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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

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 Jo Nijs, 3, 16 Nathalie Roussel, 18 Han Samwel 19 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; 6Methodological Health-Skilled Institute, Beuningen, the Netherlands; 7SOMT 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; 10Faculty of Science and Engineering, Maastricht University, Maastricht, the Netherlands; 11Department of Human Movement Sciences, Faculty of Behavioral and Movement Sciences, Vrije Universiteit Free University Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands; 12Department of Epidemiology, Center of Evidence Based Physiotherapy, Maastricht University, Maastricht, the Netherlands; 13Practice Physiotherapy ‘Klepperheide’, Druten, the Netherlands; 14Department of Physiotherapy, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus Univerisity, 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 Physiotherapy and Rehabilitation Sciences (MOVANT), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; 19Revalis 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, Berg en Dal 6572 AT, the NetherlandsTel +31 2464234219Email oostendorp.rob@gmail.comBackground: 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.Keywords: physiotherapy, whiplash injuries, outcome and process assessment, healthcare quality indicators, collected data

Rob AB Oostendorp,1–4 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,3,8,16 Marjan Laekeman,17 Jo Nijs,3,8,16 Nathalie Roussel,18 Han Samwel191Scientific 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, Free University Brussels, 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; 6Methodological Health-Skilled Institute, Beuningen, the Netherlands; 7SOMT University of Physiotherapy, Amersfoort, the Netherlands; 8Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Free University Brussels, Brussels, Belgium; 9Institute of Health Studies, Faculty of Health and Social Studies, HAN University of Applied Science, Nijmegen, the Netherlands; 10Faculty of Science and Engineering, University College Venlo, Maastricht University, Maastricht, the Netherlands; 11Department of Human Movement Sciences, Faculty of Behavioral and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; 12Department of Epidemiology, Center of Evidence-Based Physiotherapy, Maastricht University, Maastricht, the Netherlands; 13Practice Physiotherapy ‘Klepperheide’, Druten, the Netherlands; 14Department of Physiotherapy, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Torun, Poland; 15Neurocognitive Laboratory, Centre for Modern Interdisciplinary Technologies, Nicolaus Copernicus University, Torun, Poland; 16Department of Physical Medicine and Physiotherapy, University Hospital Brussels, Brussels, Belgium; 17Department of Nursing Sciences, Faculty of Health, University Witten/Herdecke, Witten, Germany; 18Department of Rehabilitation Sciences and Physiotherapy (MOVANT), Faculty of Medicine and Health Sciences, University of Antwerp, Belgium; 19Department of Medical Psychology, Canisius Wilhelmina Hospital, Nijmegen, the NetherlandsPurpose: To develop valid quality indicators (QIs) for physiotherapy care based on best available evidence, and to use these QIs to explore trends in the quality of physiotherapy care of patients with Whiplash-associated disorders (WAD) using guideline-based routinely collected data (RCD) gathered between 1996 and 2011.Materials and methods: The study consisted of two phases: 1) development of QIs and 2) analysis of patient records. A set of QIs was developed based on recommendations in the scientific literature and the Dutch Clinical Practice Guideline (CPG) “Physiotherapy Management and WAD”. QIs were expressed as percentages, allowing target performance levels to be defined (≥80% or ≤30% depending on whether desired performance required a high or low score on a QI). We then analyzed WAD patient data (N = 810) collected over a period of 16 years in two physiotherapy practices, separating patients into two groups defined as before (Group A 1996–2002; n = 353) and after (Group B 2003–2011; n = 457) implementation and transition to the Dutch CPG “Physiotherapy Management and WAD”.Results: Using an iterative process and input from both experts and users, 28 QIs were developed and subsequently classified per step of the clinical reasoning process for physiotherapy care. Based on 16 years of RCD, we found that the clinical reasoning process differed significantly (P ≤ 0.05) between the groups, in favor of Group B. Twelve of the 25 indicators (48.0%) in Group A and 19 of 26 indicators (73.1%) in Group B met predetermined performance targets. The number of target indicators also differed significantly between groups, favoring Group B (P ≤ 0.05).Conclusion: A preliminary set of novel QIs was developed. Using RCD and these QIs, we conclude that physiotherapy care in our study setting improved over the period 1996–2011. Furthermore, the QIs met the performance targets set for the clinical reasoning process after the transition to the Dutch CPG “Physiotherapy Management and WAD”. Keywords: quality of physiotherapy care, Whiplash-associated disorders, clinical guidelines, quality indicators, clinical reasoning process, routinely collected data

