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QUESTION: Can existing post-treatment prognostic models for predicting neck pain recovery (primarily in terms of disability and secondarily in terms of pain intensity and perceived improvement) be externally validated and updated at the end of the treatment period and at 6 and 12 weeks of follow-up in a new Dutch cohort of people with neck pain treated with guideline-based usual care physiotherapy?DESIGN: External validation and model updating in a new prospective cohort of three previously developed prognostic models.PARTICIPANTS: People with (sub)acute neck pain and registered for primary care physiotherapy treatment.OUTCOME MEASURES: Recovery of disability, pain intensity, and perceived recovery at 6 and 12 weeks and at the end of the treatment period.RESULTS: Discriminative performance (c-statistic) of the disability model at 6 weeks was 0.73 (95% CI 0.69 to 0.77) and reasonably well calibrated after intercept recalibration. The disability model at 12 weeks and at the end of the treatment period showed discriminative c-statistic performance values of 0.69 (95% CI 0.64 to 0.73) and 0.68 (95% CI 0.63 to 0.72), respectively, and was well calibrated. Pain models and perceived recovery models did not reach acceptable performance. Cervical mobility added value to the disability models and pain catastrophising to the disability and pain models at 6 weeks.DISCUSSION: Broad external validation of the disability model was successful in people with (sub)acute neck pain and clinicians may use this model in clinical practice with reasonable accuracy. Further research is required to assess the disability model's clinical impact and generalisability, and to identify additional valuable model predictors.REGISTRATION: https://osf.io/a6r3k/.

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

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

BackgroundNeck pain is one of the leading causes of disability in most countries and it is likely to increase further. Numerous prognostic models for people with neck pain have been developed, few have been validated. In a recent systematic review, external validation of three promising models was advised before they can be used in clinical practice.ObjectiveThe purpose of this study was to externally validate three promising models that predict neck pain recovery in primary care.MethodsThis validation cohort consisted of 1311 patients with neck pain of any duration who were prospectively recruited and treated by 345 manual therapists in the Netherlands. Outcome measures were disability (Neck Disability Index) and recovery (Global Perceived Effect Scale) post-treatment and at 1-year follow-up. The assessed models were an Australian Whiplash-Associated Disorders (WAD) model (Amodel), a multicenter WAD model (Mmodel), and a Dutch non-specific neck pain model (Dmodel). Models' discrimination and calibration were evaluated.ResultsThe Dmodel and Amodel discriminative performance (AUC < 0.70) and calibration measures (slope largely different from 1) were poor. The Mmodel could not be evaluated since several variables nor their proxies were available.ConclusionsExternal validation of promising prognostic models for neck pain recovery was not successful and their clinical use cannot be recommended. We advise clinicians to underpin their current clinical reasoning process with evidence-based individual prognostic factors for recovery. Further research on finding new prognostic factors and developing and validating models with up-to-date methodology is needed for recovery in patients with neck pain in primary care.

Highlights•Non-serious adverse events do not influence recovery in patients with neck pain.•Duration of neck pain does influence recovery in patients with neck pain.•The role of non-serious adverse events should be re-evaluated in a larger sample.

Background Most soccer injuries concern the lower extremity with a higher injury rate during the second half of matches. In advising safe return to sport, hop tests are usually assessed at the point of return to sport under non-fatigued conditions. No studies exist investigating hop test outcomes before and after a match in soccer players returning to performance after lower extremity injury and non-injured teammates. The objective is to assess differences in hop test outcomes before and after a match in and between soccer players returning to performance after lower extremity injury and their non-injured teammates. Methods A repeated-measures design was used to measure outcomes on five hop tests before and after a soccer match. For analyzing differences in hop tests before and after a match, paired sample t-tests were used. Independent t-tests were used to analyze differences between soccer players after injury and non-injured teammates. Effect sizes were calculated using Cohen's d. Results Hop tests were completed by 61 amateur soccer players after injury and 121 non-injured teammates. Differences in hop tests before and after the match within both groups had negligible to small effect sizes (d=0.00-0.49), except for the figure of 8 and 30 seconds side hop in the injured leg of RTPf soccer players (d=0.56 and d=0.71 respectively). Differences between both groups were negligible to small (d=0.00-0.36). Conclusions Soccer players returning to performance after a lower extremity injury showed similar scores on hop tests than their non-injured teammates. More demanding sport-specific performance test and measurement of quality of movement are additionally recommended for safe return to sport decision-making.

