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BackgroundStudents perceive reflective writing as difficult. Concept mapping may be an alternative format for reflection, which provides support while allowing students to freely shape their thoughts. We examined (1) the quality of reflection in reflective concept maps created by first-year medical students and (2) students' perceptions about concept mapping as a tool for reflection.MethodsMixed-method study conducted within the medical curriculum of Maastricht University, The Netherlands, consisting of: (1) Analysis of the quality of reflection in 245 reflective concept maps created by 40 first-year students. Reflection quality was analysed by assessing focus of reflection (technical/practical/sensitising) and depth of reflection (description/justification/critique/discussion). (2) Semi-structured interviews with 22 students to explore perceived effectiveness of reflective concept mapping.ResultsDepth of reflection reached at least the level of critique in 82% of maps. Three factors appeared to affect the perceived effectiveness of concept mapping for reflection: (1) reflective concept map structure; (2) alertness to meaningful experiences in practice and (3) learning by doing.ConclusionThese results yielded supportive evidence for concept mapping as a useful technique to teach novice learners the basics of effective reflection. Meaningful implementation requires a delicate balance between providing a supportive structure and allowing flexibility for the student.

Purpose: The purpose of this qualitative study was to explore how stroke patients with unilateral spatial neglect experience; (a) performance in activities of daily living; (b) alterations in bodily perceptions; and (c) personal hopes and expectations, looking at the period between stroke onset and discharge from inpatient rehabilitation. Materials and methods: We conducted individual semi-structured interviews with 7 (5 men, 2 women, mean age 69 years) consecutively sampled participants. All interviews were transcribed verbatim and analyzed using thematic analysis. Findings: Participants' experiences were captured in three over-arching themes: "unawareness of neglect," "emergent awareness for neglect-related difficulties," and "comparing the new life with the old one." Findings showed that participants progressed from initial unawareness to emergent awareness for their neglect-related difficulties over the course of rehabilitation. Comparing their current life situation with the one before their stroke triggered feelings of uncertainty and regret, with associated decreased pleasure in meaningful activities. Conclusions: This study informs health professionals regarding personal experiences of orientation in and reorganization of life of stroke patients with unilateral spatial neglect. The findings highlight that being aware of neglect-related deficits is a prerequisite for using coping strategies and incorporating them in daily life. Possible therapeutic strategies that fit the current stage of recovery and level of awareness are discussed.

Background Older adults admitted with an acute medical illness spent little time active during hospitalisation and this has been associated with negative health outcomes. Understanding which barriers and enablers influence the physical activity behaviour of hospitalised older adults is a first step towards identifying potentially modifiable factors and developing, evaluating and implementing targeted interventions aimed at increasing their physical activity behaviour. Using a theoretical framework has been found to be more successful in changing behaviour than using a non-theory driven approach. This study aimed to explore barriers and enablers to physical activity behaviour in older adults admitted to a hospital with an acute medical illness, as perceived by patients and healthcare professionals, and to categorise them using the Theoretical Domains Framework (TDF). Methods A qualitative study was conducted at a combined university and regional hospital in the Netherlands between January 2019 and February 2020. Older adults (≥70 years) admitted with an acute medical illness, and healthcare professionals (nurses, physicians, physiotherapists) were recruited using purposive sampling. Semi-structured interviews were audiotaped, transcribed and analysed using directed qualitative content analysis. Barriers and enablers to physical activity behaviour during hospitalisation were identified and coded using the TDF. Results Meaning saturation was determined after interviews with 12 patients and 16 healthcare professionals. A large number of barriers and enablers were identified and each categorised to 11 of the 14 domains of the TDF. The ‘Environmental Context and Resources’ domain in particular yielded many examples, and revealed that the hospital environment exerts an inactivating influence on patients. Conclusions The large number of identified barriers and enablers highlights the complexity of influencing older adults’ physical activity behaviour during hospitalisation. This overview of barriers and enablers to physical activity behaviour in older adults admitted to a hospital with an acute medical illness represents an initial step towards developing, evaluating and implementing theory-informed behaviour change interventions to improve hospitalised older adults’ physical activity levels. It can assist clinicians and researchers in selecting modifiable factors that can be targeted in future interventions.

Background Cervical spine (CS) range of motion (ROM) is commonly used to assess neck pain. However, this measurement is often limited by the clinician's experience and perception. Therefore, the integration of perceptual feedback of the patient can optimize and personalize treatment. Objective Develop and validate a questionnaire (S-ROM-Neck) to evaluate ROM of the CS from the patient's perspective. Design Validation study. Methods The assessment tool was developed and optimized during pretest sessions. Reliability and construct validity of the questionnaire were tested. 50 participants (age >18 years) with neck pain for >90 days, able to fluently speak, read, and write in German were included. Exclusion criteria included any condition that limited manual therapy to the CS. Participants completed S-ROM-Neck twice within seven days, along with the visual analogue scale (VAS) for pain intensity and the German version of the Neck Disability Index (NDI-G). The relative reliability, internal consistency, and absolute reliability were analyzed, and Bland–Altman plots were generated. Construct validity was established by correlating the total score of S-ROM-Neck with VAS and NDI-G based on pre-set hypotheses. Results S-ROM-Neck demonstrated moderate reliability with an intraclass correlation coefficient of 0.718 (Cronbach's alpha of 0.83). There was a medium negative correlation between VAS and S-ROM-Neck [Spearman's rank correlation coefficient (rs) = −0.30, p = 0.031] and the NDI-G and S-ROM-Neck (rs = −0.40, p = 0.002). Conclusions These results indicate the reliability and internal consistency of S-ROM-Neck. This scale provides patient feedback and perspectives to optimize assessment of neck pain.

