D posture measurements were collected in both the prototype and school computer chair. The analysis focused on the frequency of postural movement. RESULTS: Data of eleven learners were analysed. There were statistically significant increases in the number of postural changes on the 'Experimental' chair compared to the school chair, for both pelvic side-flexion and pelvic rotation (ρ= 0.01). CONCLUSION: The experimental chair provided more postural movements when compared to the school computer chair. Future studies should use this experimental chair to determine the effect of increased postural movement, of especially the pelvis, on the prevalence and intensity of musculoskeletal symptoms of high school learners in the Cape Metropole area, Western Cape, South Africa. Refereed/Peer-reviewed

Background Up-to-date, high quality, evidence-based clinical practice guidelines (CPGs) that are applicable for primary healthcare are vital to optimize services for the population with chronic musculoskeletal pain (CMSP). The study aimed to systematically identify and appraise the available evidence-based CPGs for the management of CMSP in adults presenting in primary healthcare settings. Methods A systematic review was conducted. Twelve guideline clearinghouses and six electronic databases were searched for eligible CPGs published between the years 2000 and May 2015. CPGs meeting the inclusion criteria were appraised by three reviewers using the Appraisal of Guidelines Research and Evaluation (AGREE) II. Results Of the 1082 records identified, 34 were eligible, and 12 CPGs were included based on the inclusion and exclusion criteria. The methodological rigor of CPG development was highly variable, and the median domain score was 66%. The median score for stakeholder involvement was 64%. The lowest median score was obtained for the domain applicability (48%). There was inconsistent use of frameworks to aggregate the level of evidence and the strength of the recommendation in the included CPGs. The scope and content of the included CPGs focussed on opioid prescription. Conclusion Numerous CPGs that are applicable for the primary healthcare of CMSP exists, varying in their scope and methodological quality. This study highlights specific elements to enhance the development and reporting of CPGs, which may play a role in the uptake of guidelines into clinical practice. These elements include enhanced reporting of methodological aspects, the use of frameworks to enhance decision making processes, the inclusion of patient preferences and values, and the consideration of factors influencing applicability of recommendations. Trial registration PROSPERO CRD42015022098. Electronic supplementary material The online version of this article (doi:10.1186/s13012-016-0533-0) contains supplementary material, which is available to authorized users.

Background: Dynamic movement whilst sitting is advocated as a way to reduce musculoskeletal symptoms from seated activities. Conventionally, in ergonomics research, only a 'snapshot' of static sitting posture is captured, which does not provide information on the number or type of movements over a period of time. A novel approach to analyse the number of postural changes whist sitting was employed in order to describe the sitting behaviour of adolescents whilst undertaking computing activities. Methods: A repeated-measures observational study was conducted. A total of 12 high school students were randomly selected from a conveniently selected school. Fifteen minutes of 3D posture measurements were recorded to determine the number of postural changes whilst using computers. Results: Data of 11 students were able to be analysed. Large intra-subject variation of the median and IQR was observed, indicating frequent postural changes whilst sitting. Conclusion: Better understanding of usual dynamic postural movements whilst sitting will provide new insights into causes of musculoskeletal symptoms experienced by computer users. Practitioner Summary: Dynamic movement whilst sitting and operating a computer may prevent musculoskeletal pain. A new method was used to analyse usual sitting posture at a desktop computer to determine the number of postural changes whilst sitting. Better understanding of the dynamics of sitting could unlock the association with musculoskeletal symptoms experienced by many keyboard operators. Refereed/Peer-reviewed