Background: Clinical Practice Guidelines for low back pain emphasize implementing assessment and addressing of psychosocial context. It is unknown to what extent manual physiotherapists incorporate psychological factors in their diagnostic management of patients with nonspecific low back pain. Methods: An online survey among Dutch manual physiotherapists was conducted exploring the use of 10 psychological constructs. Frequencies of attention to psychological factors during history-taking and use of questionnaires were calculated. Associations between therapists characteristics and use of psychological questionnaires were analyzed using Spearmans rank correlation coefficient (r s) and logistic regression. In addition, a retrospective patient record review was conducted. Results: One hundred and twelve manual physiotherapists returned completed surveys. Although respondents indicated psychological factors were assessed, they rarely used psychological questionnaires. Significant but negligible associations were found for age and working hours and the use of specific questionnaires. From 95 patient records reviewed, seven were identified that mentioned one psychological factor each during history taking. Conclusions: Dutch MPTs, regardless of their age and work characteristics, rarely use psychological questionnaires in patients with LBP, although they report addressing these constructs implicitly during history taking. Educational and implementation strategies are needed to warrant the use of psychological constructs and validated psychological questionnaires at all phases of the clinical reasoning process.

Methodological shortcomings in prognostic modeling for patients with spinal disorders are highly common. This general commentary discusses methodological challenges related to the specific nature of this field. Five specific methodological challenges in prognostic modeling for patients with spinal disorders are presented with their potential solutions, as related to the choice of study participants, purpose of studies, limitations in measurements of outcomes and predictors, complexity of recovery predictions, and confusion of prognosis and treatment response. Large studies specifically designed for prognostic model research are needed, using standard baseline measurement sets, clearly describing participants’ recruitment and accounting and correcting for measurement limitations.

After lower extremity injury, only half of the injured athletes return to their pre-injury sports level. Even though functional performance tests are often used to make return to sport decisions, it is unknown whether functional performance is associated with return to performance after such injuries. The aim of this systematic review was to identify, critically appraise, and analyze studies that investigated the association of functional performance tests with return to performance after lower extremity injuries in athletes participating in high-impact sports. MEDLINE, Embase, Web of Science, and CINAHL were systematically searched for relevant studies. Articles were independently screened by two authors and data were obtained from each included study using a data extraction form. Two authors independently scored methodological quality using the Quality In Prognosis Studies tool. A qualitative best evidence synthesis was conducted. Eight studies reported the association of functional performance with return to performance after lower extremity injuries, involving 1,246 athletes after anterior or posterior cruciate ligament reconstruction. No studies were found on the association of functional performance with return to performance for lower extremity injuries other than after anterior or posterior cruciate ligament reconstruction. All included studies had a high risk of bias. Two studies found significant but small associations for selected hop tests after anterior cruciate ligament reconstruction. Low evidence of association between functional performance and return to performance was present after anterior cruciate ligament reconstruction for the triple hop for distance, the 6-meter timed hop, the side hop in female athletes, and for the combination of the single and crossover hop for distance. In athletes after posterior cruciate ligament reconstruction, the vertical jump showed a significant but small association with return to performance. There is no high-quality evidence that functional performance is associated with return to performance after lower extremity injuries in athletes practicing high-impact sports. Low quality evidence suggests small associations after anterior and posterior cruciate ligament reconstruction. No evidence exists for lower extremity injuries other than after anterior or posterior cruciate ligament reconstruction. Therefore, research on functional performance associated with return to performance is recommended in high-quality prospective cohort studies including athletes with any type of lower extremity injury.

Purpose The present study analyses the kinematics of patients with neck problems and healthy controls by estimation of Finite Helical Axis behaviour. A cross sectional study design was used to investigate whether FHA behaviour differs due to neck problems. Methods: 584 subjects were recruited from private and ambulatory institutional physiotherapy practices. Among these 171 patients with neck related problems were selected based on referral diagnosis by primary care general practitioners. Cervical kinematics were compared based on minimal convex hull, path length and mean angle of the Finite Helical Axis distribution as well as on the helical angle. Three active planar motions were registered: flexion–extension, axial rotation and lateral bending. Results: Patients demonstrated a significantly reduced and less variable behaviour of the Finite Helical Axis during active flexion–extension and axial rotation motions as compared to healthy individuals and lateral bending. Conclusion: Patients with neck related problems demonstrate a more restricted motion behaviour with less variability in Finite Helical Axis distribution and orientation during active planar motions. At present it is not clear whether these kinematic differences are the result or the cause of dysfunction. Graphic abstract: These slides can be retrieved under Electronic Supplementary Material. [Figure not available: see fulltext.]