Current knowledge of neural and neuromuscular processes controlling gait and movement as well as an understanding of how these mechanisms change following stroke is an important basis for the development of effective rehabilitation interventions. To support the translation of findings from basic research into useful treatments in clinical practice, up-to-date neuroscience should be presented in forms accessible to all members of the multidisciplinary team. In this review we discuss aspects of cortical control of gait and movement, muscle synergies as a way of translating cortical commands into specific muscle activity and as an efficient means of reducing neural and musculoskeletal redundancy. We discuss how these mechanisms change following stroke, potential consequences for gait rehabilitation, and the prescription and use of walking-aids as well as areas requiring further research.

Background: Many aspects of post-stroke gait-rehabilitation are based on low-level evidence or expert opinion. Neuroscientific principles are often not considered when evaluating the impact of interventions. The use of walking-aids including canes and rollators, although widely used for long periods, has primarily been investigated to assess the immediate kinetic, kinematic or physiological effects. The long-term impact on neural structures und functions remains unclear.Methods: A literature review of the function of and factors affecting plasticity of spinal interneuronal-networks and central-pattern-generators (CPG) in healthy and post-stroke patients. The relevance of these mechanisms for gait recovery and the potential impact of walking-aids is discussed.Results: Afferent-input to spinal-networks influences motor-output and spinal and cortical plasticity. Disrupted input may adversely affect post-stroke plasticity and functional recovery. Joint and muscle unloading and decoupling from four-limb CPG control may be particularly relevant.Conclusions: Canes and rollators disrupt afferent-input and may negatively affect the recovery of gait. (C) 2016 Elsevier Ltd. All rights reserved.

BACKGROUND CONTEXT: The amount of vertebral rotation in the axial plane is of key importance in the prognosis and treatment of adolescent idiopathic scoliosis (AIS). Current methods to determine vertebral rotation are either designed for use in analogue plain radiographs and not useful in digital images, or lack measurement precision and are therefore less suitable for the follow-up of rotation in AIS patients.PURPOSE: This study aimed to develop a digital X-ray software tool with high measurement precision to determine vertebral rotation in AIS, and to assess its (concurrent) validity and reliability.STUDY DESIGN/SETTING: In this study a combination of basic science and reliability methodology applied in both laboratory and clinical settings was used.METHODS: Software was developed using the algorithm of the Perdriolle torsion meter for analogue AP plain radiographs of the spine. Software was then assessed for (1) concurrent validity and (2) intra-and interobserver reliability. Plain radiographs of both human cadaver vertebrae and outpatient AIS patients were used. Concurrent validity was measured by two independent observers, both experienced in the assessment of plain radiographs. Reliability-measurements were performed by three independent spine surgeons.RESULTS: Pearson correlation of the software compared with the analogue Perdriolle torsion meter for mid-thoracic vertebrae was 0.98, for low-thoracic vertebrae 0.97 and for lumbar vertebrae 0.97. Measurement exactness of the software was within 5 degrees in 62% of cases and within 10 degrees in 97% of cases. Intraclass correlation coefficient (ICC) for inter-observer reliability was 0.92 (0.91-0.95), ICC for intra-observer reliability was 0.96 (0.94-0.97).CONCLUSIONS: We developed a digital X-ray software tool to determine vertebral rotation in AIS with a substantial concurrent validity and reliability, which may be useful for the follow-up of vertebral rotation in AIS patients. (C) 2015 Elsevier Inc. All rights reserved.

Objective: To investigate the effect of replacing canes with an elasticated orthotic-garment on balance and gait-function in chronic stroke survivors.Design: Experimental, N-of-1 series with a replicated, ABC design with randomised phase duration in a home setting.Participants: Four cane using chronic stroke survivors (P1-4).Interventions: Phase A (9-12 weeks) cane-walking "as usual" to establish baseline values; Phase B (9-16 weeks) intervention: orthotic-garment worn throughout the day with maximal cane-use reduction; Phase C (9-10 weeks) participant-determined follow-up: either no walking-aid, orthotic-garment or cane.Outcome measures: Primary: Functional-Gait-Assessment (FGA), Secondary: Trunk-sway during walking measured as Total-Angle-Area (TAA 2) in frontal and sagittal-planes, both measured weekly.Results: Visual and statistical analysis of results showed significant improvements in FGA from phase A to B in all participants. Improvement continued in phase C in P2, stabilized in P1 and P4 and deteriorated in P3. A Minimal-Clinical-Important-Difference of 6 points-change was achieved in P2 & P4. Trunk-sway reduced during walking, indicating increased stability, in two participants from phase A to B and in three participants from A to C but no TAA changes were statistically significant. In phase C participant-selected walking-aids were: P1 cane-usage reduced by 25%, P2 independent-walking with no assistive-device, S3 usual cane-usage, P4 orthotic-garment with reduced cane-usage 2-3 days-a-week, usual cane-usage 4-5 days.Conclusions: Although walking ability is multifactorial these results indicate that the choice of walking-aids can have a specific and clinically relevant impact on gait following stroke."Hands-free" assistive-devices may be more effective than canes in improving gait-function in some patients. (C) 2020 Elsevier Ltd. All rights reserved.

Background: Adherence to an exercise programme impacts the outcome of physiotherapy treatment in patients with non-specific low back pain.Objectives: The aim of this study was to explore the patients' perspectives on long term adherence to such exercise programmes.Design: This qualitative study was embedded in a randomised controlled trial (RCT) which compared the effectiveness of two types of exercise programme on patients with nonspecific low back pain.Methods: Answers from 44 participants to three open-ended questions were analysed using thematic analysis.Results/findings: Patients' perceptions related to the following themes: 1) the role of knowledge in long-term exercise adherence; 2) strategies to support exercise adherence; 3) barriers to exercise adherence 4) the role of perceived effects of exercise.Conclusions: Adherence to long-term exercise is supported through knowledge of the exercises and correct performance. A self-initiated training strategy is the most successful in the perception of participants. Individually supervised physiotherapy treatment that includes coaching towards strategies for post-treatment long term exercise behaviour is recommended.

