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There have been repeated calls to re-evaluate how clinicians provide care for people presenting with persistent non-traumatic musculoskeletal conditions. One suggestion is to move away from the 'we can fix and cure you' model to adopting an approach that is more consistent with approaches used when managing other persistent non-communicable diseases; education, advice, a major focus on self-management including lifestyle behavioural change, physical activity and medications as required. Currently the global delivery of musculoskeletal care has many of the elements of a 'super wicked problem', namely conflict of interest from stake-holders due to the consequences of change, prevailing expectation of a structural diagnosis and concomitant fix for musculoskeletal pain, persistent funding of high risk, more expensive care when low risk more economic viable options that don't impact on the quality of outcome exist, and an unquestionable need to find a solution now with the failure resulting in a growing social and economic burden for future generations. To address these issues, 100 participants included clinicians, educators and researchers from low-, middle- and high-income countries, eight presenters representing the physiotherapy, sport medicine and the orthopaedic professions and the insurance industry, together with three people who shared their lived experiences of persistent musculoskeletal pain, discussed the benefits and barriers of implementing change to address this problem. This paper presents the results from the stakeholders' contextual analysis and forms the basis for the proposed next steps from an action and advocacy perspective.

Low back pain is a leading cause of musculoskeletal disability worldwide, recorded in both low- and high-income countries. Recent levels of disability associated with low back pain have increased despite a significant increase in expenditure on low back pain management. Effective care for persistent musculoskeletal pain is informed by triage to rule out red flags, identification of pain mechanisms and application of evidence-based interventions. Currently, research on low back pain encourages exercise rehabilitation and pain education, both of which allow for self-management. The person-centered care and shared decision-making of the self-management model can support adherence to prescribed exercise regimens and may lower healthcare utilization. As clinicians we have the responsibility to educate patients, the community, funders, policymakers, and clinicians on self-management to help reduce the disease burden on society. Although the evidence for self-management as a treatment approach in low back pain is just beginning to evolve, contemporary knowledge of pain neuroscience and a move toward patient-centered care may demonstrate improved outcomes in the future.

Background: The use of pain neuroscience education (PNE) has been shown to be effective in reducing pain, improving function and lowering fear and catastrophisation. Pain neuroscience education utilises various stories and metaphors to help patients reconceptualise their pain experience. To date no individualised study has looked at which stories and metaphors may be the most effective in achieving the positive outcomes found with the use of PNE. Objectives: This study examined patient responses to the usefulness of the various stories and metaphors used during PNE for patients who underwent surgery for lumbar radiculopathy. Method: Twenty-seven participants who received preoperative PNE from a previous randomised control trial (RCT) were surveyed 1-year post-education utilising a 5-point Likert scale (0 – ‘do not remember’, 4 – ‘very helpful’) on the usefulness of the various stories and metaphors used during the PNE session. Participant demographics and outcomes data (pain intensity, function and pain knowledge) were utilised from the previous RCT for analysis and correlations. Results: Nineteen surveys were returned for a response rate of 70%. No story or metaphor mean was below 2 – ‘neutral’, lowest mean at 2.53; 6 of the 11 stories or metaphors scored a mean above 3 – ‘helpful’. Conclusion: No individual story or metaphor stood out as being predominately important in being helpful in the recovery process through the use of PNE. Clinical implications: The overall messages of reconceptualising pain during PNE may be more important than any individual story or metaphor.

Background: Results from a previous multicenter randomized controlled trial (RCT) on preoperative pain neuroscience education (PNE) for lumbar radiculopathy found no significant difference in patient reported outcomes between groups. However, patients who received PNE viewed their surgical experience more favorably and utilized significantly less healthcare compared to those that did not. The purpose is to determine if the reduction in healthcare costs from 1-year would be continued at 3-year following surgery, and to explore differences (if any) in patient reported outcomes. Study design—analysis of 3-year follow-up data from RCT on preoperative PNE for lumbar radiculopathy. Methods: Participating patients from the previous RCT were contacted for 3-year follow-up. Of the 67 patients who commenced in the study, there were 61 who completed 1-year follow-up. Data packets were sent to these 61 patients to examine post-operative utilization of healthcare (Utilization of Healthcare Questionnaire); LBP [numeric rating scale (NRS)]; leg pain (NRS); function (Oswestry disability index); and beliefs and experiences related to LS (10 item survey with Likert responses). Results: At 3-year follow-up, 50 patients (29 females) responded, with 22 patients in the experimental group (EG) and 28 in the control group (CG). Cumulative medical expenses were 37% lower for the EG, with those patients spending less on X-rays and visits to their family physician, physical therapist, and massage therapist. There were no differences in patient reported outcomes between groups. Patients who received PNE continued to view their surgical experience more favorably compared to those that did not. Conclusions: Adding a single PNE session prior to surgery for lumbar radiculopathy results in significant healthcare savings over 3 years. Educating such patients about normal responses to lumbar surgery (LS) in a neuroscience framework may result in lasting behavior changes following surgery.