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

Question: Do measures of state anxiety and trait anxiety in people with acute low back pain (ALBP) improve prediction of chronic low back pain (CLBP), defined as pain or pain-related disability at 12 weeks? Design: Observational multi-centre prospective cohort study in primary physiotherapy care with measurements at baseline and at 12 weeks of state and trait anxiety, as well as other established prognostic factors for CLBP. Participants: People with nonspecific ALBP, aged 18 to 60 years, who had been pain free for ≥ 3 months before their current ALBP, and who were being treated according the Dutch clinical guidelines. Outcome measures and analysis: CLBP was defined as a pain score ≥ 3/10 on the Numerical Pain Rating Scale (primary outcome), and as a pain-related disability score ≥ 19/70 on the Pain Disability Inventory. Univariate and multivariate logistic regression analyses estimated how the risk of CLBP differed with state and trait anxiety and other established prognostic factors. Results: Most (204 of 225) participants completed both assessments. State anxiety was an independent predictor of CLBP, whether defined as pain or pain-related disability at 12 weeks, in contrast to trait anxiety. State anxiety improved the predictive performance of the model, with area under the curve (AUC) increasing from 0.64 (95% CI 0.56 to 0.71) to 0.75 (95% CI 0.68 to 0.82) and Nagelkerke’s R2 increasing from 0.08 to 0.24 for the primary outcome measure, pain. For the secondary outcome measure, pain-related disability: AUC 0.63 (95% CI 0.54 to 0.72) improved to 0.73 (95% CI 0.65 to 0.82) and Nagelkerke’s R2 increased from 0.05 to 0.16. Adding trait anxiety to the prognostic model for pain improved the AUC from 0.64 (95% CI 0.56 to 0.71) to 0.70 (95% CI 0.62 to 0.77) and Nagelkerke’s R2 from 0.08 to 0.15. Conclusion: State anxiety in patients with ALBP improved prediction of CLBP, defined as pain and pain-related disability at 12 weeks. Key words: Spinal low back pain, Anxiety, Prognostic factor, Risk, Prediction, Psychological

OBJECTIVES: To investigate whether illness perceptions, measured with the Brief Illness Perception Questionnaire, are an independent predictor of chronic low back pain and pain-related disability at 12 weeks.DESIGN: A prospective, observational cohort study.SETTING: 26 outpatient primary care physiotherapy practices throughout the Netherlands.PARTICIPANTS: Acute nonspecific low back pain patients between the age of 18 and 60 years, with or without radiating pain, and a pain-free episode of at least three months before onset.INTERVENTIONS: Standard physiotherapy care according to Dutch clinical practice guidelines.OUTCOME MEASURE: Chronic low back pain defined as pain ≥3/10 on the Numeric Pain Rating Scale and as pain-related disability ≥19/70 on the Pain Disability Index measured after 12 weeks.RESULTS: Two hundred and four people with acute nonspecific low back pain completed both assessments. In the multivariable analyses, adjusted for pain intensity, disability, duration, radiating pain, depressed mood, associations of illness perceptions were OR 1.04 (95% CI: 1.01 to 1.08) for pain and 1.04 (95% CI: 0.99 to 1.09) for pain-related disability.CONCLUSIONS: Illness perceptions independently predicted chronic low back pain but not pain-related disability at 12 weeks. The added predictive value of illness perceptions was relatively low.

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.