Background Prolonged sitting has been associated with musculoskeletal dysfunction. For desk workers, workstation modifications frequently address the work surface and chair. Chairs which can prevent abnormal strain of the neuromuscular system may aid in preventing musculo-skeletal pain and discomfort. Anecdotally, adjustability of the seat height and the seat pan depth to match the anthropometrics of the user is the most commonly recommended intervention. Within the constraints of the current economic climate, employers demand evidence for the benefits attributed to an investment in altering workstations, however this evidence-base is currently unclear both in terms of the strength of the evidence and the nature of the chair features. The purpose of this study was to evaluate the evidence for the effectiveness of chair interventions in reducing workplace musculoskeletal symptoms. Methods Pubmed, Cinahl, Pedro, ProQuest, SCOPUS and PhysioFocus were searched. ‘Ergonomic intervention’, ‘chair’, ‘musculoskeletal symptoms’, ‘ergonomics’, ‘seated work’ were used in all the databases. Articles were included if they investigated the influence of chair modifications as an intervention; participants were in predominantly seated occupations; employed a pre/post design (with or without control or randomising) and if the outcome measure included neuro-musculoskeletal comfort and/or postural alignment. The risk of bias was assessed using a tool based on The Cochrane Handbook. Results Five studies were included in the review. The number of participants varied from 4 to 293 participants. Three of the five studies were Randomised Controlled Trials, one pre and post-test study was conducted and one single case, multiple baselines (ABAB) study was done. Three studies were conducted in a garment factory, one in an office environment and one with university students. All five studies found a reduction in self-reported musculoskeletal pain immediately after the intervention. Bias was introduced due to poor randomization procedures and lack of concealed allocation. Meta-analysis was not possible due to the heterogeneity of the data (differing population, intervention and outcomes across studies). Conclusion The findings of this review indicate a consistent trend that supports the role of a chair intervention to reduce musculoskeletal symptoms among workers who are required to sit for prolonged periods. However the amount, level and quality of the evidence are only moderate therefore we cannot make strong recommendations until further trials are conducted. The review also highlights gaps: for example in showing whether the effectiveness of a chair intervention has long-term impact, particularly with respect to musculoskeletal symptoms, as well as the recurrence of symptoms and the consequent cost of care.

Background Psychometric properties include validity, reliability and sensitivity to change. Establishing the psychometric properties of an instrument which measures three-dimensional human posture are essential prior to applying it in clinical practice or research. Methods This paper reports the findings of a systematic literature review which aimed to 1) identify non-invasive three-dimensional (3D) human posture-measuring instruments; and 2) assess the quality of reporting of the methodological procedures undertaken to establish their psychometric properties, using a purpose-build critical appraisal tool. Results Seventeen instruments were identified, of which nine were supported by research into psychometric properties. Eleven and six papers respectively, reported on validity and reliability testing. Rater qualification and reference standards were generally poorly addressed, and there was variable quality reporting of rater blinding and statistical analysis. Conclusions There is a lack of current research to establish the psychometric properties of non-invasive 3D human posture-measuring instruments.

Objective: To systematically review the current evidence for the effectiveness of Virtual Reality (VR), in conjunction with pharmacologic analgesia on reducing pain and anxiety in bum injury patients undergoing wound dressing changes and physiotherapy management compared with pharmacologic analgesia alone or other forms of distraction. Methods: A comprehensive search was conducted between December 2007 and January 2008, and updated in January 2009,before publication. Computerized bibliographic databases wereindividually searched using specifically developed search strategies to identify eligible studies. Results: Nine studies were deemed eligible for inclusion in this review. Wound dressing changes was the most common procedure during which VR was trialed. Pain was the primary outcome measure in all of the studies included. Anxiety was a secondary outcome measure in 3 of the 9 included studies. VR, in conjunction with pharmacologic analgesics, significantly reduced pain experienced by burn injury patients during wound dressing changes and physiotherapy.There is equivocal evidence for the effect of VR in conjunction with pharmacologic analgesics on reducing anxiety in burn injury patients during wound dressing changes and physiotherapy. Discussion: This is the first known systematic review to report on the effectiveness of VR, in conjunction with pharmacologic analgesia on reducing pain and anxiety in burn injury patients undergoing wound dressing changes and physiotherapy management compared with pharmacologic analgesia alone or other forms of distraction. Used as an adjunct to the current burn pain management regimens, VR could possibly assist health professionals in making the rehabilitation process for burn patients less excruciating, thereby improving functional outcomes. Further research investigating the effect of VR on anxiety in burn injury patients is warranted Refereed/Peer-reviewed

