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Background: The STarT-MSK-Tool is an adaptation of the well established STarT-Back-Tool, used to risk-stratify patients with a wider range of musculoskeletal presentations. Objective: To formally translate and cross-culturally adapt the Keele STarT-MSK risk stratification tool into German (STarT-MSKG) and to establish its reliability and validity. Methods: A formal, multi-step, forward and backward translation approach was used. To assess validity patients aged ≥18 years, with acute, subacute or chronic musculoskeletal presentations in the lumbar spine, hip, knee, shoulder, or neck were included. The prospective cohort was used with initial data collected electronically at the point-of-consultation. Retest and 6-month follow-up questionnaires were sent by email. Test-retest reliability, construct validity, discriminative ability, predictive ability and floor or ceiling effects were analysed using intraclass correlation coefficient, and comparisons with a reference standard (Orebro-Musculoskeletal-Pain-Questionnaire: OMPQ) using correlations, ROC-curves and regression models. Results: The participants' (n = 287) mean age was 47 (SD = 15.8) years, 51% were female, with 48.8% at low, 43.6% at medium, and 7.7% at high risk. With ICC = 0.75 (95% CI 0.69; 0.81) test-retest-reliability was good. Construct validity was good with correlations for the STarT-MSKG-Tool against the OMPQ-Tool of rs = 0.74 (95% CI 0.68, 0.79). The ability of the tool [comparison OMPQ] to predict 6-month pain and disability was acceptable with AUC = 0.77 (95% CI 0.71, 0.83) [OMPQ = 0.74] and 0.76 (95% CI 0.69, 0.82) [OMPQ = 0.72] respectively. However, the explained variance (linear/logistic regression) for predicting 6-month pain (21% [OMPQ = 17%]/logistic = 29%) and disability (linear = 20%:[OMPQ = 19%]/logistic = 26%), whilst being comparable to the existing OMPQ reference standard, fell short of the a priori target of ≥30%. Conclusions: The German version of the STarT-MSK-Tool is a valid instrument for use across multiple musculoskeletal conditions and is availabe for use in clinical practice. Comparison with the OMPQ suggests it is a good alternative. [ABSTRACT FROM AUTHOR]

Background: Current research emphasizes the high prevalence and costs of low back pain (LBP). The STarT Back Tool was designed to support primary care decision making for treatment by helping to determine the treatment prognosis of patients with non-specific low back pain. The German version is the STarT-G. The cross-cultural translation of the tool followed a structured and widely accepted process but to date it was only partially validated with a small sample. The aim of the study was to test the psychometric properties construct validity, discriminative ability, internal consistency and test-retest-reliability of the STarT-G and to compare them with values given for the original English version.Methods: A consecutive cohort study with a two-week retest was conducted among patients with non-specific LBP, aged 18 to 60 years, from primary care practices. Questionnaires were collected before the first consultation, and two weeks later by post, using the following reference standards: the Roland and Morris disability questionnaire, the Tampa Scale of Kinesiophobia, the Pain Catastrophizing Scale and the Hospital Anxiety and Depression Scale. Psychometric properties examined included the tool's discriminative abilities, whether the psychosocial subscale was one factor, internal consistency, item redundancy, test-retest reliability and floor and ceiling effects.Results: There were 228 patients recruited with a mean age of 42.2 (SD 11.0) years, and 53 % were female. The areas under the curve (AUC) for discriminative ability ranged from 0.70 (STarT-G Subscale - Pain Catastrophizing Scale; CI95 0.63, 0.78) to 0.77 (STarT-G Total - Composite reference standard, CI95 0.60, 0.94). Factor loadings ranged from 0.49 to 0.74. Cronbach's alpha testing the internal consistency and redundancy for the total/subscale scores were α = 0.52/0.55 respectively. The STarT-G test-retest reliability Kappa values for the total/subscale scores were 0.67/0.68 respectively. No floor or ceiling effects were present.Conclusions: The STarT-G shows acceptable psychometric properties although not in exact agreement with the original English version. The items previously regarded as a psychosocial subscale may be better seen as an index of different individual psychosocial constructs. The relevance of using the tool at the point of consultation should be further examined. [ABSTRACT FROM AUTHOR]

