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Background: Clinically feasible and reliable methods to measure motor control in people with low back pain (LBP) are lacking. This reliability and measurement error study design (i.e. repeated measurements in stable patients) aimed to determine the intra- and interrater reliability, and measurement errors of several parameters for two clinical lumbar motor control tests. Method: Participants 18–65 years of age, with current or a history of LBP performed a spiral tracking task (n = 33; i.e., tracing a spiral on a computer monitor by making spinal movements) or a repositioning task (n = 34; i.e., returning the trunk to a predefined position). Accelerometers were used to measure trunk positions. To explore the potential of these tests, we evaluated a broad range of parameters. To assess intra- and interrater reliability, we calculated the intraclass correlation coefficient (ICC (2,1) for absolute agreement), standard error of measurement and smallest detectable change for each parameter. Findings: Overall, the interrater reliability of the spiral tracking test was good (ICC>0.75). The reliability of the second and third trial revealed higher ICC values compared to the reliability of the first two trials. The intra- and interrater reliability of the repositioning test was overall poor (ICC

Objectives The plethora of self-administered questionnaires to assess positive psychosocial factors complicates questionnaire selection. This study aimed to identify and reach consensus on the most suitable self-administered questionnaires to assess resilience, optimism, pain acceptance and social support in people with pain. Design A three-round modified Delphi study. Participants Forty international experts. Methods In Round 1, the experts suggested questionnaires deemed appropriate to assess resilience, optimism, pain acceptance and/or social support. In Round 2, experts indicated whether they considered the suggested questionnaires to be suitable (Yes/No/Don’t know) to assess these psychosocial factors, taking into consideration content, feasibility, personal experience and the measurement properties which we provided for each questionnaire. Questionnaires that were considered suitable by the majority of experts (≥60%) were retained for Round 3. In Round 3, the suitability of each questionnaire was rated on a 0–10 Likert scale. Consensus was reached if ≥75% of experts rated the questionnaire ≥7. Results From the 67 questionnaires suggested in Round 1, one questionnaire could be recommended per domain. For resilience: Pain Resilience Scale; for optimism: Revised Version of the Life Orientation Test; for pain acceptance: 8-item and Revised Versions of the Chronic Pain Acceptance Questionnaire; for social support: Emotional Support Item Bank of the PROMIS tool. Consensus for these questionnaires was also reached in a sensitivity analysis which excluded the ratings of experts involved in the development, translation and/or validation of relevant questionnaires. Conclusion We advocate the use of these recommended questionnaires so data can be compared and pooled more easily.

Background: Physiotherapy is a relatively young profession in Nepal. Education standards, and workforce organization and representation have improved in recent years, but there is no detailed workforce data to support decision-making and long-term planning. Therefore, this study aimed to describe the demographic characteristics, physiotherapy practice areas, settings and employment characteristics of physiotherapists in Nepal; and to document job satisfaction and the factors that influence it. Methods: In a cross-sectional survey, we asked Nepali physiotherapists about their sociodemographic characteristics, employment or physiotherapy practice area and settings, and job satisfaction. We assessed the associations between sociodemographic factors and job satisfaction among physiotherapists using univariable and multivariable logistic regressions. We invited all Nepali physiotherapists to participate via email, social media and visits to hospitals. Results: Of the 1120 physiotherapists who were contacted, 52% (female: 287; male: 293) completed the survey. The majority of the participants (75%) were less than 30 years old. The majority (73%) held a Bachelor of Physiotherapy degree. Eighty percent were employed at the time of data collection; 58% had 1–4 years of experience. The majority (77%) practiced in or near the capital Kathmandu. Most physiotherapist worked either in private hospitals (46%) or in private physiotherapy practices (26%), rehabilitation centres (19%) and 11% practiced in public hospitals. The most common areas of practice were musculoskeletal physiotherapy (90%) and adult neurology (67%). More than half of the physiotherapist (53%) felt that they were underpaid and 41% were not satisfied with their current job status. The majority of the physiotherapists (67%) reported that they participated in continuing professional development activities. Multivariable logistic regression showed that physiotherapists who had a higher remuneration were more likely to be satisfied with their job. Conclusions: The majority of the physiotherapy workforce in Nepal is well-educated, young and at an early career stage. Most physiotherapists work in musculoskeletal and adult neurological physiotherapy, in private practices or private hospitals near Kathmandu. Job dissatisfaction was common and was related to low annual income. This first nationwide survey described the current physiotherapy workforce and provides comparison data for future physiotherapy workforce surveys.

Introduction Musculoskeletal (MSK) injuries and associated pain disorders are one of the leading causes for soldiers not being medically fit for deployment, impacting force capability and readiness. Musculoskeletal pain continues to be a leading cause of disability within military services and is associated with a substantial financial burden. A better understanding of the effectiveness of MSK pain management strategies is required. This review was designed to determine the efficacy of nonsurgical interventions, such as physiotherapy, exercise, pharmacology, and multidisciplinary programs, to manage MSK conditions in active serving military populations. Materials and Methods MEDLINE, Embase, CINAHL, and SPORTDiscus were searched to identify relevant randomized clinical trials. Recommended methods were used for article identification, selection, and data extraction. The Cochrane Risk of Bias tool and the Grade of Recommendation, Assessment, Development, and Evaluation were used to appraise the studies. Where possible, meta-analyses were performed. The review was conducted according to the PRISMA guidelines. Results Nineteen articles (1,408 participants) met the eligibility criteria. Low back pain (LBP) was the most frequently investigated condition, followed by knee pain, neck pain, and shoulder pain. Early physiotherapy, exercise and adjunct chiropractic manipulation (for LBP), and multidisciplinary pain programs (physiotherapy, occupational therapy, and psychology) (for chronic MSK pain) improved pain (standardized mean difference ranged from −0.39 to −1.34; low strength of evidence). Participation in multidisciplinary pain programs, adjunct chiropractic manipulation, and early physiotherapy improved disability (for LBP) (standardized mean difference ranged from −0.45 to −0.86; low to very low strength of evidence). No studies evaluated pain medication. Dietary supplements (glucosamine, chondroitin sulfate, and manganese ascorbate), electrotherapy, isolated lumbar muscle exercises, home cervical traction, or training in virtual reality showed no benefit. The studies had a high risk of bias, were typically underpowered, and demonstrated high clinical heterogeneity. Conclusions Currently available randomized clinical trials do not provide sufficient evidence to guide military organizations or health care professionals in making appropriate treatment decisions to manage MSK pain in active serving military personnel. Future research is essential to enable evidence-based recommendations for the effective management of MSK pain conditions in this unique population.