The interview of a patient attending physical therapy is the cornerstone of the physical examination, diagnosis, plan of care, prognosis, and overall efficacy of the therapeutic experience. A thorough, skilled interview drives the objective tests and measures chosen, as well as provides context for the interpretation of those tests and measures, during the physical examination. Information from the interview powerfully influences the treatment modalities chosen by the physical therapist (PT) and thus also impacts the overall outcome and prognosis of the therapy sessions. Traditional physical therapy focuses heavily on biomedical information to educate people about their pain, and this predominant model focusing on anatomy, biomechanics, and pathoanatomy permeates the interview and physical examination. Although this model may have a significant effect on people with acute, sub-acute or postoperative pain, this type of examination may not only gather insufficient information regarding the pain experience and suffering, but negatively impact a patient's pain experience. In recent years, physical therapy treatment for pain has increasingly focused on pain science education, with increasing evidence of pain science education positively affecting pain, disability, pain catastrophization, movement limitations, and overall healthcare cost. In line with the ever-increasing focus of pain science in physical therapy, it is time for the examination, both subjective and objective, to embrace a biopsychosocial approach beyond the realm of only a biomedical approach. A patient interview is far more than "just" collecting information. It also is a critical component to establishing an alliance with a patient and a fundamental first step in therapeutic neuroscience education (TNE) for patients in pain. This article highlights the interview process focusing on a pain science perspective as it relates to screening patients, establishing psychosocial barriers to improvement, and pain mechanism assessment.

To determine the referral patterns, utilization and indications for postoperative physical therapy (PT) for lumbar radiculopathy. At least 50 % of patients following lumbar surgery (LS) for radiculopathy are referred for PT to address postoperative pain and disability. Very little is known regarding factors following LS that predict referral to PT, patient perceptions, satisfaction of postoperative PT and predictors of success for PT following LS for radiculopathy. Sixty-five patients who underwent LS for radiculopathy completed outcome measures on pain and disability prior to, and 1, 3, 6 and 12 months after LS. They also completed a questionnaire regarding postoperative PT at the 12-month follow-up. The majority of patients (59.32 %) attended PT after LS for an average of 14 visits and rated PT favorably. Forty-five percent of the patients who did not attend PT after LS were of the opinion that they would have benefitted from PT after LS, and 62.5 % of these patients reported the surgeon not discussing postoperative PT after LS. Patients with longer duration of symptoms prior to surgery, with greater leg pain scores 1 month after surgery, and who did not feel as well prepared for surgery at the 1 year follow-up were more likely to receive PT, but this did not result in significantly better outcomes on any measure at any follow-up period and did not predict attendance in PT after LS. There is a need to determine if a subgroup of patients following LS exists who will respond favorably to postoperative PT.

Postoperative rehabilitation for lumbar radiculopathy has shown little effect on reducing pain and disability. Current preoperative education programs with a focus on a biomedical approach feature procedural and anatomical information, and these too have shown little effect on postoperative outcomes. This report describes the development of an evidence-based educational program and booklet for patients undergoing lumbar surgery for radiculopathy using a recently conducted systematic review of neuroscience education for musculoskeletal pain. The previous systematic review produced evidence for neuroscience education as well as best-evidence synthesis of the content and delivery methods for neuroscience education for musculoskeletal pain. These evidence statements were extracted and developed into patient-centered messages and a booklet, which was then evaluated by peer and patient review. The neuroscience educational booklet and preoperative program convey key messages from the previous systematic review aimed at reducing fear and anxiety before surgery and assist in developing realistic expectations regarding pain after surgery. Key topics include the decision to undergo surgery, pain processing, peripheral nerve sensitization, effect of anxiety and stress on pain, surgery and the nervous system, and decreasing nerve sensitization. Feedback from the evaluations of the booklet and preoperative program was favorable from all review groups, suggesting that this proposed evidence-based neuroscience educational program may be ready for clinical application. Refereed/Peer-reviewed