Prolonged sitting and psychosocial factors have been associated with musculoskeletal symptoms among adolescents. However, the impact of prolonged static sitting on musculoskeletal pain among South African high school students is uncertain. A prospective observational study was performed to determine whether sitting postural alignment and psychosocial factors contribute to the development of upper quadrant musculoskeletal pain (UQMP) in grade ten high school students working on desktop computers. The sitting postural alignment, depression, anxiety and computer use of 104 asymptomatic students were measured at baseline. At three and six months post baseline, the prevalence of UQMP was determined. Twenty-seven students developed UQMP due to seated or computer-related activities. An extreme cervical angle (43.95°; OR 2.8; 95% CI: 1.1-7.3) and a combination of extreme cervical and thoracic angles (71.1°; OR 2.2; 95% CI: 1.1-5.6) were significant postural risk factors for the development of UQMP. Boys with any extreme angle were more likely to suffer pain compared with boys with all middle range angles (OR 4.9; 95% CI: 1.0-24.5). No similar effect was found for girls. There was no strong relationship between depression, anxiety, computer exposure and UQMP among South African high school students. Refereed/Peer-reviewed

Background: Youth sports injury is a public health concern, as it has detrimental effects on the health and well-being of young athletes. The knee joint is reported to be the most common joint injured by young sports participants. The potential loss of ability to participate in regular physical activity after injury is alarming, because physical inactivity is one of the major risk factors associated with systemic disease, disability and/or death worldwide. Study design: This paper presents a systematic review of the epidemiological research reporting on the prevalence of knee injuries among active adolescents to ascertain the global scope of the problem. Results: The 19 eligible studies for this review were mostly (90%) conducted in developed countries. Global adolescent knee injury prevalence ranges between 10% and 25%, with more recent studies reporting higher percentages. The average methodological appraisal score of the 19 studies was 56%. Females and adolescents appear to be more at an increased risk of sustaining a knee injury compared with males. Conclusions: Developing standard injury definitions as well as descriptions of injury causes must be taken into consideration in future injury surveillance research in order to appropriately inform effective knee injury preventative programmes for youth.

Background Low back pain (LBP) is the most prevalent musculoskeletal condition and one the most common causes of disability in the developed nations. Anecdotally, there is a general assumption that LBP prevalence in Africa is comparatively lower than in developed countries. The aim of this review was to systematically appraise the published prevalence studies conducted on the African continent to establish the prevalence of LBP in Africa. Methods A comprehensive search was conducted in April 2006. The following databases PEDro, Psychinfo, Science Direct, SportsDiscus, PubMed, CINAHL, Biblioline Pro-African Wide NiPAD and SA ePublications were individually searched using specifically developed search strategies for epidemiological research conducted on LBP amongst the African population. Two reviewers independently evaluated the methodological quality of the studies reviewed. Results A total of 27 eligible epidemiological studies were included in this review. The majority of the studies (63%) were conducted in South Africa (37%) and Nigeria (26%). The most common population group involved workers (48%), while scholars comprised 15% of the population. 67% of the studies were found to be methodologically sound, and the LBP prevalence of these were analyzed. The mean LBP point prevalence among the adolescents was 12% and among adults was 32%. The average one year prevalence of LBP among adolescents was 33% and among adults was 50%. The average lifetime prevalence of LBP among the adolescents was 36% and among adults was 62%. Conclusion The findings support the global burden of disease of LBP, in addition to suggesting that LBP prevalence among Africans is rising and is of concern. Further research into the most effective strategies to prevent and manage LBP in Africa is warranted.

Background Albeit exercise is currently advocated as one of the most effective management strategies for fibromyalgia syndrome (FMS); the implementation of exercise as a FMS treatment in reality is significantly hampered by patients' poor compliance. The inference that pain catastrophizing is a key predictor of poor compliance in FMS patients, justifies considering the alteration of pain catastrophizing in improving compliance towards exercises in FMS patients. The aim of this study is to provide proof-of-concept for the development and testing of a novel virtual reality exposure therapy (VRET) program as treatment for exercise-related pain catastrophizing in FMS patients. Methods Two interlinked experimental studies will be conducted. Study 1 aims to objectively ascertain if neurophysiological changes occur in the functional brain areas associated with pain catastrophizing, when catastrophizing FMS subjects are exposed to visuals of exercise activities. Study 2 aims to ascertain the preliminary efficacy and feasibility of exposure to visuals of exercise activities as a treatment for exercise-related pain catastrophizing in FMS subjects. Twenty subjects will be selected from a group of FMS patients attending the Tygerberg Hospital in Cape Town, South Africa and randomly allocated to either the VRET (intervention) group or waiting list (control) group. Baseline neurophysiological activity for subjects will be collected in study 1 using functional magnetic resonance imaging (fMRI). In study 2, clinical improvement in pain catastrophizing will be measured using fMRI (objective) and the pain catastrophizing scale (subjective). Discussion The premise is if exposing FMS patients to visuals of various exercise activities trigger the functional brain areas associated with pain catastrophizing; then as a treatment, repeated exposure to visuals of the exercise activities using a VRET program could possibly decrease exercise-related pain catastrophizing in FMS patients. Proof-of-concept will either be established or negated. The results of this project are envisaged to revolutionize FMS and pain catastrophizing research and in the future, assist health professionals and FMS patients in reducing despondency regarding FMS management. Trial registration PACTR201011000264179