Background: Pain is a common problem but often undiagnosed and untreated in people with dementia. Aims: This study explored the experiences of residents with dementia, family, andformal carers with (1) pain assessment and management for residents with dementia; (2) the use of the PainChek app for pain assessment, and (3) the use of a social robot PARO for pain management in residents with dementia. Design: A qualitative study. Settings/participants: Interviews were conducted with 13 residents withdementia, three family members, and 18 formal carers from a residential aged carefacility. Method: Residents with dementia interacted with PARO for 15 mins, five days perweek for three weeks. The PainChek app assessed pain levels before and after eachsession. After three-week intervention, individual interviews were conducted withresidents, family, and formal carers who experienced or observed the use of PainChekapp and PARO for residents. Interviews were audio-recorded, transcribed, andanalyzed using thematic analysis. Results: Four themes were identified regarding pain in residents with dementia: (1) the impact, challenges and strategies of pain assessment and management; (2) benefits and barriers of using PainChek app to assess pain; (3) benefits of interacting with PARO to manage pain and behavioral symptoms; and (4) implementing PainChek app and PARO to support pain assessment and management in dementia care. Conclusions: Technology, such as PainChek and PARO, is promising to improve painassessment and reduce pain for people with dementia. Barriers to using technologyinclude limited staff training and the implementation of person-centered care.

Background and Aims: Pain drawings are commonly used in the clinical assessment of people with cervical radiculopathy. This study aimed to assess (1) the agreement of clinical interpretation of pain drawings and MRI findings in identifying the affected level of cervical radiculopathy, (2) the agreement of these predictions based on the pain drawing among four clinicians from two different professions (i.e., physiotherapy and surgery) and (3) the topographical pain distribution of people presenting with cervical radiculopathy (C4–C7). Methods: Ninety-eight pain drawings were obtained from a baseline assessment of participants in a randomized clinical trial, in which single-level cervical radiculopathy was determined using MRI. Four experienced clinicians independently rated each pain drawing, attributing the pain distribution to a single nerve root (C4–C7). A post hoc analysis was performed to assess agreement. Outcome measures: Percentage agreement and kappa values were used to assess the level of agreement. Topographic pain frequency maps were created for each cervical radiculopathy level as determined by MRI. Results: The radiculopathy level determined from the pain drawings showed poor overall agreement with MRI (mean = 35.7%, K = −0.007 to 0.139). The inter-clinician agreement ranged from fair to moderate (K = 0.212–0.446). Topographic frequency maps revealed that pain distributions were widespread and overlapped markedly between patients presenting with different levels cervical radiculopathy. Conclusion: This study revealed a lack of agreement between the segmental level affected determined from the patient's pain drawing and the affected level as identified on MRI. The large overlap of pain and non-dermatomal distribution of pain reported by patients likely contributed to this result.

Aim: This study aims to test the feasibility of the PainChek app to assess pain for people with dementia living in residential aged care facilities (RACFs). It will also identify the optimal dosage and efficacy of a social robot (personal assistant robot [PARO]) intervention on chronic pain for people with dementia. Design: This is a feasibility randomized controlled trial with three groups. Methods: Forty-five residents living with dementia and chronic pain will be recruited from one RACF. The intervention consists of an individual 15-min non-facilitated session with a PARO robot twice a day (Group 1), a PARO robot once a day (Group 2), or a Plush-Toy (non-robotic PARO) once a day (Group 3) from Monday to Friday for 4 weeks. Participants will be followed at 4 and 8 weeks after baseline assessments. The primary outcome will be the feasibility of using the PainChek app to measure changes in pain levels before and after each session. Secondary outcomes include staff-rated pain levels, neuropsychiatric symptoms, quality of life and changes in psychotropic and analgesic medication use. Participants, staff and family perceptions of using PARO and the PainChek app will be collected after the 4-week intervention. Discussion: This study will test the use of the PainChek app and PARO to improve pain management for people with dementia. Results from this study will help determine its usefulness, feasibility and acceptability for pain management in people with dementia living in RACFs. Impact: As pain is a significant problem for people with dementia, this project will generate evidence on the use of the PainChek to measure the efficacy of a social robot intervention that has the potential to improve the quality of pain care in people with dementia. Trial Registration: Australian and New Zealand Clinical Trials Registry number (ACTRN12621000837820) date registered 30/06/2021.