Accelerated rehabilitation following hip fracture and joint replacement, including early unrestricted weight-bearing and muscle strengthening, has gained importance in hastening functional recovery and hospital discharge. The influence of walking aids on these parameters is sparsely investigated. In this case report, we document the effect of walking with crutches; an orthotic garment and strapping system, TheraTogs; and no walking aids over 3-4-week periods on walking speed, trunk sway, and muscle activity measured with electromyography (EMG). The patient was a 49-year-old female showing delayed healing following a conservatively treated avulsion fracture of the greater trochanter 12 weeks previously with a 14-year history of total hip arthroplasty. EMG analysis showed muscle activity increased with TheraTogs and decreased with crutches compared with walking with no aids. Walking speed improved at a faster rate in the TheraTogs phase than in the crutches phase and reduced in no-walking-aids phase. Mean speed (SD) for each phase was: crutches 1.11 (0.08) m/s, TheraTogs 1.35 (0.11) m/s, and no-aids 1.19 (0.14) m/s. Trunk sway increased in the crutch and no-aids phases, and became more stable in the TheraTogs phase. In this patient, function and recovery rate of all measured parameters increased more in the TheraTogs phase than the crutches or no-aids phase. This may be because muscle activity was facilitated enabling active support of recovering structures.

Study Design. Mixed-method.Objective. To evaluate the association between objective and subjective cervical range of motion (ROM) among patients with neck pain, and to assess the awareness of impairments.Summary of Background Data. Cervical ROM is frequently used to evaluate neck pain, but it is also important to know what a patient expects from treatment, because this can profoundly affect treatment outcomes and patient satisfaction.Methods. We used a cervical ROM instrument, the Neck Disability Index (NDI), and a self-administered ROM questionnaire for the neck (S-ROM-Neck). Ten patients took part in semi-structured interviews. Correlations were analyzed using Spearman rank order correlations (r(s)). Differences between patient and assessor were evaluated by the Mann-Whitney U test. Qualitative data were analyzed by content analysis.Results. Thirty participants (mean age 43.80 years; 21 females) were included. The correlation (r(s)) for the S-ROM-Neck between patient and assessor was 0.679 [95% confidence interval (95% CI) 0.404-0.884; P = 0.000]. The correlation between the NDI and S-ROM-Neck was 0.178 (95% CI -0.233 to -0.533; P = 346) for the assessor and -0.116 (95% CI -0.475 to -0.219, P = 0.541) for the patient (U = 448, z = -0.030, P = 0.976). Qualitative analysis revealed that patients had general restrictions in daily life and with specific movements, but that they adjusted their behavior to avoid impairment.Conclusion. There was a significant correlation between patient and therapist ratings of cervical spine mobility. Although patients experience restriction while moving and are impaired in specific activities, they adjust their lifestyle to accommodate their limitations.

Background: Exercise is an effective treatment for patients with sub-acute and chronic non-specific low back pain (NSLBP). Previous studies have shown that a subgroup of patients with NSLBP and movement control impairment (MCI) can be diagnosed with substantial reliability. However, which type of exercises are most beneficial to this subgroup is still unknown.Objectives: The effectiveness of a specific exercise treatment to improve movement control was tested in this study.Methods: Using a multicentre randomised controlled trial (RCT), we compared exercises that targeted MCI (MC) with a general exercise (GE) treatment. After randomisation, patients in both groups n(MC = 52; GE = 54) were treated in eight private physiotherapy practices and five hospital outpatient physiotherapy centres. Follow-up measurements were taken at post-treatment, six months and 12 months. The primary outcome measurement was the Patient Specific Function Scale (PSFS).Results: PSFS showed no difference between groups after treatment, or at six months and 12 months. Secondary outcome analysis for pain and disability, measured with the Graded Chronic Pain scale and the Roland Morris Disability Questionnaire respectively, showed that a small improvement post-treatment levelled off over the long term. Both groups improved significantly (p Conclusion: This study found no additional benefit of specific exercises targeting MCI. (C) 2015 Elsevier Ltd. All rights reserved.

BackgroundLittle information exists about the role of fear-avoidance beliefs and catastrophizing in subacromial pain syndrome.ObjectiveThe purpose of this study was to investigate the associations among pain, catastrophizing, fear, and disability and the contribution of fear-avoidance beliefs to disability at baseline and at 3-month follow-up.DesignA cross-sectional and longitudinal analysis was conducted.MethodsBaseline demographic and clinical data, including fear-avoidance beliefs and catastrophizing, of 90 patients were assessed for this analysis. Disability was measured with the Shoulder Pain and Disability Index at baseline and at 3-month follow-up. First, bivariate and partial correlations were calculated among pain, fear-avoidance beliefs, catastrophizing, and disability, based on the fear-avoidance model. Second, the contribution of fear-avoidance beliefs to disability at baseline and at 3-month follow-up was examined with hierarchical regression analyses.ResultsCorrelations between clinical variables and disability were largely in line with the fear-avoidance model. Regression analyses identified a significant contribution of fear-avoidance beliefs to baseline disability but not to disability at 3 months.LimitationsPatients with subacromial pain syndrome were studied; therefore, the results should be transferred with caution to other diagnoses. A modified version of the Fear-Avoidance Beliefs Questionnaire was used, which was not validated for this patient group.ConclusionsFear-avoidance beliefs contribute significantly to baseline disability but not to disability change scores after 3-month follow-up. Duration of complaints and baseline disability were the main factors influencing disability change scores. Although the results help to improve understanding of the role of fear-avoidance beliefs, further studies are needed to fully understand the influence of psychological and clinical factors on the development of disability in patients with subacromial shoulder pain.