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% CI -0.01 to 0.69) for measuring the physiological range of shoulder internal rotation using vision to 0.99 (95% CI 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. [ABSTRACT FROM AUTHOR]

Introduction: Worldwide many countries provide direct access in physiotherapy. The aim of this scoping review was to synthesize the available evidence on the quality of primary care musculoskeletal physiotherapy from different perspectives., Methods: Systematic searches were conducted in three databases up to September 2022. Studies were included when regarding assessment of at least one of the following perspectives: patient (quality of Life, patient satisfaction, pain, functioning, adverse events), provider (treatment compliance, responsibility, liability, status, prestige, job satisfaction), and society (number of referrals, amount of medical imaging, medication use, number of sessions needed for rehabilitation, and overall costs and cost-effectiveness). Selection and methodological quality assessment of systematic reviews were performed. Data extraction and analysis were performed separately for systematic reviews and individual primary studies., Results: Five systematic reviews as well as 17 primary studies were included. From a patient perspective, no significant effect of direct access was found for pain and a tendency in favour of direct access was found for quality of life, functioning, and well-being. Concerning providers, higher treatment compliance was found in direct access to physiotherapy and decision-making was more accurate. From a societal perspective, significant differences in favour of direct access physiotherapy were found for waiting time, prescribed medication, and medical imaging. In addition, there was a tendency towards lower health care costs., Conclusions: Emerging evidence suggests that direct access physiotherapy could provide at least equal quality of care for patients and better opportunities for providers and the society on selected outcomes., (© 2024 The Authors.)

Introduction: Acute lower back pain can lead to neuroplastic changes in the central nervous system, and symptoms of central sensitization after 12 weeks. While sensory sensitivity has been shown to predict symptoms of central sensitization, trait sensory profiles may be prognostic in the persistence of central sensitization symptoms in low back pain over time., Objective: To examine sensory profiles as prognostic symptoms of central sensitization in people with acute low back pain., Methods: A longitudinal type 2 prognostic factor research study was performed according to the PROGRESS framework. Baseline and 12-week follow-up measures were taken using the Adolescent/Adult Sensory Profile and the Central Sensitization Inventory measures. Study participants were consecutively included from primary care physiotherapy practices. Univariable, and multivariable regression analyses were performed to adjust sensory profiles based on previous history of low back pain, baseline Central Sensitization Inventory scores, level of pain, disability, age, and duration of low back pain., Results: After adjustment, the sensory profiles of Low Registration B = 0.44, 95%CI (0.18, 0.70), Sensation Seeking B = 0.38, 95%CI (0.19, 0.57), Sensory Sensitive B = 0.49, 95%CI (0.25, 0.74), Sensation Avoiding B = 0.40, 95% CI (0.15, 0.65) was significantly associated with the persistence of central sensitization symptoms ( N  = 103)., Conclusion: Sensory profiles may predict symptoms of central sensitization after 12 weeks in people with acute low back pain.