IntroductionPsychosocial factors predict recovery in patients with spinal pain. Several of these factors are modifiable, such as depression and anxiety. However, primary care physiotherapists who typically manage these patients indicate that they do not feel sufficiently competent and equipped to address these factors optimally. We developed an eHealth intervention with a focus on pain education and behavioural activation to support physiotherapists in managing psychosocial factors in patients with spinal pain. This paper describes the protocol for a pragmatic randomised clinical trial, which evaluates the effectiveness of this eHealth intervention blended with physiotherapy compared with physiotherapy alone.Methods and analysisParticipants with non-specific low back pain and/or neck pain for at least 6 weeks who also have psychosocial risk factors associated with the development or maintenance of persistent pain will be recruited in a pragmatic multicentre cluster randomised clinical trial. The experimental intervention consists of physiotherapy blended with six online modules of pain education and behavioural activation. The control intervention consists of usual care physiotherapy. The primary outcomes are disability (Oswestry Disability Index for low back pain and Neck Disability Index for neck pain) and perceived effect (Global Perceived Effect). Outcomes will be assessed at baseline and at 2, 6 and 12 months after baseline. The results will be analysed using linear mixed models.Ethics and disseminationThe study is approved by the Medical Ethical Committee of VU Medical Center Amsterdam, The Netherlands (2017.286). Results will be reported in peer-reviewed journals, at national and international conferences, and in diverse media to share the findings with patients, clinicians and the public.Trial registration numberNL 5941; The Netherlands Trial Register.

OBJECTIVES: The clinical course of lumbar radiculopathy following microdiscectomy and post-operative physiotherapy varies substantially. No prior studies assessed this variability by deriving outcome trajectories. The primary aims of this study were to evaluate the variability in long-term recovery after lumbar microdiscectomy followed by post-operative physiotherapy and to identify outcome trajectories. The secondary aim was to assess whether demographic, clinical characteristics and patient-reported outcome measures routinely collected at baseline could predict poor outcome trajectories.METHODS: We conducted a prospective cohort study with a 24-month follow-up. We included 479 patients with clinical signs and symptoms of lumbar radiculopathy confirmed by Magnetic Resonance Imaging findings, who underwent microdiscectomy and post-operative physiotherapy. Outcomes were leg pain and back pain measured with Visual Analogue Scales, and disability measured with the Roland-Morris Disability Questionnaire. Descriptive statistics were performed to present the average and the individual clinical course. A latent class trajectory analysis was conducted to identify leg pain, back pain, and disability outcome trajectories. The best number of clusters was determined using the Bayesian Information Criterion, Akaike's information criteria, entropy, and overall interpretability. Prediction models for poor outcome trajectories were assessed using multivariable logistic regression analyses.RESULTS: Several outcome trajectories were identified. Most patients were assigned to the 'large improvement' trajectory (leg pain: 79.3%; back pain: 70.2%; disability: 59.5% of patients). Smaller proportions of patients were assigned to the 'moderate improvement' trajectory (leg pain: 7.9%; back pain: 10.6%; disability: 20.7% of patients), the 'minimal improvement' trajectory (leg pain: 4.9%, back pain: 6.7%, disability: 16.3% of patients) and the 'relapse' trajectory (leg pain: 7.9%; back pain: 12.5%; disability: 3.5%). Approximately one-third of patients (32.6%) belonged to one or more than one poor outcome trajectory. Patients with previous treatment (prior back surgery, injection therapy, and medication use) and those who had higher baseline pain and disability scores were more likely to belong to the poor outcome trajectories in comparison to the large improvement trajectories in back pain, leg pain and disability, and the moderate improvement trajectory in disability. The explained variance (Nagelkerke R2) of the prediction models ranged from 0.06 to 0.13 and the discriminative ability (Area Under the Curve) from 0.66 to 0.73.CONCLUSION: The clinical course of lumbar radiculopathy varied following microdiscectomy and post-operative physiotherapy, and several outcome trajectories could be identified. Although most patients were allocated to favorable trajectories, one in three patients was assigned to one or more poor outcome trajectories following microdiscectomy and post-operative physiotherapy for lumbar radiculopathy. Routinely gathered data were unable to predict the poor outcome trajectories accurately. Prior to surgery, clinicians should discuss the high variability and the distinctive subgroups that are present in the clinical course with their patients.

In this case report, we used virtual reality (VR) to explore pain evoked by only the appearance of being touched (rather than actually being touched) in a person with complex regional pain syndrome type II. Furthermore, we explored the degree to which this visually evoked pain could be extinguished by applying exposure principles in VR. In stage 1, we identified 4 specific scenarios where pain was triggered by visually simulated touch (without physical stimulation) and used these scenarios to quantify baseline sensitivity to visuotactile stimulation. In stage 2, the patient undertook a 12-week virtual exposure program, and the visual triggers were reassessed 3 weeks after the commencement and immediately upon completion of the program. At baseline, severe pain and a profound cold sensation were immediately and consistently evoked in concert with visually simulated touch. At 12-week follow-up, only one of the initially provocative visual stimuli triggered pain and only after 60 seconds of repeated stimulation. Unfortunately, the transfer of desensitisation from VR to the real world was limited. This case report describes the phenomena of visually evoked pain. Moreover, it describes the near complete extinguishing of visually evoked pain through virtual graded exposure. How improvements gained in VR might be better transferred to real-word improvements merits further investigation.

Objective The association between low-grade systemic inflammation and musculoskeletal pain may be influenced by multiple factors. However, little is known about the relative importance of these factors, and few studies account for them. This Delphi study aimed to reach consensus on the most important confounders which influence the association between low-grade systemic inflammation and musculoskeletal pain. Methods The panel consisted of 48 experts. In Round 1, the experts proposed what they believed were important confounders. In Round 2, the experts indicated for each confounder whether they believed it was important (yes/no). At least 50% of experts had to indicate the confounder was important to be considered in the final round. In Round 3, the experts rated the importance of each confounder on a 7-point Likert scale. Consensus was reached if ≥75% of the experts considered the factor either extremely or moderately important. Results In Round 1, 120 confounders were proposed, which were synthesized into 38 distinct factors. In Round 2, 33 confounders met the criterion to be considered important. In Round 3, consensus was reached for 14 confounders: acute illness/trauma, immune disease, medication use, endocrine, nutritional, or metabolic disease, other musculoskeletal conditions, age, handling of blood samples, sex, cancer, body composition, pregnancy, cardiovascular disease, physical activity, and pain characteristics. Conclusions These findings provide insight in the complexity of the association between low-grade systemic inflammation and musculoskeletal pain. Some factors currently listed as confounders may be re-classified as moderators or mediators as insights progress.