Objective. To evaluate the evidence for the effectiveness of sham surgery in orthopedics by conducting a systematic review of literature. Methods. Systematic searches were conducted on Biomed Central, BMJ.com, CINAHL, the Cochrane Library, NLM Central Gateway, OVID, ProQuest (Digital Dissertations), PsycInfo, PubMed/Medline, ScienceDirect and Web of Science. Secondary searching (PEARLing) was undertaken, whereby reference lists of the selected articles were reviewed for additional references not identified in the primary search. All randomized controlled trials comparing surgery versus sham surgery in orthopedics were included. Data were extracted and methodological quality was assessed by two reviewers using the Critical Review Form—Quantitative Studies. Levels of scientific evidence, based on the direction of outcomes of the trials, were established following the Australian National Health and Medical Research Council (NHMRC) Hierarchy of Evidence (Australian National Health and Medical Research Council, 1999). Results. This review includes six randomized controlled trials (RCTs) involving 277 subjects. All six studies were rated as very good on methodological quality. Heterogeneity across the studies, with respect to participants, interventions evaluated, and outcome measures used, prevented meta-analyses. Narrative synthesis of results, based on effect size, demonstrated that sham surgery in orthopedics was as effective as actual surgery in reducing pain and improving disability. Conclusions. This review suggests that sham surgery has shown to be just as effective as actual surgery in reducing pain and disability; however, care should be taken to generalize findings because of the limited number of studies.

Systematic review of randomized control trials (RCTs) for the effectiveness of pain neuroscience education (PNE) on pain, function, disability, psychosocial factors, movement, and healthcare utilization in individuals with chronic musculoskeletal (MSK) pain.Systematic searches were conducted on 11 databases. Secondary searching (PEARLing) was undertaken, whereby reference lists of the selected articles were reviewed for additional references not identified in the primary search.All experimental RCTs evaluating the effect of PNE on chronic MSK pain were considered for inclusion. Additional Limitations: Studies published in English, published within the last 20 years, and patients older than 18 years. No limitations were set on specific outcome measures.Data were extracted using the participants, interventions, comparison, and outcomes (PICO) approach.Study quality of the 13 RCTs used in this review was assessed by 2 reviewers using the PEDro scale. Narrative summary of results is provided for each study in relation to outcomes measurements and effectiveness.Current evidence supports the use of PNE for chronic MSK disorders in reducing pain and improving patient knowledge of pain, improving function and lowering disability, reducing psychosocial factors, enhancing movement, and minimizing healthcare utilization.

Background Lumbar radiculopathy remains a clinical challenge among primary care clinicians in both assessment and diagnosis. This often leads to misdiagnosis and inappropriate treatment of patients resulting in poor health outcomes, exacerbating this already debilitating condition. This review evaluated 12 primary diagnostic accuracy studies that specifically assessed the performance of various individual and grouped clinical neurological tests in detecting nerve root impingement, as established in the current literature. Methods Eight electronic data bases were searched for relevant articles from inception until July 2016. All primary diagnostic studies which investigated the accuracy of clinical neurological test (s) in diagnosing lumbar radiculopathy among patients with low back and referred leg symptoms were screened for inclusion. Qualifying studies were retrieved and independently assessed for methodological quality using the ‘Quality Assessment of Diagnostic tests Accuracy Studies’ criteria. Results A total of 12 studies which investigated standard components of clinical neurological examination of (sensory, motor, tendon reflex and neuro-dynamics) of the lumbo-sacral spine were included. The mean inter-observer agreement on quality assessment by two independent reviewers was fair (k = 0.3 – 0.7). The diagnostic performance of sensory testing using MR imaging as a reference standard demonstrated a sensitivity (confidence interval 95%) 0.61 (0.47-0.73) and a specificity of 0.63 (0.38-0.84). Motor tests sensitivity was poor to moderate, ranging from 0.13 (0.04-0.31) to 0.61 (0.36-0.83). Generally, the diagnostic performance of reflex testing was notably good with specificity ranging from (confidence interval 95%) 0.60 (0.51-0.69) to 0.93 (0.87-0.97) and sensitivity ranging from 0.14 (0.09-0.21) to 0.67 (0.21-0.94). Femoral nerve stretch test had a high sensitivity of (confidence interval 95%) 1.00 (0.40-1.00) and specificity of 0.83 (0.52-0.98) while SLR test recorded a mean sensitivity of 0.84 (0.72-0.92) and specificity of 0.78 (0.67-0.87). Conclusions There is a scarcity of studies on the diagnostic accuracy of clinical neurological examination testing. Furthermore there seem to be a disconnect among researchers regarding the diagnostic utility of lower limb neuro-dynamic tests which include the Straight Leg Raise and Femoral Nerve tests for sciatic and femoral nerve respectively. Whether these tests are able to detect the presence of disc herniation and subsequent nerve root compression or hyper-sensitivity of the sacral and femoral plexus due to mechanical irritation still remains debatable.