BACKGROUND: In facilitating and predicting successful return to sport (RTS), not only are physical factors important, but also the athlete's psychological status. No questionnaire in the Dutch language exists for measuring psychological readiness for RTS after injuries in general. PURPOSE: To translate and validate the Injury-Psychological Readiness to Return to Sport scale into the Dutch language. STUDY DESIGN: Cross-sectional, validation study. METHODS: One hundred and sixty-eight athletes, returning to high impact sports after lower extremity injuries, completed the Dutch I-PRRS twice. Another 162 athletes who visited their physical therapist for initial intake also completed the questionnaire. Floor and ceiling effects, internal consistency, reproducibility, construct validity, and divergent validity were analyzed. RESULTS: The I-PRRS was successfully translated into Dutch and showed no floor or ceiling effects. It had good internal consistency (0.85) and good test-retest reproducibility (ICC 0.74, 95% CI 0.43-0.86) where the lower bound of 95% CI indicates at least fair reproducibility. The SEM was 2.02 and the MDC 5.58 points. There was a significant fair correlation between total scores on the I-PRRS and TSK (r(s) = 0.41, p

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

Objectives Development and internal validation of prognostic models for post-treatment and 1-year recovery in patients with neck pain in primary care. Design Prospective cohort study. Setting Primary care manual therapy practices. Participants Patients with non-specific neck pain of any duration (n = 1193). Intervention Usual care manual therapy. Outcome measures Recovery defined in terms of pain intensity, disability, and global perceived improvement directly post-treatment and at 1-year follow-up. Results All post-treatment models exhibited acceptable discriminative performance after derivation (AUC ≥ 0.7). The developed post-treatment disability model exhibited the best overall performance (R2 = 0.24; IQR, 0.22–0.26), discrimination (AUC = 0.75; 95% CI, 0.63–0.84), and calibration (slope 0.92; IQR, 0.91–0.93). After internal validation and penalization, this model retained acceptable discriminative performance (AUC = 0.74). The five other models, including those predicting 1-year recovery, did not reach acceptable discriminative performance after internal validation. Baseline pain duration, disability, and pain intensity were consistent predictors across models. Conclusion A post-treatment prognostic model for disability was successfully developed and internally validated. This model has potential to inform primary care clinicians about a patient’s individual prognosis after treatment, but external validation is required before clinical use can be recommended.

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...

© 2017 Australian Physiotherapy Association Question Which multivariable prognostic model(s) for recovery in people with neck pain can be used in primary care? Design Systematic review of studies evaluating multivariable prognostic models. Participants People with non-specific neck pain presenting at primary care. Determinants Baseline characteristics of the participants. Outcome measures Recovery measured as pain reduction, reduced disability, or perceived recovery at short-term and long-term follow-up. Results Fifty-three publications were included, of which 46 were derivation studies, four were validation studies, and three concerned combined studies. The derivation studies presented 99 multivariate models, all of which were at high risk of bias. Three externally validated models generated usable models in low risk of bias studies. One predicted recovery in non-specific neck pain, while two concerned participants with whiplash-associated disorders (WAD). Discriminative ability of the non-specific neck pain model was area under the curve (AUC) 0.65 (95% CI 0.59 to 0.71). For the first WAD model, discriminative ability was AUC 0.85 (95% CI 0.79 to 0.91). For the second WAD model, specificity was 99% (95% CI 93 to 100) and sensitivity was 44% (95% CI 23 to 65) for prediction of non-recovery, and 86% (95% CI 73 to 94) and 55% (95% CI 41 to 69) for prediction of recovery, respectively. Initial Neck Disability Index scores and age were identified as consistent prognostic factors in these three models. Conclusion Three externally validated models were found to be usable and to have low risk of bias, of which two showed acceptable discriminative properties for predicting recovery in people with neck pain. These three models need further validation and evaluation of their clinical impact before their broad clinical use can be advocated. Registration PROSPERO CRD42016042204. [Wingbermühle RW, van Trijffel E, Nelissen PM, Koes B, Verhagen AP (2018) Few promising multivariable prognostic models exist for recovery of people with non-specific neck pain in musculoskeletal primary care: a systematic review. Journal of Physiotherapy 64: 16–23]

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.