Background: With medical information widely available, patients often have preconceived ideas regarding diagnostic procedures and management strategies. Objectives: To investigate whether expectations, such as beliefs about the source of symptoms and knowledge about diagnostic tests, influence pain perception during a clinical diagnostic test. Design: Cross-sectional study. Methods: Pain was induced by intramuscular hypertonic saline infusion in the thenar muscles. In line with sample size calculations, fifteen participants were included. All participants received identical background information regarding basic median nerve biomechanics and basic concepts of differential diagnosis via mechanical loading of painful structures. Based on different explanations about the origin of their induced pain, half of the participants believed (correctly) they had ‘muscle pain’ and half believed (incorrectly) they had ‘nerve pain’. Pain intensity and size of the painful area were evaluated in five different positions of the median nerve neurodynamic test (ULNT1 MEDIAN). Data were analysed with two-way analyses of variance. Results: /findings: Changes in pain in the ULNT1 MEDIAN positions were different between the ‘muscle pain’ and ‘nerve pain’ group (p < 0.001). In line with their expectations, the ‘muscle pain’ group demonstrated no changes in pain throughout the test (p > 0.38). In contrast, pain intensity (p ≤ 0.003) and size of the painful area (p ≤ 0.03) increased and decreased in the ‘nerve pain’ group consistent with their expectations and the level of mechanical nerve loading. Conclusion: Pain perception during a clinical diagnostic test may be substantially influenced by pain anticipation. Moreover, pain was more aligned with beliefs and expectations than with the actual pathobiological process.

Background: The passive straight leg raise (SLR) and crossed SLR are recommended tests for lumbar radicular pain. There are no recent reviews of test reliability. Objectives: To summarize SLR and crossed SLR reliability in patients with suspected lumbar radicular pain. Design: Systematic review with meta-analysis. Method: MEDLINE and CINAHL were searched for studies published before April 2021 that reported SLR or crossed SLR reliability in patients with low back-related leg pain. Supplemental analyses also included patients with low back pain only. Study selection, risk of bias assessment (QAREL), and data extraction were performed in duplicate. Kappa, intraclass correlation coefficients, and smallest detectable difference (SDD95) quantified reliability. Meta-analysis was performed when appropriate. Confidence in the evidence was determined by applying GRADE principles. Results/findings: Fifteen studies met selection criteria. One-hundred-eighty-nine participants had low back-related leg pain. Four-hundred-thirty-nine were included in supplemental analyses. Meta-analyses showed at least fair inter-rater reliability when a positive SLR required provocation of lower extremity symptoms or pain. SLR reliability was at least moderate when testing included structural differentiation (e.g., ankle dorsiflexion). A low prevalence of positive crossed SLR tests led to wide-ranging reliability estimates. Confidence in the evidence for identifying a positive SLR or crossed SLR was moderate to very low. SDD95 values for different raters measuring SLR range of motion ranged from 13 to 20°. Conclusions: Reliability data support testing SLR with structural differentiation manoeuvres. Crossed SLR reliability data are inconclusive. Measurement error likely prohibits using SLR range of motion for clinical decision-making.

Ultrasound shear wave elastography has become a promising method in peripheral neuropathy evaluation. Shear wave velocity, a surrogate measure of stiffness, tends to increase in peripheral neuropathies regardless of etiology. However, little is known about the spatial variation in shear wave velocity of healthy peripheral nerves and how tensile loading is distributed along their course. Sixty healthy young adults were scanned using ultrasound shear wave elastography. Five regions of the sciatic (Sciatic PROXIMAL, Sciatic DISTAL) and tibial nerve (Tibial PROXIMAL, Tibial INTERMEDIATE, and Tibial DISTAL) were assessed in two hip positions that alter nerve tension: 1) neutral in supine position; and 2) flexed at 90°. Knee and ankle remained in full-extension and neutral position. We observed spatial variations in shear wave velocity along the sciatic and tibial nerve (P < 0.0001). Shear wave velocities were significantly different between all nerve locations with the exception of Sciatic DISTAL vs. Tibial INTERMEDIATE (P = 0.999) and Tibial PROXIMAL vs. Tibial INTERMEDIATE (P = 0.708), and tended to increase in the proximal-distal direction at both upper and lower leg segments. Shear wave velocity increased with hip flexion (+54.3%; P < 0.0001), but the increase was not different among nerve locations (P = 0.233). This suggests that the increase in tensile loading with hip flexion is uniformally distributed along the nerve tract. These results highlight the importance of considering both limb position and transducer location for biomechanical and clinical assessments of peripheral nerve stiffness. These findings provide evidence about how tension is distributed along the course of sciatic and tibial nerves.