Background: We sought to determine current utilization, importance, content, and delivery methods of preoperative education by spine surgeons in the United States for patients with lumbar radiculopathy. Methods: An online cross-sectional survey was used to study a random sample of spine surgeons in the United States. The Spinal Surgery Education Questionnaire (SSEQ) was developed based on previous related surveys and assessed for face and content validity by an expert panel. The SSEQ captured information on demographics, content, delivery methods, utilization, and importance of preoperative education as rated by surgeons. Descriptive statistics were used to describe the current utilization, importance, content, and delivery methods of preoperative education by spine surgeons in the United States for patients with lumbar radiculopathy. Results: Of 200 surgeons, 89 (45% response rate) responded to the online survey. The majority (64.2%) provide preoperative education informally during the course of clinical consultation versus a formal preoperative education session. The mean time from the decision to undergo surgery to the date of surgery was 33.65 days. The highest rated educational topics are surgical procedure (96.3%), complications (96.3%), outcomes/expectations (93.8%), anatomy (92.6%), amount of postoperative pain expected (90.1%), and hospital stay (90.1%). Surgeons estimated spending approximately 20% of the preoperative education time specifically addressing pain. Seventy-five percent of the surgeons personally provide the education, and nearly all surgeons (96.3%) use verbal communication with the use of a spine model. Conclusions: Spine surgeons believe that preoperative education is important and use a predominantly biomedical approach in preparing patients for surgery. Larger studies are needed to validate these findings. Refereed/Peer-reviewed

Objective: Evaluate content and educational delivery methods of preoperative education in total joint arthroplasties of the hip and knee (THA and TKA) addressing postoperative pain. Conclusions: Preoperative education centered on a biomedical model of anatomy and pathoanatomy as well as procedural information has limited effect in reducing postoperative pain after THA and TKA surgeries. Preoperative educational sessions that aim to increase patient knowledge of pain science may be more effective in managing postoperative pain. Data extraction: Data were extracted utilizing the participants, interventions, comparisons, and outcomes approach. Data sources: Systematic searches conducted on Biomed Central, BMJ.com, CINAHL, the Cochrane Library, NLM Central Gateway, OVID, ProQuest (Digital Dissertations), PsycInfo, PubMed/Medline, ScienceDirect, and Web of Science. Secondary searching (pearling) was undertaken. Data synthesis: This review included 13 RCTs involving a total of 1,017 subjects who underwent THA or TKA. Educational delivery methods comprised verbal one-onone or group education sessions, delivered within 4 weeks of surgery lasting an average of 30 minutes, and accompanied by other written materials. The educational content centered on descriptions of preoperative preparation, hospital stay, surgical procedure, immediate/intermediate experiences, expectations following surgery, rehabilitation, encouragement/reassurance, and answering common question associated with the surgical experience. Limitations: Studies published in English; published within the last 20 years and patients over the age of 18. No limitations were set on specific outcome measures of pain. Study selection: All randomized controlled trials (RCTs) evaluating the effect of preoperative education on postoperative pain in THA and TKA surgery were considered for inclusion. Refereed/Peer-reviewed

This experimental design study investigated the effect of a combination of Mulligan techniques and traditional treatment compared with that of traditional treatment alone in patients with lateral epicondylitis. The applied Mulligan techniques included mobilisation with movement and taping, and were aimed to reduce pain, increase grip strength, and improve activities of daily living. A total of 34 patients aged between 16 and 69 years underwent 11 sessions of a combination of Mulligan techniques and traditional treatment (experimental group, n = 17) or traditional treatment only (control group, n = 17). They were evaluated before the treatment, and after 4 weeks, using visual analogue scale, maximum grip strength, and Patient-Rated Tennis Elbow Evaluation. Analysis showed statistically significant improvement in all outcomes in both the experimental and the control groups. In addition, the mean improvement in visual analogue scale and maximum grip strength was significantly greater in the experimental group than that in the control group. This study showed that the combination of Mulligan techniques with traditional treatment leads to better outcomes in treatment of lateral epicondylitis than traditional treatment alone.