BACKGROUND: There is a lack of valid, reliable, and feasible instruments for measuring planar active cervical range of motion (aCROM) and associated 3D coupling motions in patients with neck pain. Smartphones have advanced sensors and appear to be suitable for these measurements.OBJECTIVES: To estimate the concurrent validity and interrater reliability of a new iPhone application for assessing planar aCROM and associated 3D coupling motions in patients with neck pain, using an electromagnetic tracking device as a reference test.DESIGN: Cross-sectional study.METHODS: Two samples of neck pain patients were recruited; 30 patients for the validity study and 26 patients for the reliability study. Validity was estimated using intraclass correlation coefficients (ICCs), and by calculating 95% limits of agreement (LoA). To estimate interrater reliability, ICCs were calculated. Cervical 3D coupling motions were analyzed by calculating the cross-correlation coefficients and ratio between the main motions and coupled motions for both instruments.RESULTS: ICCs for concurrent validity and interrater reliability ranged from 0.90 to 0.99. The width of the 95% LoA ranged from about 5° for right lateral bending to 11° for total rotation. No significant differences were found between both devices for associated coupling motion analysis.CONCLUSIONS: The iPhone application appears to be a useful discriminative tool for the measurement of planar aCROM and associated coupling motions in patients with neck pain. It fulfills the need for a valid, reliable, and feasible instrument in clinical practice and research. Therapists and researchers should consider measurement error when interpreting scores.

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 To summarize and appraise the literature on the intraexaminer reliability of hand-held dynamometry (HHD) in the upper extremity. Data Sources MEDLINE, CINAHL, and EMBASE were searched for relevant studies published up to December 2011. In addition, experts were contacted, and journals and reference lists were hand searched. Study Selection To be included in the review, articles needed to (1) use a repeated-measures, within-examiner(s) design; (2) include symptomatic or asymptomatic individuals, or both; (3) use HHD to measure muscle strength in any of the joints of the shoulder, elbow, or wrist with the "make" or the "break" technique; (4) report measurements in kilogram, pound, or torque; (5) use a device that is placed between the examiner's hand and the subject's body; and (6) present estimates of intraexaminer reliability. Data Extraction Quality assessment and data extraction were performed by 2 reviewers independently. Data Synthesis Fifty-four studies were included, of which 26 (48%) demonstrated acceptable intraexaminer reliability. Seven high-quality studies showed acceptable reliability for flexion and extension of the elbow in healthy subjects. Conflicting results were found for shoulder external rotation and abduction. Reliability for all other movements was unacceptable. Higher estimates were reached for within-sessions reliability and if means of trials were used. Conclusions Intraexaminer reliability of HHD in upper extremity muscle strength was acceptable only for elbow measurements in healthy subjects. We provide specific recommendations for future research. Physical therapists should not rely on HHD measurements for evaluation of treatment effects in patients with upper extremity disorders.

STUDY DESIGN: Clinical measurement, longitudinal. OBJECTIVES: To assess the test-retest reliability, construct validity, and responsiveness of the Patient-Specific Functional Scale (PSFS) in patients with a primary shoulder complaint. BACKGROUND: Health measurement outcomes have become increasingly important for evaluating treatment. Patient-specific questionnaires are useful tools for determining treatment goals and evaluating treatment in individual patients. These questionnaires have not yet been validated in patients with nonspecific shoulder pain. METHODS: Patients completed the PSFS, the numeric pain rating scale, and the Shoulder Pain and Disability Index at baseline, and after 1 week and 4 to 6 weeks. Test-retest reliability was determined using intraclass correlation coefficients. To assess convergent validity, change scores of the PSFS were correlated with the numeric pain rating scale and Shoulder Pain and Disability Index change scores. Responsiveness was assessed by calculating the area under the curve, the minimal clinically important change, and minimal detectable change, using the global rating of change as an external criterion. RESULTS: Fifty patients (37 men; mean age, 47.7 years) participated in the study. Reliability was high (intraclass correlation coefficient = 0.87; 95% confidence interval [CI]: 0.72, 0.94). The correlations between the change scores of the PSFS and those of the Shoulder Pain and Disability Index and numeric pain rating scale were 0.45(95% CI: 0.17, 0.80) and 0.55 (95% CI: 0.29, 0.73), respectively. The area under the curve for the PSFS was 0.67 (95% CI: 0.51, 0.83). The minimal detectable change and minimal clinically important change were 0.97 and 1.29 points, respectively. CONCLUSION: These results suggest that the PSFS is a reliable, valid, and responsive instrument that can be used as an evaluative instrument in patients with a primary shoulder complaint

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]