Question: What is the diagnostic accuracy of the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) framework to assess the risk of vascular complications in patients seeking physiotherapy care for neck pain and/or headache?, Design: Cross-sectional diagnostic accuracy study., Participants: One hundred and fifty patients seeking physiotherapy for neck pain and/or headache in primary care., Methods: Nineteen physiotherapists performed the index test according to the IFOMPT framework. Patients were classified as having a high, intermediate or low risk of vascular complications, following manual therapy and/or exercise, derived from the estimated risk of the presence of vascular pathology. The reference test was a consensus medical decision reached by a vascular neurologist and an interventional neurologist, with input from a neuroradiologist. The neurologists had access to clinical data and magnetic resonance imaging of the cervical spine, including an angiogram of the cervical arteries., Outcome Measures: Diagnostic accuracy measures were calculated for 'no contraindication' (ie, the low-risk category) and 'contraindication' (ie, the high-risk and intermediate-risk categories) for manual therapy and/or exercise. Sensitivity, specificity, predictive values, likelihood ratios and the area under the curve were calculated., Results: Manual therapy and/or exercise were contraindicated in 54.7% of the patients. The sensitivity of the IFOMPT framework was low (0.50, 95% CI 0.39 to 0.61) and its specificity was moderate (0.63, 95% CI 0.51 to 0.75). The positive and negative likelihood ratios were weak at 1.36 (95% CI 0.93 to 1.99) and 0.79 (95% CI 0.60 to 1.05), respectively. The area under the curve was poor (0.57, 95% CI 0.49 to 0.65)., Conclusion: The IFOMPT framework has poor diagnostic accuracy when compared with a reference standard consisting of a consensus medical decision., (Copyright © 2023 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.)

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/., (Copyright © 2023. Published by Elsevier B.V.)

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., Competing Interests: The authors report no conflict of interest in this work.

Background: Evidence 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., Method: A 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 p<.01), had a wider distribution of their neck pain (p=.02), more restricted cervical flexion-extension (-11.9°) and rotation (-12.4°), less muscle endurance (-5.5 seconds), and more disability (+14.0%), compared to patients with NTNP. More patients with WAD reported low back pain (+9.5%) and headache (+12.2%) as musculoskeletal comorbidities. Regarding anxiety, depression, and stress, most patients (>83%) 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., Conclusion: WAD 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.

Competing Interests: Declaration of competing interest None.

Quality improvement is now a central tenet in physiotherapy care, and quality indicators (QIs), as measurable elements of care, have been applied to analyze and evaluate the quality of physiotherapy care over the past two decades. QIs, based on Donabedian's model of quality of care, provide a foundation for measuring (improvements in) quality of physiotherapy care, providing insight into the many remaining evidentiary gaps concerning diagnostics, prognostics and treatment, as well as patient-related outcome measures. In this overview we provide a synthesis of four recently published articles from our project group on the topic of quantitative measures of quality improvement in physiotherapy care, in this context specifically focused on patients with WAD in primary care physiotherapy. A set of process and outcome QIs ( n = 28) was developed for patients with WAD and linked to a database consisting of routinely collected data (RCD) on patients with WAD collected over a 16-year period. The QIs were then embedded per step of the clinical reasoning process: (a) administration ( n = 2); (b) history taking ( n = 7); (c) objectives of examination ( n = 1); (d) clinical examination ( n = 5); (e) analysis and conclusion ( n = 1); (f) treatment plan ( n = 3); (g) treatment ( n = 2); (h) evaluation ( n = 5); and (i) discharge ( n = 2). QIs were expressed as percentages, allowing target performance levels to be defined ≥70% or ≤30%, depending on whether the desired performance required an initially high or low QI score. Using RCD data on primary care patients with WAD ( N = 810) and a set of QIs, we found that the quality of physiotherapy care has improved substantially over a 16-year period. This conclusion was based on QIs meeting predetermined performance targets of ≥70% or ≤30%. Twenty-three indicators met the target criterium of ≥70% and three indicators ≤30%. Our recommended set of QIs, embedded in a clinical reasoning process for patients with WAD, can now be used as a basis for the development of a validated QI set that effectively measures quality (improvement) of primary care physiotherapy in patients with WAD., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Oostendorp, Elvers, van Trijffel, Rutten, Scholten-Peeters, De Kooning, Laekeman, Nijs, Roussel and Samwel.)

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.

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 (R 2 =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., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Neck 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., Objective: The purpose of this study was to externally validate three promising models that predict neck pain recovery in primary care., Methods: This 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., Results: The 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., Conclusions: External 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., Competing Interests: Conflict of Interest The authors declare no conflicts of interest, (Copyright © 2021 The Authors. Publicado por Elsevier España, S.L.U. All rights reserved.)

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.