Therapeutic neuroscience education (TNE) has been shown to be effective in the treatment of mainly chronic musculoskeletal pain conditions. This case study aims to describe the changes in brain activation on functional magnetic resonance imaging (fMRI) scanning, before and after the application of a newly-designed preoperative TNE program. A 30-year-old female with a current acute episode of low back pain (LBP) and radiculopathy participated in a single preoperative TNE session. She completed pre- and post-education measures including visual analog scale (VAS) for LBP and leg pain; Oswestry Disability Index (ODI); Fear Avoidance Beliefs Questionnaire (FABQ); Pain Catastrophizing Scale (PCS) and a series of Likert-scale questions regarding beliefs and attitudes to lumbar surgery (LS). After a 30-minute TNE session, ODI decreased by 10%, PCS decreased by 10 points and her beliefs and attitudes shifted positively regarding LS. Immediately following TNE straight leg raise increased by 7° and forward flexion by 8 cm. fMRI testing following TNE revealed 3 marked differences compared to pre-education scanning: (1) deactivation of the periaqueductal gray area; (2) deactivation of the cerebellum; and (3) increased activation of the motor cortex. The immediate positive fMRI, psychometric and physical movement changes may indicate a cortical mechanism of TNE for patients scheduled for LS.

Background Recently a preoperative pain neuroscience education (NE) program was developed for lumbar surgery (LS) for radiculopathy as a means to decrease postoperative pain and disability. This study attempts to determine the short term effects, if any, of providing NE before surgery on patient outcomes. Methods A case series of 10 patients (female = 7) received preoperative one-on-one educational session by a physical therapist on the neuroscience of pain, accompanied by an evidence-based booklet, prior to LS for radiculopathy. Post-intervention data was gathered immediately after NE, as well as 1, 3 and 6 months following LS. Primary outcome measures were Pain Catastrophization Scale (PCS), forward flexion, straight leg raise (SLR) and beliefs regarding LS. Results Immediately following NE for LS for radiculopathy, all patients had lower PCS scores, with 5 patients exceeding the MDC score of 9.1 and 8 of the patients had PCS change scores exceeding the MDC by the 1, 3 and 6 month follow ups. Physical changes showed that fingertip-to-floor test in 6 patients had changes in beyond the MDC of 4.5 cm and 6 patients had changes in SLR beyond the MDC of 5.7°. The main finding, however, indicated a positive and more realistic shift in expectations regarding pain after the impending LS by all patients. Conclusions The results of the case series suggest that immediately after NE, patients scheduled for LS for radiculopathy had meaningful detectable changes in pain catastrophizing, fingertip-to-floor test, passive SLR and positive shifts in their beliefs about LS.

De hoofdpijnintensiteit, -frequentie, -duur en het medicatiegebruik zijn belangrijke uitkomstmaten in hoofdpijnonderzoek. De gemakkelijkste manier om ze te inventariseren is een hoofdpijndagboek.

Multicenter, randomized, controlled trial on preoperative pain neuroscience education (NE) for lumbar radiculopathy.To determine if the addition of NE to usual preoperative education would result in superior outcomes with regard to pain, function, surgical experience, and health care utilization postsurgery.One in 4 patients after lumbar surgery (LS) for radiculopathy experience persistent pain and disability, which is nonresponsive to perioperative treatments. NE focusing on the neurophysiology of pain has been shown to decrease pain and disability in populations with chronic low back pain.Eligible patients scheduled for LS for radiculopathy were randomized to receive either preoperative usual care (UC) or a combination of UC plus 1 session of NE delivered by a physical therapist (verbal one-on-one format) and a NE booklet. Sixty-seven patients completed the following outcomes prior to LS (baseline), and 1, 3, 6, and 12 months after LS: low back pain (numeric rating scale), leg pain (numeric rating scale), function (Oswestry Disability Index), various beliefs and experiences related to LS (10-item survey with Likert scale responses), and postoperative utilization of health care (utilization of health care questionnaire).At 1-year follow-up, there were no statistical differences between the experimental and control groups with regard to primary outcome measure of low back pain (P = 0.183), leg pain (P = 0.075), and function (P = 0.365). In a majority of the categories regarding surgical experience, the NE group scored significantly better: better prepared for LS (P = 0.001); preoperative session preparing them for LS (P0.001) and LS meeting their expectations (P = 0.021). Health care utilization post-LS also favored the NE group (P = 0.007) resulting in 45% less health care expenditure compared with the control group in the 1-year follow-up period.NE resulted in significant behavior change. Despite a similar pain and functional trajectory during the 1-year trial, patients with LS who received NE viewed their surgical experience more favorably and used less health care facility in the form of medical tests and treatments.2.