Background and Objective: The STarT Back stratified primary care approach has demonstrated clinical and cost effectiveness in the UK, and is commonly used by General Practitioners (GPs). However, it remains unknown how this approach could be implemented into the German healthcare system. The aim of this study was therefore to explore the views and perceptions of German GPs in respect to using a stratified primary care for low back pain (LBP). Methods: A 90-minute think-tank workshop was conducted with 14 male and five female GPs, during which the STarT-Back-Screening-Tool (SBST) and related research evidence was presented. This was followed by two focus groups, based on a semi-structured interview guideline to identify potential implementation barriers and opportunities. Discussions were audiotaped, transcribed and coded using a content analysis approach. Results: For the three deductively developed main themes, 15 subthemes emerged: (1) application of the SBST, with the following subthemes: which health profession should administer it, patients known to the GP practice, the reason for the GP consultation, scoring the tool, the tool format, and the anticipated impact on GP practice; (2) psychologically informed physiotherapy, with subthemes including: provision by a physiotherapist, anticipated impact, the skills of physiotherapists, management of patients with severe psychosocial problems, referral and remuneration; (3) the management of low-risk patients, with subthemes including: concern about the appropriate advising health professional, information and media, length of consultation, and local exercise venues. Conclusions: The attitudes of GPs towards stratified primary care for LBP indicated positive support for pilot-testing in Germany. However, there were mixed reactions to the ability of German physiotherapists to manage high-risk patients and handle their complex clinical needs. GPs also mentioned practical difficulties in providing extended advice to low-risk patients, which nevertheless could be addressed by involvement of specifically trained medical assistants. [ABSTRACT FROM AUTHOR]

The aim of the study was to identify factors that predict impairment in daily life for patients of working age with knee complaints 6 months after receiving physiotherapy. A prospective, multicentre observational study was conducted in private physiotherapy practices. Patients ( n = 237) aged 18-65 years with a physiotherapy referral because of knee complaints were studied. Treatment was documented on a standardized form by the physiotherapists and was not influenced by the investigators. The 16-item version of the Musculoskeletal Function Assessment Questionnaire was used as primary outcome measure. Baseline scores for impairment in daily life, symptom characteristics, socio-demographic and psychosocial factors, physical activity, nicotine consumption and comorbidities were investigated as possible predictors of recovery. Predictors identified by multiple linear regression were: self-prognosis on work ability, mental resources, obesity, diagnostic subgroup anterior knee pain and the comorbidities rheumatoid arthritis and diabetes. An active primary therapy approach enhanced recovery. Variables explained 38% of variance (adjusted R2). The knowledge of the identified factors supports the setting of therapy goals together with the patient. Therefore, only a short questionnaire is necessary. Moreover, the results underpin the importance of an active therapy plan. [ABSTRACT FROM AUTHOR]