Purpose Thoracic paravertebral block (TPVB) may be an alternative to thoracic epidural analgesia. A detailed knowledge of the anatomy of the TPV-space (TPVS), content and adnexa is essential in understanding the clinical consequences of TPVB. The exploration of the posterior TPVS accessibility in this study allows (1) determination of the anatomical boundaries, content and adnexa, (2) description of an ultrasound-guided spread of low and high viscous liquid.Methods In two formalin-fixed specimens, stratification of the several layers and the 3D-architecture of the TPVS were dissected, observed and photographed. In a third unembalmed specimen, ultrasound-guided posterolateral injections at several levels of the TPVS were performed with different fluids.Results TPVS communicated with all surrounding spaces including the segmental dorsal intercostal compartments (SDICs) and the prevertebral space. TPVS transitions to the SDICs were wide, whereas the SDICs showed narrowed transitions to the lateral intercostal spaces at the costal angle. Internal subdivision of the TPVS in a subendothoracic and an extra-pleural compartment by the endothoracic fascia was not observed. Caudally injected fluids spread posteriorly to the costodiaphragmatic recess, showing segmental intercostal and slight prevertebral spread.Conclusions Our detailed anatomical study shows that TPVS is a potential space continuous with the SDICs. The separation of the TPVS in a subendothoracic and an extra-pleural compartment by the endothoracic fascia was not observed. Based on the ultrasound-guided liquid spread we conclude that the use of a more lateral approach might increase the probability of intravascular puncture or catheter position.

Background: Anatomical validation studies of cervical ultrasound images are sparse. Validation is crucial to ensure accurate interpretation of cervical ultrasound images and to develop standardized reliable ultrasound procedures to identify cervical anatomical structures. The aim of this study was to acquire validated ultrasound images of cervical bony structures and to develop a reliable method to detect and count the cervical segmental levels. Methods: An anatomical model of a cervical spine, embedded in gelatin, was inserted in a specially developed measurement device. This provided ultrasound images of cervical bony structures. Anatomical validation was achieved by laser light beams projecting the center of the ultrasound image on the cervical bony structures through a transparent gelatin. Results: Anatomically validated ultrasound images of different cervical bony structures were taken from dorsal, ventral, and lateral perspectives. Potentially relevant anatomical landmarks were defined and validated. Test/retest analysis for positioning showed a reproducibility with an intraclass correlation coefficient for single measures of 0.99. Besides providing validated ultrasound images of bony structures, this model helped to develop a method to detect and count the cervical segmental levels in vivo at long-axis position, in a dorsolateral (paramedian) view at the level of the laminae, starting from the base of the skull and sliding the ultrasound probe caudally. Conclusions: Ultrasound bony images of the cervical vertebrae were validated with an in vitro model. Anatomical bony landmarks are the mastoid process, the transverse process of C1, the tubercles of C6 and C7, and the cervical laminae. Especially, the cervical dorsal laminae serve best as anatomical bony landmarks to reliably detect the cervical segmental levels in vivo.

The project was supported by the Swiss National Science Foundation (SNSF, Project no. 127240)., Background: Exercise is an effective treatment for patients with sub-acute and chronic low back pain (LBP). Patients with a movement control impairment (MCI) can be diagnosed as a subgroup of patients with LBP. Unknown is which exercise intervention is most beneficial for this subgroup. This study assessed the short-term effect of a specific exercise program targeting movement control impairment versus general exercise treatment on disability in patients with LBP and MCI. Methods: In a multicentre parallel group randomised controlled pragmatic trial, patients with sub-acute and chronic LBP were included. Further inclusion criteria were disability of ≥5 points on the Roland-Morris Disability Questionnaire and ≥2 positive tests out of a set of 6 movement control impairment tests. A total of 106 patients were randomly assigned to either tailored movement control exercise intervention (MC, n=52) or a general exercise intervention (GE, n=54); both 9-18 individual treatment sessions, over a maximum of 12 weeks. . The primary outcome was disability measured with the Patient Specific Functional scale (PSFS). Secondary outcome was the Roland-Morris disability scale (RMDQ). Measurements were taken pre- and posttreatment. Results: No significant difference was found following the treatment period. Baselineadjusted between-group mean difference for the PSFS was 0.5 (SD = 0.5; p = 0.32) in favour of MC exercises. The Roland-Morris Disability Questionnaire revealed a significant, but not clinically relevant, between-group difference of 2.0 points (SD = 0.8; p= 0.01). Conclusion: Disability in LBP patients was reduced considerably by both interventions. However, the limited contrast between the two exercise programs may have influenced outcomes.

Study Design: Diffusion tensor magnetic resonance imaging (DTMRI) reconstruction of lumbar erector spinae (ES) compared with cadaver dissection. Objective: The aim of this study was to reconstruct the human lumbar ES from in vivo DT-MRI measurements and to compare the results with literature and cadaver dissection. Summary of Background Data: DT-MRI enables 3-dimensional in vivo reconstruction of muscle architecture. Insight in ES architecture may improve the understanding of low back function. Furthermore, DT-MRI reconstructions allow individualized biomechanical modeling, which may serve as a clinical tool in injury evaluation and in improvement of understanding of pathologies like scoliosis. Materials and Methods: The lumbar spine of 1 healthy male volunteer was scanned using a 3.0 T clinical MRI scanner. MRI data acquisition consisted of 3 parts: (1) high-resolution T1-weighted turbo spin echo for anatomical reference; (2) DT-MRI measurements for fiber tractography; (3) dual echo gradient echo sequence for signal correction purposes. After processing, DT-MRI data were exported to a custom-built software program for fiber tractography. The resulting reconstructions were anatomically validated by comparison with cadaver dissection and literature. Results: DT-MRI reconstruction of 4 parts of the lumbar ES (thoracic part of iliocostalis lumborum, lumbar part of iliocostalis lumborum, thoracic part of longissimus thoracis, and lumbar part of longissimus thoracis) adequately reflected its complex geometry. Some inaccuracies were found in reconstruction details. DT-MRI reconstructions were generally in agreement with anatomical descriptions from literature and with findings in a dissected cadaver specimen. Conclusions: DT-MRI enables anatomically valid reconstruction of ES architecture. However, for reliable reconstruction of the smallest fascicles and attachments a higher resolution or application of higher-order models is needed. Reconstructions can be used as input for estimation of muscle architecture parameters in individualized biomechanical modeling. Such models are promising as a tool in clinical evaluation and in research of low back pain mechanisms.