Levator scapulae is a “twisted” muscle with four separate origins from upper cervical vertebrae and two folds at its attachment on the scapula. It is active with every movement of the arm and is frequently in static contraction in order to stabilise the scapulae during precision use of the hand. Although its role in shoulder movement has been well researched, its effect on cervical function has seldom been investigated. Described tests for length and tone seem to test only the more vertical fibres or do not make use of enough cervical rotation to test the more horizontal fibres.The hypothesis is made that the more horizontal fibres have a stronger tendency to become tight. An alternative muscle length test, emphasising C2 contralateral rotation, is described and substantiated from anatomy and possible biomechanics.102 subjects were assessed to determine the most effective way to test the length of levator scapula. The tests described by Janda, Travell and Simons were compared with the suggested al...

Purpose: To compare the usage of ‘provocative’ terms in two patient education booklets for lumbar surgery. Background: The recently completed FASTER trial failed to support the use of an evidence-based educational booklet to significantly improve postsurgical outcomes over rehabilitation and usual care. The use of a different booklet in another recently completed trial resulted in a significant saving in healthcare utilization; earlier return to work; and greater patient satisfaction with surgery. We propose that the terminology used in these booklets may account for the differing results. Methods: An expert review panel was identified and tasked with identifying and highlight ‘provocative’ words within two patient educational booklets – Booklet A ‘Your Back Operation’ and Booklet B‘Your Nerves are Having Back Surgery’. Reviewers were blinded to title and authorship of the booklets. Data Analysis: Descriptive statistics including means, total scores. Results: Seventeenreviewers from 7 different countries participated and found that Booklet A had almost 3 times as many provocative terms as Booklet B. Booklet A had an average of 67.2 provocative terms per reviewer compared to only 22.6 terms for Booklet B. Conclusions: The findings of this study suggest that use of an educational booklet that minimizes the use of provocative terminology may have the potential to decrease fear, anxiety and patient pain experiences following lumbar surgery. Further research is warranted.