Background and Objective: From observational studies, there is only sparse information available on the predictors of development of impairment in daily life for patients receiving physiotherapy. Therefore, our aim was to identify factors which predict impairment in daily life for patients with back pain 6 months after receiving physiotherapy. Methods: We conducted a prospective cohort study with 6-month follow-up. Patients were enrolled for treatment in private physiotherapy practices. Patients with a first physiotherapy referral because of thoracic or low back pain, aged 18 to 65 years were included. Primary outcome impairment was measured utilising the 16-item version of the Musculoskeletal Function Assessment Questionnaire. Therapy was documented on a standardized form. Baseline scores for impairment in daily life, symptom characteristics, sociodemographic and psychosocial factors, physical activity, nicotine consumption, intake of analgesics, comorbidity and delivered primary therapy approach were investigated as possible predictors. Univariate and multiple linear regression analyses were performed. Results: A total of 792 patients participated in the study (59% female, mean age 44.4 (SD 11.4), with 6-month follow-up results available from 391 patients. In univariate analysis 17 variables reached significance. In multiple linear regression identified predictors were: impairment in daily life before therapy, mental disorders, duration of the complaints, self-prognosis on work ability, rheumatoid arthritis, age, form of stress at work and physical activity. The variables explain 34% of variance (adjusted R2, p<0.001). Conclusions: With minimal information available from observational studies on the predictors of development of back problems for physiotherapy patients, this study adds new knowledge for forming appropriate referral guidelines. Impairment in daily life before therapy, mental disorder as comorbidity and the duration of the complaints can be named as outstanding factors. The results of this study can be used to facilitate comparison of patient therapy goals with the prognosis in everyday practice. [ABSTRACT FROM AUTHOR]

Background: Stratified care is an up-to-date treatment approach suggested for patients with back pain in several guidelines. A comprehensively studied stratification instrument is the STarT Back Tool (SBT). It was developed to stratify patients with back pain into three subgroups, according to their risk of persistent disabling symptoms. The primary aim was to analyse the disability differences in patients with back pain 12 months after inclusion according to the subgroups determined at baseline using the German version of the SBT (STarT-G). Moreover, the potential to improve prognosis for disability by adding further predictor variables, an analysis for differences in pain intensity according to the STarT-Classification, and discriminative ability were investigated.Methods: Data from the control group of a randomized controlled trial were analysed. Trial participants were members of a private medical insurance with a minimum age of 18 and indicated as having persistent back pain. Measurements were made for the risk of back pain chronification using the STarT-G, disability (as primary outcome) and back pain intensity with the Chronic Pain Grade Scale (CPGS), health-related quality of life with the SF-12, psychological distress with the Patient Health Questionnaire-4 (PHQ-4) and physical activity. Analysis of variance (ANOVA), multiple linear regression, and area under the curve (AUC) analysis were conducted.Results: The mean age of the 294 participants was 53.5 (SD 8.7) years, and 38% were female. The ANOVA for disability and pain showed significant differences (p < 0.01) among the risk groups at 12 months. Post hoc Tukey tests revealed significant differences among all three risk groups for every comparison for both outcomes. AUC for STarT-G's ability to discriminate reference standard 'cases' for chronic pain status at 12 months was 0.79. A prognostic model including the STarT-Classification, the variables global health, and disability at baseline explained 45% of the variance in disability at 12 months.Conclusions: Disability differences in patients with back pain after a period of 12 months are in accordance with the subgroups determined using the STarT-G at baseline. Results should be confirmed in a study developed with the primary aim to investigate those differences. [ABSTRACT FROM AUTHOR]

Background: The STarT-Back-Approach (STarT: Subgroups for Targeted Treatment) was developed in the UK and has demonstrated clinical and cost effectiveness. Based on the results of a brief questionnaire, patients with low back pain are stratified into three treatment groups. Since the organisation of physiotherapy differs between Germany and the UK, the aim of this study is to explore German physiotherapists' views and perceptions about implementing the STarT-Back-Approach.Methods: Three two-hour think-tank workshops with physiotherapists were conducted. Focus groups, using a semi-structured interview guideline, followed a presentation of the STarT-Back-Approach, with discussions audio recorded, transcribed and qualitatively analysed using content analysis.Results: Nineteen physiotherapists participated (15 female, mean age 41.2 (SD 8.6) years). Three main themes emerged, each with multiple subthemes: 1) the intervention (15 subthemes), 2) the healthcare context (26 subthemes) and 3) individual characteristics (8 subthemes). Therapists' perceptions of the extent to which the STarT-Back intervention would require changes to their normal clinical practice varied considerably. They felt that within their current healthcare context, there were significant financial disincentives that would discourage German physiotherapists from providing the STarT-Back treatment pathways, such as the early discharge of low-risk patients with supported self-management materials. They also discussed the need for appropriate standardised graduate and post-graduate skills training for German physiotherapists to treat high-risk patients with a combined physical and psychological approach (e.g., communication skills).Conclusions: Whilst many German physiotherapists are positive about the STarT-Back-Approach, there are a number of substantial barriers to implementing the matched treatment pathways in Germany. These include financial disincentives within the healthcare system to early discharge of low-risk patients. Therapists also highlighted the need for solutions in respect of scalable physiotherapy training to gain skills in combined physical and psychological approaches. [ABSTRACT FROM AUTHOR]