Objective: To confirm previous findings that hip abductor activity measured by electromyography (EMG) on the side contralateral to cane use is reduced during walking in stroke patients. To assess whether an orthosis (TheraTogs) or hip abductor taping increase hemiplegic hip abductor activity compared with activity during cane walking or while walking without aids. To investigate the effect of each condition on temporo-spatial gait parameters. Design: Randomized, within-participant experimental study. Setting: Gait laboratory. Subjects: Thirteen patients following first unilateral stroke. Intervention: Data collection over six gait cycles as subjects walked at self-selected speed during: baseline (without aids) and in randomized order with (1) hip abductor taping, (2) TheraTogs, (3) cane in non-hemiplegic hand. Main measures: Peak EMG of gluteus medius and tensor fascia lata and temporo-spatial gait parameters. Results: Cane use reduced EMG activity in gluteus medius from baseline by 21.86%. TheraTogs increased it by 16.47% (change cane use—TheraTogs P=0.001, effect size = -0.5) and tape by 5.8% (change cane use—tape P=0.001, effect size = -0.46). In tensor fascia lata cane use reduced EMG activity from baseline by 19.14%. TheraTogs also reduced EMG activity from baseline by 1.10% (change cane use—TheraTogs P=0.009, effect size -0.37) and tape by 3% (not significant). Gait speed (m/s) at: baseline 0.44, cane use 0.45, tape 0.48, TheraTogs 0.49. Conclusion: Hip abductor taping and TheraTogs increase hemiplegic hip abductor activity and gait speed during walking compared with baseline and cane use.

AIMS: The aim of this study was to investigate whether pre-operative, sensory-motor movement-training as a standard treatment-programme results in improved Physical Function, Quality-of-Life and Sensory-Motor-Function and reduced Disability in patients undergoing Total-Hip-Replacement. METHODS: 80 subjects awaiting Total-Hip-Replacement (mean-age 66.8±10.3; 31 women) at a Swiss regional hospital were consecutively recruited to this Randomised Controlled Trial. The intervention-group undertook a pre-operative 2-6 week home-exercise sensory-motor training-programme, the control-group received no therapy. Following surgery both groups underwent a standard physiotherapy-programme. The Primary Outcome-Measure was Physical Function, secondary Outcome-Measures were Quality-of-Life, Disability and Sensory-Motor-Function. Outcomes were measured using patient-administered generic (SF-36) and disease-specific (WOMAC) questionnaires as well as objectively assessed balance-ability (Biodex-Balance-System). Measurements were taken one day before the Total-Hip-Replacement and 10 days, 4 and 12 months following. Treatment-effect was determined pre-operatively with t-test and post-operatively with analysis-of-variance as well as effect-size. RESULTS: The intervention improved Quality-of-Life (subscale pain; p

Bed rest has been shown to be an ineffective treatment for non-specific low back pain (LBP). Despite this, during a new episode of pain some patients still rely on bed rest. Which patients choose bed rest is however unknown. The objectives of the present study were, firstly, to assess characteristics of patients choosing bed rest in (sub)acute pain and secondly to study whether prolonged bed rest in the (sub)acute phase of pain will result in long term disability. A prospective longitudinal cohort study included 282 patients with non-specific LBP for less than 7 weeks. Main outcome measures were duration of bed rest (in three categories) and disability. Results showed that 33% of patients with (sub)acute LBP had bed rest, but only 8% stayed in bed for more than four days. An ordinal regression analysis revealed that behavioural factors (catastrophizing (OR = 1.05 per bed rest category p

Aim of investigation: To evaluate whether a perceived decline in the level of physical activity after the onset of pain (PAD) is more appropriate in the explanation of disability as compared to the actual level of physical activity (PAL) in patients with sub-acute back pain. Methods: Patients with 4–7 weeks of non-specific low back pain (LBP) participated in this study. Their habitual physical activity level before the back pain started (H-PAL), their actual level of physical activity (PAL) and their perceived decline in the level of physical activity after the onset of pain (PAD) were assessed. The association between these physical activity related variables and perceived disability (QBPDS), fear of movement/(re)injury (TSK), pain catastrophizing (PCS) and pain intensity (VAS) was examined. The role of PAD as a mediator in the association between fear of movement/(re)injury and disability was examined by three linear regression analyses. Results: 123 patients (66 male and 57 female) with a mean age of 44.1 years (SD = 10.3) participated in this study. PAD was significantly correlated with disability, fear of movement/(re)injury, pain catastrophizing and pain intensity. PAD and PAL appeared more important in the explanation of disability in the subgroup of patients who were physically active before their back pain started. Generally, PAD indeed mediated the association between fear of movement/(re)injury and disability. Conclusions: The perceived decline in physical activity, rather than the current physical activity itself is important in the evaluation of the impact of activity related changes on disability in low back pain.