ObjectivesTo systematically review the literature regarding the reliability and validity of assessment methods available in primary care for bladder outlet obstruction or benign prostatic obstruction in men with lower urinary tract symptoms (LUTS).DesignSystematic review with best evidence synthesis.SettingPrimary care.ParticipantsMen with LUTS due to bladder outlet obstruction or benign prostatic obstruction.Review methodsPubMed, Ebsco/CINAHL and Embase databases were searched for studies on the validity and reliability of assessment methods for bladder outlet obstruction and benign prostatic obstruction in primary care. Methodological quality was assessed with the COSMIN checklist. Studies with poor methodology were excluded from the best evidence synthesis.ResultsOf the 5644 studies identified, 61 were scored with the COSMIN checklist, 37 studies were included in the best evidence synthesis, 18 evaluated bladder outlet obstruction and 17 benign prostatic obstruction, 2 evaluated both. Overall, reliability was poorly evaluated. Transrectal and transabdominal ultrasound showed moderate to good validity to evaluate bladder outlet obstruction. Measured prostate volume with these ultrasound methods, to identify benign prostatic obstruction, showed moderate to good accuracy, supported by a moderate to high level of evidence. Uroflowmetry for bladder outlet obstruction showed poor to moderate diagnostic accuracy, depending on used cut-off values. Questionnaires were supported by high-quality evidence, although correlations and diagnostic accuracy were poor to moderate compared with criterion tests. Other methods were supported by low level evidence.ConclusionClinicians in primary care can incorporate transabdominal and transrectal ultrasound or uroflowmetry in the evaluation of men with LUTS but should not solely rely on these methods as the diagnostic accuracy is insufficient and reliability remains insufficiently researched. Low-to-moderate levels of evidence for most assessment methods were due to methodological shortcomings and inconsistency in the studies. This highlights the need for better study designs in this domain.

Pain Practice published by Wiley Periodicals LLC on behalf of World Institute of Pain. Background: Based on associative learning theories it is hypothesized that pain might be a conditioned response. In people with musculoskeletal pain, the occurrence of movement-induced pain might be a protective response, influenced by visual cues suggesting that the person is approaching a painful position. This study aimed to determine (1) whether the pain-free range of motion (ROM) increased and decreased when visual feedback understated or overstated true rotation in people with neck pain and (2) whether this effect was more pronounced if pain was chronic. Method: People with subacute and chronic nonspecific neck pain wore a VR-headset and rotated their head to the left and right until the onset of pain. Visual feedback about the amount of movement was either equal, 20% less, or 20% greater than their actual rotation. Maximal pain-free ROM was measured using the VR-headset sensors. Data were analyzed using a mixed-design ANOVA. Results: There was no effect of visual feedback manipulation on pain-free ROM (P = 0.13) and no interaction effect between the visual feedback condition and duration of pain (P = 0.86). Discussion: The inability to influence pain-free ROM by manipulating visual feedback in people with subacute or chronic neck pain does not support associative learning theories for the perception of neck pain.

IntroductionJoint mobilisation and manipulation often results in immediate pain relief in people with neck pain. However, the biological mechanisms behind pain relief are largely unknown. There is preliminary evidence that joint mobilisation and manipulation lessens the upregulated neuroimmune responses in people with persistent neck pain.Methods and analysisThis study protocol describes a randomised placebo-controlled trial to investigate whether joint mobilisation and manipulation influence neuroimmune responses in people with persistent neck pain. People with persistent neck pain (N=100) will be allocated, in a randomised and concealed manner, to the experimental or control group (ratio 3:1). Short-term (ie, baseline, immediately after and 2 hours after the intervention) neuroimmune responses will be assessed, such as inflammatory marker concentration following in vitro stimulation of whole blood cells, systemic inflammatory marker concentrations directly from blood samples, phenotypic analysis of peripheral blood mononuclear cells and serum cortisol. Participants assigned to the experimental group (N=75) will receive cervical mobilisations targeting the painful and/or restricted cervical segments and a distraction manipulation of the cervicothoracic junction. Participants assigned to the control group (N=25) will receive a placebo mobilisation and placebo manipulation. Using linear mixed models, the short-term neuroimmune responses will be compared (1) between people in the experimental and control group and (2) within the experimental group, between people who experience a good outcome and those with a poor outcome. Furthermore, the association between the short-term neuroimmune responses and pain relief following joint mobilisation and manipulation will be tested in the experimental group.Ethics and disseminationThis trial is approved by the Medical Ethics Committee of Amsterdam University Medical Centre, location VUmc (Approval number: 2018.181).Trial registration numberNL6575 (trialregister.nl

Introduction: Embodying fit avatars in virtual reality (VR) is proposed as a possible treatment for cortical body representations and pain-related self-perceptions. Objective: To explore consumer perceptions of a novel VR intervention (VR-BiT) for chronic low back pain. Methods: Adults (n = 17, mean age(SD) = 52(14)) with chronic low back pain who had undergone a single session of VR-BiT as part of a randomized controlled trial underwent a semi-structured interview using open-ended questions. Interviews were audio-recorded, transcribed verbatim, and analyzed thematically. Results: Data reduction identified four themes: clinically beneficial and beyond; helping and hindering use; desire for more; and individualized future. Participants experienced wide ranging effects, including improved physical self-efficacy, pain, ability to perform physical activity and psychological symptoms. The intervention was well tolerated, except for two reports of nausea, and a few participants indicating pain associated with unaccustomed movement. Most participants were motivated to use VR-BiT again, despite some having technical issues. Participants suggested that personalizing VR-BiT and regular use would be beneficial. Conclusions: There was strong consumer support for further use of VR-BiT. Future studies of VR-BiT effectiveness are warranted and should consider incorporating individual user preferences, including people with diverse pain presentations, and involving a multi-session design. Refereed/Peer-reviewed