STUDY DESIGN.: Systematic review. OBJECTIVE.: To review and critically evaluate the past literature for spinal mechanical load as risk factor for low back pain (LBP). SUMMARY OF BACKGROUND DATA.: LBP is a costly health problem worldwide, and treatments are often unsuccessful. Therefore, prevention might be more beneficial in the management of LBP. With respect to prevention, the knowledge of risk factors is essential. From the literature, exposures involving spinal mechanical load is frequently discussed as a potential risk factor for LBP. For a better understanding of this risk factor, we performed a systematic review of the literature. Additionally, we evaluated exposures of spinal mechanical load for possible dose-response relations with LBP. METHODS.: We systematically searched Medline, Embase, PsycINFO, and CINAHL databases (without language restriction) for full-report publications of prospective cohort studies, evaluating spinal mechanical load during work and/or leisure time activities as risk factors for nonspecific LBP in patients (>18 years of age) free of LBP at baseline. We assessed the methodology of each article and extracted information on population, response rates, characteristics of LBP, exposures, and estimated association(s), using standardized forms. We performed a best evidence synthesis of the obtained information. RESULTS.: In total, 18 studies were eligible (all rated as high methodologic quality) reporting on 24,315 subjects. CONCLUSION.: We found strong evidence that leisure time sport or exercises, sitting, and prolonged standing/walking are not associated with LBP. Evidence for associations in leisure time activities (e.g., do-it-yourself home repair, gardening), whole-body vibration, nursing tasks, heavy physical work, and working with ones trunk in a bent and/or twisted position and LBP was conflicting. We found no studies, thus no evidence, for an association between sleeping or sporting on a professional level and LBP.

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.

Valid questionnaires for measuring functional limitations in patients with Whiplash Associated Disorders (WAD) are lacking, since existing measures are not suitable for addressing the specific limitations of these patients and because of cross contamination between theoretical constructs. The objective of this study was to evaluate dimensionality, test-retest reliability, measurement error, construct validity, and responsiveness of a new condition-specific questionnaire for WAD as well as to estimate the minimally important change score. Patients with WAD grade I or II were recruited from physical therapy practices and rehabilitation centers. Dimensionality was examined by internal consistency analysis (Cronbach's alpha) and factor analysis. Test-retest reliability was estimated by intraclass correlations and measurement error was calculated by the minimal detectable change (MDC) scores. Construct validity was investigated by testing predefined hypotheses on correlations of the WAL scores with generic health measures and by using the known group method. Responsiveness was expressed as the minimal clinically important change (MCIC) score. 73 patients (53 women) were included. Cronbach's alpha was high (0.95) and unidimensionality was plausible because factor analysis showed 40.3% variance explained by one dominant factor, which was more than 4.5 times larger than the second largest factor. Test-retest reliability was excellent (0.92, 95% CI 0.87-0.95). Construct validity was supported by 14 out of 15 confirmed hypotheses and the WAL showed statistically significant differences between known groups. MDC was 16 points while the MCIC was 18 points. In conclusion, the present study suggests that the WAL has adequate measurement properties, but additional research is needed.

Het passief segmentaal bewegingsonderzoek van de wervelkolom is een beroepsspecifieke manuele verrichting van fysiotherapeuten en vooral van manueeltherapeuten om aangedane bewegingssegmenten te identificeren. Uit een door ons uitgevoerd systematisch literatuuronderzoek is gebleken dat de interbeoordelaarsbetrouwbaarheid van deze diagnostische procedure voor de cervicale en lumbale wervelkolom laag is. In dit artikel worden de methoden en resultaten van dit literatuuroverzicht kort toegelicht. De methodologische kwaliteit van de ingesloten onderzoeken was veelal onvoldoende. Expliciete aanbevelingen voor de opzet, uitvoering en rapportage van toekomstig betrouwbaarheidsonderzoek worden gegeven.