Up to date, empiric evidence about effects of thoracic spine mobilisation (TH4) on the sympathetic nervous system is lacking. The primary goal of this feasibility study was to determine adherence rate, side effects and the protocol as well as the implementation of the study design. The secondary goal was to analyse and interpret acute effects on the sympathetic nervous system after thoracic mobilisation in anterior thrust and posterior thrust on six healthy participants on two following days. The feasibility of this study was adequate. The spine mobilisations did not produce any adverse effects. The anterior thrust spine mobilisations showed a tendency in reducing the heart rate activity. [ABSTRACT FROM AUTHOR]

Background: Stratified care approach involving use of the STarT-Back tool to optimise care for patients with low back pain is gaining widespread attention in western countries. However, adoption and implementation of this approach in low-and-middle-income countries will be restricted by context-specific factors that need to be addressed. This study aimed to develop with physiotherapists, tailored intervention strategies for the implementation of stratified care for patients with low back pain. Methods: A two-round web-based Delphi survey was conducted among purposively sampled physiotherapists with a minimum of three years of clinical experience, with post-graduation certification or specialists. Thirty statements on barriers and enablers for implementation were extracted from the qualitative phase. Statements were rated by a Delphi panel with additional open-ended feedback. After each Delphi round, participants received feedback which informed their subsequent responses. Additional qualitative feedback were analysed using qualitative content analysis. The criteria for consensus and stability were pre-determined using percentage agreement (≥ 75%), median value (≥ 4), Inter-quartile range (≤ 1), and Wilcoxon matched-pairs test respectively. Results: Participants in the first round were 139 and 125 of them completed the study, yielding a response rate of 90%. Participants were aged 35.2 (SD6.6) years, and 55 (39.6%) were female. Consensus was achieved in 25/30 statements. Wilcoxon’s test showed stability in responses after the 5 statements failed to reach consensus: ‘translate the STarT-Back Tool to pidgin language’ 71% (p = 0.76), ‘begin implementation with government hospitals’ 63% (p = 0.11), ‘share knowledge with traditional bone setters’ 35% (p = 0.67), ‘get second opinion on clinician’s advice’ 63% (p = 0.24) and ‘carry out online consultations’ 65% (p = 0.41). Four statements strengthened by additional qualitative data achieved the highest consensus: ‘patient education’ (96%), ‘quality improvement appraisals’ (96%), ‘undergraduate training on psychosocial care’ (96%) and ‘patient-clinician communication’ (95%). Conclusion: There was concordance of opinion that patients should be educated to correct misplaced expectations and proper time for communication is vital to implementation. This communication should be learned at undergraduate level, and for already qualified clinicians, quality improvement appraisals are key to sustained and effective care. These recommendations provide a framework for future research on monitored implementation of stratified care in middle-income countries. [ABSTRACT FROM AUTHOR]

An editorial is presented on expecting manuscripts for using estimation methods instead of null hypothesis statistical tests. Topics include statistical inference being the process of making inferences about populations using data from samples; and availability of alternative methods of statistical inference and promotion of the methods in statistical, medical, and physiotherapy journals.