Question: In people with carpal tunnel syndrome who are waitlisted for surgical consultation, does a therapist-led care pathway involving education, splinting and exercises reduce the need for surgery and improve patient outcomes? Design: A multicentre, randomised controlled trial with concealed allocation, blinded assessment and intention-to-treat analysis. Participants: One hundred and five people with electrodiagnostically confirmed carpal tunnel syndrome on a waitlist for surgical consultation and recruited from four public hospitals in Australia. Interventions: The experimental group (n = 52) received a one-off group session of education, splinting, and nerve and tendon gliding exercises. The control group (n = 53) continued on the waitlist without additional care. Outcome Measures: The primary outcome measures were conversion to surgery by 24 weeks, the global rating of change (GROC) scale and patient satisfaction. Secondary outcomes included symptom severity and functional limitation. Results: At 24 weeks, conversion to surgery was 59% in the experimental group and 80% in the control group (risk difference −0.21, 95% CI −0.38 to −0.03). More participants in the experimental group identified as improved at 6 weeks (20% vs 4%; risk difference 0.15, 95% CI 0.03 to 0.28) but not at 24 weeks (24% vs 10%; risk difference 0.14, 95% CI −0.01 to 0.29). The intervention was also estimated to be beneficial on some measures of satisfaction, symptom severity and functional limitation. The study’s estimates of the benefits came with some uncertainty, which makes it unclear whether the wider population of people awaiting carpal tunnel surgery would consider that the benefits make the intervention worthwhile. No serious adverse effects were reported. Conclusions: A therapist-led pathway reduced conversion to carpal tunnel surgery and increased perceived improvement and satisfaction in people who were already on a waitlist for surgical consultation. Registration: ACTRN12613001095752.

Depression, anxiety and somatization influence the recovery of people with musculoskeletal pain. A Delphi study was conducted to reach consensus on the most appropriate self-administered questionnaires to assess these psychosocial factors in people at risk of developing persistent musculoskeletal pain. A multidisciplinary panel of international experts was identified via PubReMiner. The experts (N=22) suggested 24 questionnaires in Round 1. In Round 2, experts rated the questionnaires on suitability, considering clinimetrics, content, feasibility, personal experiences and expertise. The highest ranked questionnaires were retained for Round 3, in which the experts made a final assessment of the suitability of the questionnaires. Sensitivity analyses were performed to assess the impact of (1) not all experts having participated in each round, and (2) experts having been involved in relevant questionnaire development. Consensus (i.e., ≥75% agreement) was reached for the following questionnaires. For depression: Patient Health Questionnaire-9, Beck Depression Inventory-II, Center for Epidemiological Studies-Depression Scale, and Depression Subscale of the Depression, Anxiety and Stress Scales. In the sensitivity analyses, consensus was also reached for the Depression Subscale of the Hospital Anxiety Depression Scale. For anxiety: Generalized Anxiety Disorder Scale-7, State and Trait Anxiety Inventory, and Pain Anxiety Symptoms Scale. For somatization: no recommendation could be made. Perspective This study generated a short-list of preferred questionnaires to assess depression, anxiety and somatization in people with musculoskeletal pain. Broad implementation of these questionnaires by clinicians and researchers will facilitate easier comparison and pooling of baseline and outcome data. Some of the recommended questionnaires still require validation in this population.

Background: Neck pain can be associated with a reduction in tactile acuity that is thought to reflect disrupted sensory processing. Tactile acuity training may normalise sensory processing and improve symptoms. This proof-of-concept trial will assess the feasibility of a novel tactile acuity training method and whether this intervention improves tactile acuity in people with persistent neck pain.Methods: and analysis: In this two-arm randomised clinical proof-of-concept trial we will recruit participants with neck pain receiving usual care physiotherapy in a secondary outpatient healthcare setting. Thirty-six participants will be randomised 2:1 to receive four weeks of either tactile acuity training using the Imprint Tactile Acuity Device (iTAD) or a placebo intervention, in addition to usual care. The placebo intervention will consist of a de-activated TENS machine (iTENS) said to deliver a sub-threshold inhibitory therapy. Outcomes will be assessed at baseline, mid-treatment, and at 5-weeks and 2-months follow-up. The primary outcome tactile acuity will be evaluated using the two-point discrimination test and locognosia tests. Feasibility will be informed by recruitment and attrition rates, adherence, credibility of the interventions, treatment satisfaction and blinding. Pain intensity and anatomical spread will be analysed as secondary outcomes. The effect of iTAD training on tactile acuity will be assessed using a 2 (Group: iTAD vs. iTENS) x 4 (Time: baseline, mid-treatment, 5-week and 2-month outcome assessment) mixed ANOVA. Secondary outcomes including pain and pain spread, will be analysed with a focus on informing sample size calculations in future trials.Ethics and dissemination: Risks associated with this study are minor. Usual care is not withheld, and participants consent to random allocation of either iTAD or iTENS. Potential benefits to participants include any benefit associated with the interventions and contributing to research that may assist people with chronic pain in the future. Trial results will be disseminated via academic journals and conference presentations. The study is approved by the Human Research Ethics Committee of Griffith University (2017/128). usc Refereed/Peer-reviewed

Objective: Impaired left/right discrimination of an affected body part has been observed in various chronic pain states. This study aimed to examine whether people with unilateral chronic Achilles tendinopathy also present with impaired left/right discrimination. Design: Cross-sectional study. Methods: Nineteen runners with persistent unilateral Achilles tendinopathy and 19 matched healthy volunteers performed a left/right discrimination task in a laboratory setting. Participants were shown pictures of feet, hands and Shepard-Metzler figures and were asked to decide as accurately and as fast as possible whether the body part belonged to the left or right side of the body, or whether the Shepard-Metzler figures were rotated or mirrored. Performance was evaluated in terms of accuracy and response time. Data were analysed with mixed-design ANOVAs. Results: The decline in left/right discrimination ability at group level, if present, between affected and unaffected side, or compared to healthy participants, was negligible for both accuracy ( 0.36) or response time (p > 0.69). Conclusions: People with Achilles tendinopathy recognised the affected side as accurately and as fast as the non-affected side and their performance was comparable to healthy participants. The absence of impaired left/right discrimination despite the chronicity of the condition may be attributable to the typical intermittent nature of Achilles tendinopathy pain and/or maintained sports activity.