Objective: Clinicians are recommended to use the clinical reasoning framework developed by the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) to provide guidance regarding assessment of the cervical spine and potential for cervical artery dysfunction prior to manual therapy and exercise. However, the interexaminer agreement and reliability of this framework is unknown. This study aimed to estimate the interexaminer agreement and reliability of the IFOMPT framework among physical therapists in primary care., Methods: Ninety-six patients who consulted a physical therapist for neck pain or headache were included in the study. Each patient was tested independently by 2 physical therapists, from a group of 17 physical therapists (10 pairs) across The Netherlands. Patients and examiners were blinded to the test results. The overall interexaminer agreement, specific agreement per risk category (high-, intermediate-, and low-risk), and interexaminer reliability (weighted κ) were calculated., Results: Overall agreement was 71% (specific agreement in high-risk category = 63%; specific agreement in intermediate-risk category = 38%; specific agreement in low-risk category = 84%). Overall reliability was moderate (weighted κ = 0.39; 95% CI = 0.21-0.57) and varied considerably between pairs of physical therapists (κ = 0.14-1.00)., Conclusion: The IFOMPT framework showed an insufficient interexaminer agreement and fair interexaminer reliability among physical therapists when screening the increased risks for vascular complications following manual therapy and exercise prior to treatment., Impact: The IFOMPT framework contributes to the safety of manual therapy and exercise. It is widely adopted in clinical practice and educational programs, but the measurement properties are unknown. This project describes the agreement and reliability of the IFOMPT framework., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Physical Therapy Association.)

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., (Copyright © 2020. Published by Elsevier Ltd.)

Background: Single-legged hop tests are frequently used in substantiating return to sport decisions following lower extremity injury. Evidence for using the non-injured leg as a reference for the injured leg in the return to sport decision-making at the criterion-based point of return to sport following lower extremity injury is lacking., Purpose: To compare absolute values in single-legged hop tests between the non-injured leg of athletes returning to high-impact sports after lower extremity injury and the matched leg of healthy athletes., Study Design: Cross-sectional study., Methods: One hundred and sixty-nine athletes returning to high-impact sports after lower extremity injury and 169 matched healthy athletes executed five single-legged hop tests. Differences between athletes returning to high-impact sports after lower extremity injury and matched healthy athletes on five single-legged hop tests were analyzed using paired t-tests., Results: There were no statistically significant differences between the non-injured leg of athletes returning to sport and the matched leg of healthy athletes. Effect sizes ranged from 0.05 to 0.14 indicating negligible effects., Conclusion: Clinicians can use the non-injured leg as a reference for the injured leg in single-legged hop tests for deciding on return to high-impact sports after lower extremity injuries., Level of Evidence: 3b., Competing Interests: All authors declare that they have no conflicts of interest relevant to the content of this manuscript.

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., (Copyright © 2020 Elsevier Inc. All rights reserved.)

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. These slides can be retrieved under Electronic Supplementary Material.

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., (© Journal of Sports Science and Medicine.)

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 R 2 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 R 2 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 R 2 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., (Copyright © 2019 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.)

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<0.001). Athletes who RTS and those who initially visited their physical therapist differed significantly on all items and on total scores (p<0.001)., Conclusions: The I-PRRS was successfully translated into Dutch and can be administered to athletes with lower extremity injuries who have clearance to RTS. The MDC of 5.58 on the total score indicated that with a score below six, there is no noticeable change outside the measurement error. For measuring and monitoring psychological readiness for RTS, the use of the Dutch I-PRRS is recommended for Dutch physical therapists., Level of Evidence: 3b., (© 2019 by the Sports Physical Therapy Section.)

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., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

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]., (Copyright © 2017 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.)

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.

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., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

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.

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., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

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.

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.

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±6.1years) 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±7.3years) 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., (Copyright © 2014 Elsevier B.V. All rights reserved.)

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 < 0.001). People in the experimental group were relatively more often "very satisfied" than "satisfied" in comparison with participants in the control group for "attention being paid by the optometrist" (p = 0.025) and "advice on refractive correction" (p = 0.047)., Conclusions: In diabetic patients, dilating pupils before refraction and visual acuity assessment does not lead to different advice given to patients compared with dilating pupils after refraction and visual acuity assessment, whereas waiting time significantly decreases and patient satisfaction is similar or even better. Increased efficiency is beneficial to both patients and clinicians.