Introduction La reeducation met l’accent sur l’activite du cote hemiplegique avec de nombreuses repetitions afin d’augmenter la plasticite corticale ipsilesionnelle et d’ameliorer les resultats fonctionnels. Une charge articulaire normale au niveau de l’articulation de la hanche facilite l’activite normale du reseau locomoteur spinal. L’utilisation quotidienne d’une canne du cote non hemiplegique reduit de maniere significative l’activite des muscles hemiplegiques et decharge la hanche. Les vetements de contention TheraTogs augmentent considerablement l’activite des muscles hemiplegiques pendant le cycle de marche et permettent une charge articulaire normale [1] . L’objectif de cette etude etait d’analyser l’effet des TheraTogs sur la marche et l’equilibration lors du remplacement des cannes comme aide a la marche chez des patients qui ont ete victimes d’un AVC et qui utilisent une canne. Methodes Recherche sur le modele ABC simple et multiple portant sur 4 sujets. Effet principal : Functional Gait Assessment (FGA) (echelle fonctionnelle de la marche) ; effet secondaire : balancement du tronc lors de la marche. Toutes les mesures ont ete effectuees sur une base hebdomadaire. Phase A : Canne de base. Sujets repartis au hasard pour des durees de 9 a 12 semaines. Phase B : Action de TheraTogs. Les sujets repartis au hasard pour des durees de 15 a 17 semaines ont marche a l’aide des TheraTogs (application d’une combinaison de bandes elastiques du matin au soir) pour faciliter l’activite de l’abducteur et de l’extenseur de la hanche. Phase C : Les sujets de l’etude ont soit commence a marcher sans aide a la marche, soit commence a marcher a l’aide des TheraTogs, soit conserve leur canne. Repartition au hasard pour des durees de 9 a 10 semaines. Resultats Score du Functional Gait Assessment (*MCID = 5), valeur p (Friedmans Anova) et condition au terme de la phase C. Sujet 1 : phase A : 10, phase B : 13, phase C : 12 ; p = 0,05 et a conserve sa canne. Sujet 2 : phase A : 13, phase B : 16, phase C : 20* ; p = 0,001 et a commence a marcher sans canne. Sujet 3 : phase A : 12, phase B : 15, phase C : 11 ; p = 0,03 et a conserve sa canne. Sujet 4 : phase A : 8, phase B : 13*, phase C : 12 ; p = 0,022 et a commence a marcher a l’aide des TheraTogs. Le balancement du tronc pendant la marche mesure comme zone d’angle totale (Total Angle Area (TAA)) sur les plans frontal et sagittal a diminue chez deux patients entre la phase A et la phase B, et chez trois patients entre la phase A et la phase C, ce qui indique une stabilite augmentee. Les ameliorations se sont confirmees chez tous les sujets en phase C bien qu’aucun changement de TAA ne soit statistiquement significatif. Moyenne du TAA (ET) Sujet 1 : A : 161,9° (42,4), B : 137,3° (41), C ; 117,38° (32,4) ; Sujet 2 : A : 223,4° (32,2), B : 216,5° (30,5), C : 207,70 (38,88) ; Sujet 3 : A : 116,9° (25,7), B : 121,8° (28), C : 116° (12,22) ; Sujet 4 : A : 166,2° (29,6), B : 169,15° (28,26), C : 151,25° (39,14). Discussion et conclusion Un patient victime d’AVC et qui utilisait auparavant une canne a pu commencer a marcher sans aide. Cela represente une amelioration cliniquement significative et indique que les aides a la marche peuvent avoir un impact decisif sur la marche fonctionnelle et l’equilibre. D’autres sujets ont montre une tendance similaire, mais les effets etaient moins importants. En augmentant l’activite musculaire, en permettant une charge articulaire normale et en ne sollicitant pas les mains, les aides a la marche peuvent etre plus efficaces que des cannes dans la reeducation a la marche des personnes victimes d’AVC. Le controle multifactoriel de la marche et de l’equilibre peut expliquer les reponses variees des patients. De plus amples recherches sont necessaires afin d’identifier les patients qui pourraient beneficier de cette approche.

De uitvoering van fysieke bewegingen leidt bij vrijwel alle patienten met rugpijn direct of enige tijd later tot meer pijn. Hierdoor worden bewegingen vaak zo veel mogelijk vermeden. Deze vermijding is op korte termijn nuttig: zij laat het organisme toe zich te herstellen. Langdurige vermijding kan echter nadelige gevolgen hebben, zoals verslechtering van de algehele conditie en toename van functionele beperkingen. In dit artikel wordt nader ingegaan op de cognitieve en emotionele factoren die van invloed zijn op pijn- en vermijdingsgedrag. Gesteld wordt dat de catastrofale misinterpretatie van pijn en andere lichaamssignalen de belangrijkste etiologische factor is die verantwoordelijk is voor het chronisch worden van pijnklachten. De volgende vragen zijn hierbij relevant: Wat is de invloed van een catastroferende denkstijl en vrees voor beweging/letsel op de fysieke conditie en functionele beperkingen? Wordt de relatie tussen aan pijn gerelateerde vrees en pijn gemedieerd door aandacht voor pijn? Leidt de door vrees veroorzaakte vermijding ook tot het zogenaamde disuse-syndroom? Wat zijn de implicaties voor de diagnostiek en behandeling van patienten met acute of chronische rugpijn die een overmatige vrees voor pijn/letsel rapporteren? Is exposure in vivo met gedragsexperimenten effectiever dan de gebruikelijke graded activity-benadering? Deze vragen, die in dit artikel de revue passeren, worden thans bestudeerd in het kader van het door NWO/ZonMW gefinancierde onderzoeksprogramma ‘Fear-avoidance beliefs, disuse and disability in non-specific low back pain’.