Background Manual spinal joint mobilisations and manipulations are widely used treatments in patients with neck and low-back pain. Inter-examiner reliability of passive intervertebral motion assessment of the cervical and lumbar spine, perceived as important for indicating these interventions, is poor within a univariable approach. The diagnostic process as a whole in daily practice in manual therapy has a multivariable character, however, in which the use and interpretation of passive intervertebral motion assessment depend on earlier results from the diagnostic process. To date, the inter-examiner reliability among manual therapists of a multivariable diagnostic decision-making process in patients with neck or low-back pain is unknown. Methods This study will be conducted as a repeated-measures design in which 14 pairs of manual therapists independently examine a consecutive series of a planned total of 165 patients with neck or low-back pain presenting in primary care physiotherapy. Primary outcome measure is therapists’ decision about whether or not manual spinal joint mobilisations or manipulations, or both, are indicated in each patient, alone or as part of a multimodal treatment. Therapists will largely be free to conduct the full diagnostic process based on their formulated examination objectives. For each pair of therapists, 2×2 tables will be constructed and reliability for the dichotomous decision will be expressed using Cohen’s kappa. In addition, observed agreement, prevalence of positive decisions, prevalence index, bias index, and specific agreement in positive and negative decisions will be calculated. Univariable logistic regression analysis of concordant decisions will be performed to explore which demographic, professional, or clinical factors contributed to reliability. Discussion This study will provide an estimate of the inter-examiner reliability among manual therapists of indicating spinal joint mobilisations or manipulations in patients with neck or low-back pain based on a multivariable diagnostic reasoning and decision-making process, as opposed to reliability of individual tests. As such, it is proposed as an initial step toward the development of an alternative approach to current classification systems and prediction rules for identifying those patients with spinal disorders that may show a better response to manual therapy which can be incorporated in randomised clinical trials. Potential methodological limitations of this study are discussed.

Purpose. The aim of this randomized controlled equivalence trial was to demonstrate that, in diabetic patients, dilating the pupils before as compared with after refraction and visual acuity assessment would not lead to different advice given to patients. Methods. Three hundred sixteen adult patients with diabetes mellitus were randomized. The experimental group was administered tropicamide 0.5% before refraction and visual acuity assessment and the control group after refraction and visual acuity assessment. Study outcomes were the advised time till next visit, the advice on adjustment of refractive correction, further diagnostics, treatment, duration of the eye examination, and patient satisfaction. Results. No difference was seen in advised time till next visit between the experimental group (12.39 +/- 5.01 months) and the control group (12.84 +/- 4.96 months) (p = 0.425). In addition, the advice concerning adjustment of refractive correction (p = 0.069), further diagnostics (p = 1.000), and therapy (p = 0.178) did not significantly differ. Waiting time was significantly shorter for the experimental group (22.25 vs. 36.18 minutes; p

Study design Pretest post-test observational parallel-group design. Objectives To evaluate the efficacy of passive knee extension mobilization in addition to exercise therapy on extension range of motion (ROM) in patients with osteoarthritis (OA) of the knee. Secondary objectives were to determine changes in pain and functional abilities. Background Patients with knee OA complain of pain, limited range of motion, and impaired activities. Efficacy of mobilization as a treatment option next to exercises has not been studied rigorously. Methods and measures Thirty-four participants with persistent knee pain, a positive radiography for knee OA, and a passive extension deficit were included. Seventeen participants (mean age ± SD, 59.8 ± 6.1 years) were treated with an exercise protocol and were additionally given manual mobilizations to improve passive extension ROM. The other group (mean age ± SD, 61.5 ± 7.3 years) with equal characteristics was treated with an identical exercise therapy protocol only. Prior to participation, detailed ROM measurements were recorded next to muscle function tests, pain (VAS), six-minute walking tests (6MWTs), a condition-specific questionnaire, and the patient-specific function scale (PSFS). Participants in both groups completed 16 treatment sessions each. Results Passive mobilization significantly improved extension ROM in the intervention group (5.2 versus 8.6°, p = .017). The manually mobilized group also had better physical capacities as assessed by 6MWT, less pain, and a lower PSFS score. Conclusion A combined protocol including exercise therapy and passive mobilization was beneficial for patients with OA of the knee complaining of pain, decreased extension ROM and decreased limited abilities. Level of evidence Therapy, 2b.