Introduction Despite scientific progress with regard to pain neuroscience, perioperative education tends to stick to the biomedical model. This may involve, for example, explaining the surgical procedure or ‘back school' (education that focuses on biomechanics of the lumbar spine and ergonomics). Current perioperative education strategies that are based on the biomedical model are not only ineffective, they can even increase anxiety and fear in patients undergoing spinal surgery. Therefore, perioperative pain neuroscience education is proposed as a dramatic shift in educating patients prior to and following surgery for lumbar radiculopathy. Rather than focusing on the surgical procedure, ergonomics or lumbar biomechanics, perioperative pain neuroscience education teaches people about the underlying mechanisms of pain, including the pain they will feel following surgery. Research objectives The primary objective of the study is to examine whether perioperative pain neuroscience education (‘brain school') is more effective than classic back school in reducing pain and improving pain inhibition in patients undergoing surgery for spinal radiculopathy. A secondary objective is to examine whether perioperative pain neuroscience education is more effective than classic back school in: reducing postoperative healthcare expenditure, improving functioning in daily life, increasing return to work, and improving surgical experience (ie, being better prepared for surgery, reducing incongruence between the expected and actual experience) in patients undergoing surgery for spinal radiculopathy. Design A multi-centre, two-arm (1:1) randomised, controlled trial with 2-year follow-up. Participants and setting People undergoing surgery for lumbar radiculopathy (n=86) in two Flemish hospitals (one tertiary care, university-based hospital and one regional, secondary care hospital) will be recruited for the study. Intervention All participants will receive usual preoperative and postoperative care related to the surgery for lumbar radiculopathy. The experimental group will also receive perioperative pain neuroscience education comprising one preoperative and one postoperative individual educational session plus an educational booklet. Control Participants in the control group will receive perioperative back school on top of usual preoperative and postoperative care, comprising one preoperative and one postoperative individual educational session plus an educational booklet. Measurements Self-reported pain and endogenous pain modulation (including measurements of simultaneous cortical activation via electroencephalography) will be the primary outcome measures. Secondary outcome measures will include daily functioning, return to work, postoperative healthcare utilisation and surgical experience/satisfaction. Psychological factors will be measured as possible treatment mediators. Procedure All assessments will take place in the week preceding surgery (baseline), and at 3 days and 6 weeks after surgery. Intermediate and long-term follow-up assessments will take place at 6, 12 and 24 months after surgery. Analysis All data analyses will be based on the intention-to-treat principle. Repeated measures AN(C)OVA analyses will be used to evaluate and compare treatment effects. Baseline data, treatment centre, age and gender will be included as covariates. Statistical, as well as clinically, significant differences will be evaluated and effect sizes will be determined. In addition, the numbers needed to treat will be calculated. Discussion This study will determine whether pain neuroscience education is worthwhile for patients undergoing surgery for lumbar radiculopathy. It is expected that participants who receive perioperative pain neuroscience education will report less pain and have improved endogenous pain modulation, lower postoperative healthcare costs and improved surgical experience. Lower pain and improved endogenous pain modulation after surgery may reduce the risk of developing postoperative chronic pain.

Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Objective To evaluate the evidence for the effectiveness of neuroscience education (NE) for pain, disability, anxiety, and stress in chronic musculoskeletal (MSK) pain. Data Sources Systematic searches were conducted on Biomed Central , BMJ.com , CINAHL, the Cochrane Library , NLM Central Gateway, OVID, ProQuest (Digital Dissertations) , PsycInfo, PubMed/Medline, ScienceDirect, and Web of Science. Secondary searching (PEARLing) was undertaken, whereby reference lists of the selected articles were reviewed for additional references not identified in the primary search. Study Selection All experimental studies including randomized controlled trials (RCTs), nonrandomized clinical trials, and case series evaluating the effect of NE on pain, disability, anxiety, and stress for chronic MSK pain were considered for inclusion. Additional limitations: studies published in English, published within the last 10 years, and patients older than 18 years. No limitations were set on specific outcome measures of pain, disability, anxiety, and stress. Data Extraction Data were extracted using the participants, interventions, comparison, and outcomes (PICO) approach. Data Synthesis Methodological quality was assessed by 2 reviewers using the Critical Review Form–Quantitative Studies. This review includes 8 studies comprising 6 high-quality RCTs, 1 pseudo-RCT, and 1 comparative study involving 401 subjects. Most articles were of good quality, with no studies rated as poor or fair. Heterogeneity across the studies with respect to participants, interventions evaluated, and outcome measures used prevented meta-analyses. Narrative synthesis of results, based on effect size, established compelling evidence that NE may be effective in reducing pain ratings, increasing function, addressing catastrophization, and improving movement in chronic MSK pain. Conclusions For chronic MSK pain disorders, there is compelling evidence that an educational strategy addressing neurophysiology and neurobiology of pain can have a positive effect on pain, disability, catastrophization, and physical performance.

Professional journals are used to disseminate the knowledge of scholars in the profession and to provide clinicians with guidance for best practice. This article aimed to retrospectively review the role of the South African Journal of Physiotherapy and its contribution to the profession. An archival research design was used to collect information from the archives of the South African Society of Physiotherapy website. The information was retrieved using a data capture sheet and descriptive statistics were used throughout to establish frequencies for the relevant information. During the identified period, 170 articles were published. The greatest number of papers originated in South Africa (81%), 8% from the rest of Africa and 11% written by international authors. Authors with a Masters degree contributed almost 50% of the papers and those with doctorates were responsible for at least 25% of the papers. Most of the papers presented original research (81%) with secondary research such as reviews and scholarly papers accounting for 19% of the total. The most common speciality area addressed through research was linked to musculoskeletal conditions. The journal appears to have provided an important platform for South African academics and emerging researchers to publish their findings. It is suggested that the journal should give preference to papers that deal with issues that are unique to South Africa and sub-Saharan Africa, as these are the least likely to be published elsewhere. In addition, the journal should emphasise papers that will advance the profession.