Purpose: To assess the optimal cut-off for of a summary score of six movement control impairments tests. Methods: Subjects were 1180 patients with back pain and 102 healthy subjects without back pain. Design:A cross sectional study with cases and controls to find out the best cut off point score or the best test combination for discriminative validity between patients with back pain and healthy controls. Statistical analyses: Diagnostic odds ratios, sensitivity and specificity for the different cutoffs as well as area under the curve values were calculated with logistic regressions with corresponding 95% confidence intervals. Results: The optimal cut-off was with two or more positive movement control impairment tests out of six, resulting in a diagnostic odds ratio of 8.04 (95%CI 4.30 to 15.06 and a sensitivity of 68% and a specificity of 79%. If analysed individually, the test with the best discriminative validity was the prone knee bend (AUC0.67; OR 5.58, sensitivity 51%, specificity 84%), followed by four point kneeling (AUC 0.65, OR 3.7, sensitivity 52%, specificity 77%; and waiters bow (AUC 0.62, OR 4.6, sensitivity 33% and specificity 90%). Conclusion(s): The optimal cut-off for discriminating patients with back pain from healthy controls was with two or more positive movement control impairment tests out of six, resulting in a diagnostic odds ratio of 8.04. Implications: It is recommendable to use the whole test battery of six tests tpoevaluate the movement control ability of the subjects. If two or more tests are positive, the Odds are 6 to 1 that this person has back pain.

Anatomical validation studies of cervical ultrasound images are sparse. Validation is crucial to ensure accurate interpretation of cervical ultrasound images and to develop standardized reliable ultrasound procedures to identify cervical anatomical structures. The aim of this study was to acquire validated ultrasound images of cervical bony structures and to develop a reliable method to detect and count the cervical segmental levels.An anatomical model of a cervical spine, embedded in gelatin, was inserted in a specially developed measurement device. This provided ultrasound images of cervical bony structures. Anatomical validation was achieved by laser light beams projecting the center of the ultrasound image on the cervical bony structures through a transparent gelatin.Anatomically validated ultrasound images of different cervical bony structures were taken from dorsal, ventral, and lateral perspectives. Potentially relevant anatomical landmarks were defined and validated. Test/retest analysis for positioning showed a reproducibility with an intraclass correlation coefficient for single measures of 0.99. Besides providing validated ultrasound images of bony structures, this model helped to develop a method to detect and count the cervical segmental levels in vivo at long-axis position, in a dorsolateral (paramedian) view at the level of the laminae, starting from the base of the skull and sliding the ultrasound probe caudally.Ultrasound bony images of the cervical vertebrae were validated with an in vitro model. Anatomical bony landmarks are the mastoid process, the transverse process of C1, the tubercles of C6 and C7, and the cervical laminae. Especially, the cervical dorsal laminae serve best as anatomical bony landmarks to reliably detect the cervical segmental levels in vivo.

Anatomy education often consists of a combination of lectures and laboratory sessions, the latter frequently including surface anatomy. Studying surface anatomy enables students to elaborate on their knowledge of the cadaver's static anatomy by enabling the visualization of structures, especially those of the musculoskeletal system, move and function in a living human being. A recent development in teaching methods for surface anatomy is body painting, which several studies suggest increases both student motivation and knowledge acquisition. This article focuses on a teaching approach and is a translational contribution to existing literature. In line with best evidence medical education, the aim of this article is twofold: to briefly inform teachers about constructivist learning theory and elaborate on the principles of constructive, collaborative, contextual, and self-directed learning; and to provide teachers with an example of how to implement these learning principles to change the approach to teaching surface anatomy. Student evaluations of this new approach demonstrate that the application of these learning principles leads to higher student satisfaction. However, research suggests that even better results could be achieved by further adjustments in the application of contextual and self-directed learning principles. Successful implementation and guidance of peer physical examination is crucial for the described approach, but research shows that other options, like using life models, seem to work equally well. Future research on surface anatomy should focus on increasing the students' ability to apply anatomical knowledge and defining the setting in which certain teaching methods and approaches have a positive effect.

Background Non-specific low back pain (NSLBP) in subacute and chronic stages can be treated effectively with exercise therapy. Research guidelines recommend evaluating different treatments in defined subgroups of patients with NSLBP. A subgroup of patients with movement control impairment (MCI) improved significantly on patient specific function and disability in a previous case series after movement control exercises. Methods/Design In a randomised controlled trial (RCT) we will compare the effectiveness of movement control and general exercise in patients with MCI. 106 participants aged 18 - 75 will be recruited in 5 outpatient hospital departments and 7 private practices. Patients randomly assigned to the movement control exercise group will be instructed to perform exercises according to their MCI. The general exercise group will follow an exercise protocol aimed at improving endurance and flexibility. Patients in both groups will receive 9 - 18 treatments and will be instructed to do additional exercises at home. The primary outcome is the level of disability assessed using the patient specific functional scale (PSFS) which links the perceived pain to functional situations and is measured before treatment and at 6 and 12 months follow-up. Secondary outcomes concern low back pain related disability (Roland Morris questionnaire, RMQ), graded chronic pain scale (GCPS), range of motion and tactile acuity. Discussion To our knowledge this study will be the first to compare two exercise programs for a specific subgroup of patients with NSLBP and MCI. Results of this study will provide insight into the effectiveness of movement control exercise and contribute to our understanding of the mechanisms behind MCI and its relation to NSLBP. Trial registration Current Controlled Trials ISRCTN80064281

The aim of this study was to investigate whether pre-operative, sensorimotor training results in improved physical function, quality of life, sensorimotor function and reduced disability in total hip replacement patients. 80 subjects awaiting total hip replacement at a Swiss hospital were recruited for this randomised controlled trial. The intervention group participated in a pre-operative home exercise sensorimotor training programme; the control group received no therapy. Primary outcome measure was physical function, secondary outcome measures were quality of life, disability and sensorimotor function. Outcomes were measured using generic and disease-specific questionnaires as well as objectively assessed balance ability. Measurements were taken one day before surgery and 10 days, 4 and 12 months after surgery. The intervention showed improved quality of life and sensorimotor function before surgery. These effects were lost following surgery. The intervention group experienced more disability at 4 months than the control group. At one year follow-up group-membership influenced quality of life scores depending on the measurement-time-point. It can be concluded that no useful effect was identified for a pre-operative sensory-motor training-programme. The psychological aspects following total hip replacement need to be considered in order to facilitate coping-strategies, reduce unrealistic expectations and increase satisfaction.