Objectives: Interprofessional collaboration leads to an improvement in health care. This call for increased interprofessional collaboration has led to national and international recommendations for interprofessional learning and education. The GMA has taken up this challenge and has implemented a working group on "interprofessional education in the health professions" to address this topic. The terminology used to describe collaboration among the health professions seems to vary and does not reflect any clear consensus. The aim of this paper is to identify the different terms used to describe collaboration between health professions and to analyse their use in German journals. Methods: The terms frequently used to describe collaboration between health professionals were identified and defined. German medical journals were then pragmatically analyzed regarding the use of the terms interprof* and interdiszip*. Results: The German terms for interprofessional and interdisciplinary were not used consistently in the journals reviewed. Conclusion: There seems to be no agreement on the use of terms to describe the collaboration between health professions. Consistent terminology should be used as a basis for promoting collaboration and improving understanding among the parties involved. [ABSTRACT FROM AUTHOR]

Laws regulating education of most health professional groups in Germany today mean that curricula re-profiling in response to changing priorities in the practice environment is a significant challenge. Legally dictated theoretical and clinical requirements for the vocational training of health professionals leaves little room for re-profiling in response to movements such as interprofessional education. An educational innovation was needed that worked within existing structures in Germany. The result was a formal collaboration between the Academy for Health Professionals and the University of Heidelberg allowing students undertaking vocational training to also complete a university degree in parallel. The aim of this article is to describe the curriculum development for the Bachelor of Science - Interprofessional Health Care. This article outlines an evidence-based approach to the process to curriculum development that resulted in a competency-based degree offering comprehensive interprofessional education at undergraduate level for healthcare students based in Germany. [ABSTRACT FROM AUTHOR]

Background: The Musculoskeletal Health Questionnaire (MSK-HQ) has been developed to measure musculoskeletal health status across musculoskeletal conditions and settings. However, the MSK-HQ needs to be further evaluated across settings and different languages.Objective: The objective of the study was to evaluate and compare measurement properties of the MSK-HQ across Danish (DK) and English (UK) cohorts of patients from primary care physiotherapy services with musculoskeletal pain.Methods: MSK-HQ was translated into Danish according to international guidelines. Measurement invariance was assessed by differential item functioning (DIF) analyses. Test-retest reliability, measurement error, responsiveness and minimal clinically important change (MCIC) were evaluated and compared between DK (n = 153) and UK (n = 166) cohorts.Results: The Danish version demonstrated acceptable face and construct validity. Out of the 14 MSK-HQ items, three items showed DIF for language (pain/stiffness at night, understanding condition and confidence in managing symptoms) and three items showed DIF for pain location (walking, washing/dressing and physical activity levels). Intraclass Correlation Coefficients for test-retest were 0.86 (95% CI 0.81 to 0.91) for DK cohort and 0.77 (95% CI 0.49 to 0.90) for the UK cohort. The systematic measurement error was 1.6 and 3.9 points for the DK and UK cohorts respectively, with random measurement error being 8.6 and 9.9 points. Receiver operating characteristic (ROC) curves of the change scores against patients' own judgment at 12 weeks exceeded 0.70 in both cohorts. Absolute and relative MCIC estimates were 8-10 points and 26% for the DK cohort and 6-8 points and 29% for the UK cohort.Conclusions: The measurement properties of MSK-HQ were acceptable across countries, but seem more suited for group than individual level evaluation. Researchers and clinicians should be aware that some discrepancy exits and should take the observed measurement error into account when evaluating change in scores over time. [ABSTRACT FROM AUTHOR]