Evidence-based practice (EBP) is gaining momentum in the physiotherapy profession. The main focus of EBP, however, has been in clinical practiceand in the move towards global EBP, very little attention has been given tothe contents of physiotherapy education programs. There is very limitedinformation regarding the attitudes of health professional lecturers, especially physiotherapists, towards the teaching of evidence based practice.The aim of this study was to determine the attitudes of lecturers and use ofevidence in teaching among physiotherapists at tertiary institutions in South Africa. The study employed a within stage mixed model approach. The study population consisted of all physiotherapy lecturers at the 8 training institutions in South Africa. Out of 76 physiotherapy lecturers at the 8 insti-tutions, the response rate to the questionnaire was 47% (35). Respondents identified that teaching EBP depends on personal experience, current literature, and availability of time, current practice patterns and CPD courses. Barriers toincluding evidence in the content of what is being taught were mainly time constraints, accessibility of journals, work-load and knowledge on how to obtain the evidence. Facilitators to including evidence in subject content were adequateresources and a well equipped library, the environment and departmental support/encouragement. Teaching EBPrequires the integration of factors such as research evidence, clinical expertise and patient values. Although the majority of respondents in the current study demonstrated a positive attitude towards teaching EBP, they reported finding it difficult to implement it in practice due to several identified barriers. It can only be to the benefit of lecturers, studentsand patients if university departments create favourable circumstances for lecturers to facilitate teaching of EBP.

Low back pain (LBP) is a musculoskeletal disorder, affecting humans from adolescent to adult age. It is a health and socio-economic problem worldwide. The cause and contributing factors to LBP are multifactorial resulting in different approaches for its management. The attitudes and beliefs of patient with LBP, play an important role in the whole process of pain management. Negative attitudes and beliefs may lead to fear -avoidance behaviour, resulting into pain chronicity and disability. Thus, this study aimed to identify the attitudes and beliefs among patients with LBP, attending physiotherapy treatment in Malawi. Queen Elizabeth and Kamuzu Central hospitals were selected as study settings. A quantitative cross-sectional survey was done, using a self-administered questionnaire, employing a convenience sampling method. Twelve statements about attitudes and beliefs on LBP were adopted from the Back Beliefs Questionnaire (BBQ) and from the Survey of Pain Attitudes (SOPA). The SPSS (version 19.0) was used for data capturing and analysis. Descriptive and inferential statistics were used to summarize data. The Chi-square test was used to determine any association between variables and the Alpha level of significance was set at 0.05. All ethical issues were sought and adhered to throughout the study period. The results showed that out of 205 participants, with mean age of 47.74 years, (SD=13.29), female constituted 53.2% of the sample. More than half (67%) of all participants portrayed negative attitudes and beliefs about their LBP. We concluded that, majority of patients with LBP in Malawi hold negative attitudes and beliefs about their pain. Therefore, patient health education is needed to change these attitudes and beliefs if recovery and treatment goal are to be achieved.

Background MRI is considered to be the diagnostic tool of choice in diagnosing nerve root compromise among patients presenting with clinical suspicion of lumbo-sacral radiculopathy. There exists controversy among researchers and clinicians regarding the diagnostic utility and accuracy of MRI in detecting nerve root compromise and radiculopathy. This review evaluated 4 primary diagnostic accuracy studies that specifically assessed the accuracy of MRI in detecting nerve root compromise, as established in the current literature. Methods Eight electronic data bases were searched for relevant articles from inception until January 2014. All primary diagnostic studies which investigated the accuracy of MRI in diagnosing nerve root compromise among patients with low back and referred leg symptoms were screened for inclusion. Qualifying studies were retrieved and independently assessed for methodological quality using the ‘Quality Assessment of Diagnostic tests Accuracy Studies’ criteria. Results Four studies qualified for inclusion in this review. The sensitivity of MRI in detecting lumbar nerve root compromise was very low at 0.25 (95 % CI) while the specificity was relatively high at 0.92 (95 % CI). Conclusions There is lack of sufficient high quality scientific evidence in support or against the use of MRI in diagnosing nerve root compression and radiculopathy. Therefore, clinicians should always correlate the findings of MRI with the patients’ medical history and clinical presentation in clinical decision making.