Item does not contain fulltext BACKGROUND: In low back pain (LBP) treatment and research attention has shifted from a biomedical towards a biopsychosocial approach. Patients' LBP beliefs and attitudes were found to predict long-term outcome, and recently it has been suggested that the health care providers' ideas about LBP are also important predictors of treatment behaviour and outcome. AIMS: In the present study we examined whether (1) differences in General Practitioners' (GP) LBP treatment orientation are associated with differences in actual treatment behaviour and (2) whether treatment orientation is related to LBP outcome in patients. METHODS: Two hundred twenty two patients consulting their GP with a new episode of LBP were recruited and completed questionnaires on (among others) LBP outcome (graded chronic pain scale) at baseline, during 12 months of follow-up and at the end of the study. Data on treatment were collected from the GPs. The GPs also completed a set of questionnaires on LBP treatment orientation. Associations between measures of treatment orientation, treatment recommendations, treatment behaviour and LBP outcome were analysed. RESULTS: A biomedical treatment orientation was found to be associated with more concern about tissue damage and the effect of physical activity on pain and recovery in vignettes. No associations were found between treatment orientation measures, actual treatment behaviour and LBP outcome. CONCLUSIONS: Associations were not found as expected. Still these findings are relevant and may feed a clinically important debate on widely accepted assumptions about the role and influence of health care providers in changing patients' pain behaviours.

Recently, fear-avoidance models have been quite influential in understanding the transition from acute to chronic low back pain (LBP). Not only has pain-related fear been found to be associated with disability and increased pain severity, but also treatment focused at reducing pain-related fear has shown to successfully reduce disability levels. In spite of these developments, there is still a lack in well-designed prospective studies examining the role of pain-related fear in acute back pain. The aim of the current study was to prospectively test the assumption that pain-related fear in acute stages successfully predicts future disability. Subjects were primary care acute LBP patients consulting because of a new episode of LBP (

The overall aim of this study was to explore the natural course of pain-related fear during the early stage of a new low back pain episode, using a prospective case series design. Specific research questions addressed the existence of typical patterns in individual time series of pain-related fear and sequential relationships between the occurrence of pain-related fear, pain and pain catastrophizing. Forty-four general practice patients who consulted their physician with a new episode of non-specific low back pain were recruited. They completed diaries on pain-related fear, pain and pain catastrophizing for 14 days following the consultation. Follow-up questionnaires on disability were completed at 3 months and 12 months. Time series analyses produced subgroups of patients with descending, stable and rising levels of pain-related fear over the 2-week period. These groups differed on baseline characteristics and outcome at follow-up. A time-shift between the occurrence of pain-events and pain-related fear or pain catastrophizing could not be demonstrated.In summary, these results fit in with previous findings in chronic patients. A relevant subgroup of patients who might benefit from early intervention could be identified. These findings support the need for further research into fear mechanisms in acute low back pain.

Background Annually, some 9000 people in Switzerland suffer a first time stroke. Of these 60% are left with moderate to severe walking disability. Evidence shows that rehabilitation techniques which emphasise activity of the hemiplegic side increase ipsilesional cortical plasticity and improve functional outcomes. Canes are commonly used in gait rehabilitation although they significantly reduce hemiplegic muscle activity. We have shown that an orthosis "TheraTogs" (a corset with elasticated strapping) significantly increases hemiplegic muscle activity during gait. The aim of the present study is to investigate the long term effects on the recovery of gait, balance and social participation of gait rehabilitation with TheraTogs compared to gait rehabilitation with a cane following first time acute stroke. Methods/Design Multi-centre, single blind, randomised trial with 120 patients after first stroke. When subjects have reached Functional Ambulation Category 3 they will be randomly allocated into TheraTogs or cane group. TheraTogs will be applied to support hip extensor and abductor musculature according to a standardised procedure. Cane walking held at the level of the radial styloid of the sound wrist. Subjects will walk throughout the day with only the assigned walking aid. Standard therapy treatments and usual care will remain unchanged and documented. The intervention will continue for five weeks or until patients have reached Functional Ambulation category 5. Outcome measures will be assessed the day before begin of intervention, the day after completion, 3 months, 6 months and 2 years. Primary outcome: Timed "up and go" test, secondary outcomes: peak surface EMG of gluteus maximus and gluteus medius, activation patterns of hemiplegic leg musculature, temporo-spatial gait parameters, hemiplegic hip kinematics in the frontal and sagittal planes, dynamic balance, daily activity measured by accelerometry, Stroke Impact Scale. Significance levels will be 5% with 95% CI's. IntentionToTreat analyses will be performed. Descriptive statistics will be presented. Discussion This study could have significant implications for the clinical practice of gait rehabilitation after stroke, particularly the effect and appropriate use of walking aids. The results could be important for the development of clinical guidelines and for the socio-economic costs of post-stroke care Trial registration number ClinicalTrials.gov NCT01366729.

Previous research supports the fear-avoidance model in explaining chronic low back pain (LBP) disability. The aims of the present study were to determine: (1) whether fear-avoidance model variables are associated already during acute stages of LBP and (2) whether (increases in) pain-related fear are associated with other patient characteristics routinely assessed by the General Practitioner (GP). General practice patients consulting because of a new episode of LBP completed questionnaires on pain-related fear, avoidance, pain and disability. A sample of 247 acute LBP patients (median duration of current episode was 5 days) was collected. Significant associations were found between pain intensity, pain-related fear, avoidance behaviour and disability, but correlations were generally modest. A strong association was found between pain and disability. Pain-related fear was slightly higher in patients reporting low job satisfaction and in those taking bedrest. These results suggest that the fear-avoidance model as it was developed and tested in chronic LBP, might not entirely apply to acute LBP patients. Future research should focus on the transition from acute to chronic LBP and the shifts that take place between fear-avoidance model associations.