The implementation of a bachelor degree in Interprofessional Health Care at the University of Heidelberg, Germany, has fostered the need to evaluate the impact of this innovative programme. The University of the West of England Interprofessional Questionnaire (UWE-IP) was developed for longitudinal evaluation of an interprofessional curriculum. The UWE-IP consists of 35 items in four scales: “Communication and Teamwork Scale,” “Interprofessional Learning Scale,” “Interprofessional Interaction Scale,” and “Interprofessional Relationships Scale.” The UWE-IP was translated to German according to international guidelines. Psychometrics were assessed: reliability of the four scales was tested with Cronbach‘s alpha and confirmatory factor analysis was performed to examine the underlying factor structure. The sample consisted of 326 datasets. Reliability for the scales was between 0.75 and 0.90. The underlying factor structure showed a good fit. We conclude that the German UWE-IP shows good psychometrics and recommend its use for evaluation of interprofessional learning activities. These results add to the body of knowledge on evaluation instruments in interprofessional education. [ABSTRACT FROM PUBLISHER]

A correction to the article "Statistical Inference Through Estimation: Recommendations From the International Society of Physiotherapy Journal Editors," by M. R. Elkins et al, that was published in a 2022 issue is presented.

Over the past five years, the development of interprofessional education programmes has been gaining momentum in Germany fostering the need to evaluate these with appropriate instruments. Instead of developing a new instrument for evaluation purposes, the Readiness for Interprofessional Learning Scale (RIPLS) was chosen, as it is a widespread instrument that has been used in a variety of different educational settings and countries. The German version of the RIPLS was administered in two sites to health professional students in Heidelberg and Freiburg, Germany. Cronbach’s alpha was used to examine internal consistency. Confirmatory factor analysis (CFA) was performed for confirmation of the underlying factor structure of the RIPLS-D. In total, 531 questionnaires were analysed. The instrument showed overall reliability (0.81) and low reliability (< 0.7) in the subscales. The underlying factor structure could not be confirmed. These results contribute further evidence on deficits with the RIPLS. Despite known issues, the RIPLS continues to be translated and applied. This paper highlights the problematic issues in the RIPLS-D and does not recommend its use. [ABSTRACT FROM AUTHOR]

Background: Although evidence based treatment approaches for acute low back pain are available, the prevention of persistent disabling symptoms remains a challenge. Subgroup targeted treatment using adequate screening tools may be a key component for the development of new treatment concepts and is demonstrating promising early evidence. The Keele STarT Back Screening Tool is a practical instrument, developed to stratify patients with back pain according to their risk of persistent disabling symptoms. The aim of this study was to translate and cross-culturally adapt the STarT tool into German (STarT-G) and to investigate its psychometric properties. Methods: The translation was performed according to internationally accepted guidelines and pretested to assess face validity among patients. Psychometric testing was then performed within a cross-sectional cohort of adult patients attending physiotherapy practices for back pain. Patients completed a booklet containing STarT-G and 5 reference standard questionnaires. Measurement properties of the STarT-G were explored including construct validity, floor and ceiling effects, and discriminative abilities. Results: The pretests (n=25) showed good face validity including strong comprehension and acceptability of the STarT-G with only item 5 (fear avoidance) manifesting some ambiguities. The questionnaires were sent to 74 and completed by 50 patients (68%) of whom mean age was 46 (SD 14.5) years and 52% were male. Spearman’s rank correlations for construct validity ranged from 0.35 to 0.56. AUCs for discriminative ability ranged from 0.79 to 0.91. Neither floor nor ceiling effects were observed. There were 28 (57%) participants defined as low risk, 17 (35%) as medium risk, and 4 (8%) as high risk. Conclusion: STarT-G is linguistically valid for German speaking countries. For the selected population, the correlations indicate acceptable validity and AUC showed satisfying discrimination. Data for psychometric properties have to be confirmed in a large scale study with a representative sample. [ABSTRACT FROM AUTHOR]

The article presents the position statement of trade body German Medical Association (GMA) on interprofessional education for medical personnel. Topics include the condition of health care as of April 2015, interprofessional education concepts in several European countries, and the state of research. A background of GMA's Committee for Interprofessional Education in the Health Professions is provided which was established in 2011 to review interprofessional education.

The article presents the recommendations from the "International Society of Physiotherapy Journal" on the use of statistical inference through estimation.