Background: The lack of clear understanding of the association between sitting posture and adolescent musculoskeletal pain, might reflect invalid and/or unreliable posture measurement instruments. The psychometric properties of any new measurement instrument should be demonstrated prior to use for research or clinical purposes. This paper describes psychometric testing of a new three-dimensional (3D), portable, non-invasive posture analysis tool (3D-PAT), from sequential studies using a mannequin and high school students. Conclusions: The 3D-PAT is appropriate for research and clinical settings to measure five upper quadrant postural angles in three dimensions. As a measurement instrument it can provide further understanding of the relationship between sitting posture, changes to sitting posture and adolescent musculoskeletal pain. Methods: The first study compared the 3D-(X-, Y- and Z-) coordinates of reflective markers placed on a mannequin using the 3D-PAT, and the Vicon motion analysis system. This study also tested the reliability of taking repeated measures of the 3D-coordinates of the reflective markers. The second study determined the concurrent validity and test-retest reliability of the 3D-PAT measurements of nine sitting postural angles of high school students undertaking a standard computing task. In both studies, concordance correlation coefficients and Intraclass correlation coefficients described test-retest reliability, whilst Pearson product moment correlation coefficients and Bland-Altman plots demonstrated concurrent validity. Results: The 3D-PAT provides reliable and valid 3D measurements of five of the nine postural angles i.e. head flexion, neck flexion, cranio-cervical angle, trunk flexion and head lateral bending in adolescents undertaking a standard task. Refereed/Peer-reviewed

Background Pain catastrophization has recently been recognized as a barrier to the healthy development of physical functioning among chronic pain patients. Levels of pain catastrophization in chronic pain patients are commonly measured using the Pain Catastrophizing Scale (PCS). Objective To cross-culturally adapt and validate the South African PCS (SA-PCS) among English-, Afrikaans- and Xhosa-speaking patients with fibromyalgia living in the Cape Metropole area, Western Cape, South Africa. Methods The original PCS was cross-culturally adapted in accordance with international standards to develop an English, Afrikaans and Xhosa version of the SA-PCS using a repeated measures study design. Psychometric testing included face/content validity, internal consistency (Cronbach’s alpha-α), test-retest reliability (intraclass coefficient correlations-ICC), sensitivity-to-change and cross-sectional convergent validity (by comparing the adapted SA-PCS to related constructs). Results The cross-culturally adapted English, Afrikaans and Xhosa SA-PCS showed good face and content validity, excellent internal consistency (with Chronbach’s α = 0.98, 0.98 and 0.97 for the English, Afrikaans and Xhosa SA-PCS, as a whole, respectively), excellent test-retest reliability (with ICC’s of 0.90, 0.91 and 0.89 for the English, Afrikaans and Xhosa SA-PCS, respectively); as well as satisfactory sensitivity-to-change (with a minimum detectable change of 8.8, 9.0 and 9.3 for the English, Afrikaans and Xhosa SA-PCS, respectively) and cross-sectional convergent validity (when compared to pain severity as well as South African versions of the Tampa scale for Kinesiophobia and the revised Fibromyalgia Impact Questionnaire). Conclusion The SA-PCS can therefore be recommended as simple, efficient, valid and reliable tool which shows satisfactory sensitivity-to-change and cross-sectional convergent validity, for use among English, Afrikaans and Xhosa-speaking patients with fibromyalgia attending the public health sector in the Western Cape area of South Africa.