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.

To determine the diagnostic accuracy of patient interview items and clinical tests to diagnose cervical radiculopathy. Design A prospective diagnostic accuracy study. Participants Consecutive patients (N = 134) with a suspicion of cervical radiculopathy were included. A medical specialist made the diagnosis of cervical radiculopathy based on the patient's clinical presentation and corresponding Magnetic Resonance Imaging findings. Participants completed a list of patient interview items and the clinical tests were performed by a physiotherapist. Main outcome measures Diagnostic accuracy was determined in terms of sensitivity, specificity, and positive (+LR) and negative likelihood ratios (-LR). Sensitivity and specificity values >= 0.80 were considered high. We considered +LR >= 5 and -LR = 10and -LR

Background: Proprioceptive deficits in people with low back pain (LBP) have traditionally been attributed to altered paraspinal muscle spindle afference and its central processing. Studies conducted in the upper limb demonstrated that sense of effort is also an important source of kinaesthetic information. Objectives: To better understand proprioceptive deficits in people with chronic LBP (cLBP), this study aimed to test whether sense of effort is affected in people with cLBP. Design: Cross-sectional study. Method: Fourteen participants with cLBP and fourteen healthy participants performed a 120 s force matching task with their trunk extensor muscles at a low intensity. Results: When visual feedback of the generated force was provided, both groups performed the task accurately. Removal of visual feedback resulted in an increase in error for both groups (p < 0.0001), but the increase in error was significantly larger for the cLBP group (p = 0.023). This larger error could be attributed to undershooting of the target force (p = 0.020). The control group did not consistently undershoot or overshoot the target force (p = 0.93). Furthermore, the amount of undershooting for the cLBP group increased as the task progressed (p = 0.016), which was not observed for the control group (p = 0.80). Conclusions: The results of this study revealed that sense of effort is affected in cLBP. People with cLBP overestimated the trunk extension force they generated, and the error increased as the trial progressed. With visual feedback however, people with cLBP were able to compensate and perform the task as accurately as people without cLBP.

Supplemental Digital Content is Available in the Text. Through a Delphi study, consensus was reached regarding recommended self-administered questionnaires to assess fear of movement, coping, self-efficacy, and catastrophizing in patients with musculoskeletal pain., The way people with musculoskeletal disorders deal with pain influences their prognosis. Psychosocial factors that influence outcomes include fear of movement, coping, self-efficacy, and catastrophizing. A 3-round modified Delphi study was conducted with the aim to reach consensus on the most appropriate questionnaires to assess these 4 psychosocial factors in patients at risk of developing persistent musculoskeletal pain. The panel consisted of 36 experts, with track records in medicine, psychology, and allied health. To be considered an expert, a minimum number of authorships were required on research articles using self-administered questionnaires to assess these psychosocial factors in relevant patient populations. In round 1, the experts proposed 30 questionnaires to assess the 4 factors. In round 2, experts rated the questionnaires on suitability, considering clinimetric properties, content, feasibility, personal experiences, and expertise. The highest ranked questionnaires (maximally 5 per factor) were retained for round 3, in which the experts made a final assessment of the questionnaires and provided their positive and negative experiences with the questionnaires. Consensus was reached for the following questionnaires to assess (1) fear of movement: Fear Avoidance Beliefs Questionnaire and Tampa Scale (full version or 11-item version); (2) coping: Coping Strategies Questionnaire (initial or revised version) and Chronic Pain Coping Index; (3) self-efficacy: Pain Self-Efficacy Questionnaire (full version or 2-item version); and (4) catastrophizing: Pain Catastrophizing Scale and the revised version of the Coping Strategies Questionnaire. Although other questionnaires can be considered in specific circumstances, these questionnaires are recommended in people with musculoskeletal pain.

Background: Neurodynamic assessment and management are advocated for femoral nerve pathology. Contrary to neurodynamic techniques for other nerves, there is limited research that quantifies femoral nerve biomechanics. Objectives: To quantify longitudinal and transverse excursion of the femoral nerve during knee and neck movements. Design: Single-group, experimental study, with within-participant comparisons. Methods: High-resolution ultrasound recordings of the femoral nerve were made in the proximal thigh/groin region in 30 asymptomatic participants. Scans were made during knee flexion in supine and a semi-seated position, and during neck flexion in side-lying slump (Slump FEMORAL). Healthy participants were assessed to reveal normal nerve biomechanics, not influenced by pathology. Data were analysed with one-sample and paired t-tests. Reliability was assessed with intraclass correlation coefficients (ICC). Results: Longitudinal and transverse excursion measurements were reliable (ICC≥0.87). With knee flexion, longitudinal femoral nerve excursion was significant and larger in supine than in sitting (supine (mean (SD)): 3.6 (2.0) mm; p < 0.001; sitting: 1.1 (1.6) mm; p = 0.001; comparison: p = 0.001). There was also excursion in a medial direction (supine: 1.4 (0.3) mm; p < 0.001; sitting: 0.7 (0.6) mm; p < 0.001) and anterior direction (supine: 0.2 (0.2) mm; p < 0.001; sitting: 0.1 (0.2) mm; p = 0.06). Neck flexion in Slump FEMORAL did not result in longitudinal (0.0 (0.3) mm; p = 0.55) or anteroposterior (0.0 (0.1) mm; p = 0.10) excursion, but resulted in medial excursion (1.1 (0.5) mm; p < 0.001). Conclusion: Although the femoral nerve terminates proximal to the knee, femoral nerve excursion in the proximal thigh occurred with knee flexion; Neck flexion in Slump FEMORAL resulted in medial excursion.