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

The medical costs associated with low back pain (LBP) potentially pose an enormous economic burden to society. Prevention (secondary) might be beneficial when there is no definitive Conclusion on the most appropriate intervention. For this purpose, individual advice focusing on modification of spinal mechanical load obtained with the 24 Hour Schedule-24HS-(an instrument for quantifying spinal mechanical load) in addition to standard care of guideline-recommendations might be effective. Naturally, this should be examined in controlled studies. Considering the costs involved carrying out a controlled Study, the feasibility of 24HS-advice should be assessed first. We performed two surveys in primary care setting in 97 patients with acute (

Contains fulltext : 80530.pdf (Publisher’s version ) (Closed access) Manual therapists commonly use passive intervertebral motion (PIVM) assessment within physical examination. Data describing the use and interpretation of this manual diagnostic procedure, as well as therapists' perception of related importance and confidence, are lacking. A survey was conducted among Dutch physiotherapists specializing in manual therapy (MT) using a 13-item, self-administered, structured questionnaire. Three hundred and sixty-seven questionnaires were analysed. Response rate from the postal part of the survey was 56%. Dutch manual therapists most frequently apply passive segmental motion assessment to the cervical region and they prefer three-dimensionally coupled motions. They consider end-feel or, to a lesser extent, provocation of patient's pain as decisive for diagnostic conclusions. Respondents believe that these spinal motion tests are important for treatment decisions and are confident in their conclusions drawn from it. These perceptions were largely stable across subgroups of therapists with different gender, age, experience, and educational background. Weekly amount of work related to spinal disorders was positively associated with perceived importance and confidence. Reported use and interpretation of PIVM assessment and related perceptions could only partly be substantiated by evidence. Results from this survey will help researchers design studies better reflecting daily practice in MT.

Question: What is the inter-rater reliability for measurements of passive physiological or accessory movements in upper extremity joints? Design: Systematic review of studies of inter-rater reliability. Participants: Individuals with and without upper extremity disorders. Outcome measures: Range of motion and end-feel using methods feasible in clinical practice. Results: Twenty-one studies were included of which 11 demonstrated acceptable inter-rater reliability. Two studies satisfied all criteria for internal validity while reporting almost perfect reliability. Overall, the methodological quality of studies was poor. ICC ranged from 0.26 (95% Cl -0.01 to 0.69) for measuring the physiological range of shoulder internal rotation using vision to 0.99 (95% Cl 0.98 to 1.0) for the physiological range of finger and thumb flexion/extension using a goniometer. Measurements of physiological range of motion using instruments were more reliable than using vision. Measurements of physiological range of motion were also more reliable than measurements of end-feel or of accessory range of motion. Conclusions: Inter-rater reliability for the measurement of passive movements of upper extremity joints varies with the method of measurement. In order to make reliable decisions about joint restrictions in clinical practice, we recommend that clinicians measure passive physiological range of motion using goniometers or inclinometers. [van de Pol RJ, van Trijffel E, Lucas C (2010) Inter-rater reliability for measurement of passive physiological range of motion of upper extremity joints is better if instruments are used: a systematic review. Journal of Physiotherapy 56: 7-17]

After lower extremity injury, only half of the injured athletes return to their pre-injury sports level. Even though functional performance tests are often used to make return to sport decisions, it is unknown whether functional performance is associated with return to performance after such injuries. The aim of this systematic review was to identify, critically appraise, and analyze studies that investigated the association of functional performance tests with return to performance after lower extremity injuries in athletes participating in high-impact sports. MEDLINE, Embase, Web of Science, and CINAHL were systematically searched for relevant studies. Articles were independently screened by two authors and data were obtained from each included study using a data extraction form. Two authors independently scored methodological quality using the Quality In Prognosis Studies tool. A qualitative best evidence synthesis was conducted. Eight studies reported the association of functional performance with return to performance after lower extremity injuries, involving 1,246 athletes after anterior or posterior cruciate ligament reconstruction. No studies were found on the association of functional performance with return to performance for lower extremity injuries other than after anterior or posterior cruciate ligament reconstruction. All included studies had a high risk of bias. Two studies found significant but small associations for selected hop tests after anterior cruciate ligament reconstruction. Low evidence of association between functional performance and return to performance was present after anterior cruciate ligament reconstruction for the triple hop for distance, the 6-meter timed hop, the side hop in female athletes, and for the combination of the single and crossover hop for distance. In athletes after posterior cruciate ligament reconstruction, the vertical jump showed a significant but small association with return to performance. There is no high-quality evidence that functional performance is associated with return to performance after lower extremity injuries in athletes practicing high-impact sports. Low quality evidence suggests small associations after anterior and posterior cruciate ligament reconstruction. No evidence exists for lower extremity injuries other than after anterior or posterior cruciate ligament reconstruction. Therefore, research on functional performance associated with return to performance is recommended in high-quality prospective cohort studies including athletes with any type of lower extremity injury.