Background: It is unknown whether the treatment effects of partial meniscectomy and physical therapy differ when focusing on activities most valued by patients with degenerative meniscal tears. Purpose: To compare partial meniscectomy with physical therapy in patients with a degenerative meniscal tear, focusing on patients’ most important functional limitations as the outcome. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: This study is part of the Cost-effectiveness of Early Surgery versus Conservative Treatment with Optional Delayed Meniscectomy for Patients over 45 years with non-obstructive meniscal tears (ESCAPE) trial, a multicenter noninferiority randomized controlled trial conducted in 9 orthopaedic hospital departments in the Netherlands. The ESCAPE trial included 321 patients aged between 45 and 70 years with a symptomatic, magnetic resonance imaging–confirmed meniscal tear. Exclusion criteria were severe osteoarthritis, body mass index >35 kg/m2, locking of the knee, and prior knee surgery or knee instability due to an anterior or posterior cruciate ligament rupture. This study compared partial meniscectomy with physical therapy consisting of a supervised incremental exercise protocol of 16 sessions over 8 weeks. The main outcome measure was the Dutch-language equivalent of the Patient-Specific Functional Scale (PSFS), a secondary outcome measure of the ESCAPE trial. We used crude and adjusted linear mixed-model analyses to reveal the between-group differences over 24 months. We calculated the minimal important change for the PSFS using an anchor-based method. Results: After 24 months, 286 patients completed the follow-up. The partial meniscectomy group (n = 139) improved on the PSFS by a mean of 4.8 ± 2.6 points (from 6.8 ± 1.9 to 2.0 ± 2.2), and the physical therapy group (n = 147) improved by a mean of 4.0 ± 3.1 points (from 6.7 ± 2.0 to 2.7 ± 2.5). The crude overall between-group difference showed a –0.6-point difference (95% CI, –1.0 to –0.2; P = .004) in favor of the partial meniscectomy group. This improvement was statistically significant but not clinically meaningful, as the calculated minimal important change was 2.5 points on an 11-point scale. Conclusion: Both interventions were associated with a clinically meaningful improvement regarding patients’ most important functional limitations. Although partial meniscectomy was associated with a statistically larger improvement at some follow-up time points, the difference compared with physical therapy was small and clinically not meaningful at any follow-up time point. Registration: NCT01850719 ( ClinicalTrials.gov identifier) and NTR3908 (the Netherlands Trial Register).

Background: Virtual reality (VR) allows people to embody avatars that are different from themselves in appearance and ability. These experiences provide opportunities to challenge bodily perceptions. We devised a novel VR Body Image Training (VR-BIT) approach to target self-perceptions and pain in people with persistent pain. Methods: A 45-year old male with a 5-year history of disabling chronic low back pain participated in a 4-week VR-BIT intervention. Pain began following a fall from a first-floor deck. Pain was central and on the right side of his lower back, radiating to his right buttock and thigh. Pain was constant and varying at a 5/10 average intensity. The 4-week intervention consistent of three face-to-face sessions 1-week apart, followed by 1-week of in-home VR-BIT. During the first face-to-face session, the participant embodied three athletic avatars: a superhero (Incredible Hulk), a boxer, and a rock climber. Since the participant strongly identified with the boxer, only boxing experiences were subsequently used. Primary outcomes relating to body image (self-perceived strength, vulnerability, agility, and confidence with activity) and pain intensity were assessed using numerical rating scales (0–10 NRS). Disability, kinesiophobia, overall change, and self-efficacy were assessed as secondary outcomes. Outcomes were assessed during each face-to-face session, and at 1-week and 3-month follow-up. Results: The participant reported a high degree of engagement. Positive changes were noted during and after VR for all body image and pain assessments. Improvements were retained at 3-months for body image ratings (mean change: 4.5/10 NRS) and average pain intensity (change: 2/10 NRS). Improvements in disability (45% improvement); self-efficacy (pre: 2/12; post: 10/12); and overall change (“Very much improved”) were noted at 3-month follow-up. No change in kinesiophobia was detected. No adverse advents were recorded. Conclusion: The participant engaged strongly with the intervention and showed clinically meaningful changes in body image, pain, disability, and self-efficacy. Despite his long history of pain and rapid improvements, reported changes may be due to non-treatment effects. Nonetheless, VR-BIT clearly warrants further investigation as a potential addition to usual care. Refereed/Peer-reviewed

BACKGROUND: Lower urinary tract symptoms (LUTS) may be a relevant comorbidity when managing people with low back or pelvic girdle pain. It is unknown how often physiotherapists inquire about LUTS, and what the potential barriers and facilitators are to inquire about LUTS in this patient population.OBJECTIVE: To explore the frequency of inquiring about LUTS, and to identify the barriers and facilitators among physiotherapists with and without additional pelvic health training to ask for LUTS in people with low back or pelvic girdle pain.DESIGN: A qualitative study using thematic analysis.METHODS: Through purposeful sampling, 29 primary care physiotherapists were interviewed (16 physiotherapists and 13 physiotherapists with additional pelvic health training). Thematic analysis was performed to identify themes regarding facilitators and barriers.FINDINGS: The frequency of inquiring about LUTS was: 'never': 10%, 'sometimes': 38%, and 'always': 52%. Four barriers were identified: (1) lack of knowledge of the physiotherapist, (2) a standardised assessment approach which did not include LUTS, (3) patient expectations assumed by the physiotherapist, and (4) social, cultural and personal barriers. Three facilitators were identified: (1) communication skills and experience of the physiotherapist, (2) education and knowledge, and (3) interprofessional consultation and referral.CONCLUSION: The majority of physiotherapists surveyed in this study regularly asked for LUTS in people with low back or pelvic pain. For when not asked, the identified barriers seem modifiable with adequate training, knowledge and skill acquisition, and sound clinical reasoning.