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Rationale: Cervical radiculopathy is initially typically managed conservatively. Surgery is indicated when conservative management fails or with severe/progressive neurological signs. Personalised multimodal physiotherapy could be a promising conservative strategy. However, aggregated evidence on the (cost-)effectiveness of personalised multimodal physiotherapy compared to surgery with/without post-operative physiotherapy is lacking., Aim/objectives: To systematically summarise the literature on the (cost-)effectiveness of personalised multimodal physiotherapy compared to surgery with or without post-operative physiotherapy in patients with cervical radiculopathy., Methods: PubMed, Embase, CINAHL, PsycINFO and Web of Science were searched from inception to 1st of March 2023. Primary outcomes were effectiveness regarding costs, arm pain intensity and disability. Neck pain intensity, perceived recovery, quality of life, neurological symptoms, range-of-motion, return-to-work, medication use, (re)surgeries and adverse events were considered secondary outcomes. Randomised clinical trials comparing personalised multimodal physiotherapy versus surgical approaches with/without post-operative physiotherapy were included. Two independent reviewers performed study selection, data-extraction, and risk of bias assessment using the Cochrane RoB 2 and Consolidated Health Economic Evaluation Reporting Standards statement. Certainty of the evidence was determined using Grading of Recommendations, Assessment, Development and Evaluations., Results: From 2109 records, eight papers from two original trials, with 117 participants in total were included. Low certainty evidence showed there were no significant differences on arm pain intensity and disability, except for the subscale 'heavy work' related disability (12 months) and disability at 5-8 years. Cost-effectiveness was not assessed. There was low certainty evidence that physiotherapy improved significantly less on neck pain intensity, sensory loss and perceived recovery compared to surgery with/without physiotherapy. Low certainty evidence showed there were no significant differences on numbness, range of motion, medication use, and quality of life. No adverse events were reported., Conclusion: Considering the clinical importance of accurate management recommendations and the current low level of certainty, high-quality cost-effectiveness studies are needed., (© 2024 The Author(s). Journal of Evaluation in Clinical Practice published by John Wiley & Sons Ltd.)

Pre-clinical evidence shows that neuropathy is associated with complex neuroimmune responses, which in turn are associated with increased intensity and persistence of neuropathic pain. Routine exercise has the potential to mitigate complications of future nerve damage and persistence of pain through neuroimmune regulation. This systematic review aimed to explore the effect of pre-injury exercise on neuroimmune responses, and other physiological and behavioural reactions following peripheral neuropathy in animals. Three electronic databases were searched from inception to July 2022. All controlled animal studies assessing the influence of an active exercise program prior to experimentally-induced traumatic peripheral neuropathy compared to a non-exercise control group on neuroimmune, physiological and behavioural outcomes were selected. The search identified 17,431 records. After screening, 11 articles were included. Meta-analyses showed that pre-injury exercise significantly reduced levels of IL-1β (SMD: -1.06, 95% CI: -1.99 to -0.13, n=40), but not iNOS (SMD: -0.71 95% CI: -1.66 to 0.25, n=82). From 72 comparisons of different neuroimmune outcomes at different anatomical locations, vote counting revealed reductions in 23 pro-inflammatory and increases in 6 anti-inflammatory neuroimmune outcomes. For physiological outcomes, meta-analyses revealed that pre-injury exercise improved one out of six nerve morphometric related outcomes (G-ratio; SMD: 1.95, 95%CI: 0.77 to 3.12, n=20) and one out of two muscle morphometric outcomes (muscle fibre cross-sectional area; SMD: 0.91, 95%CI: 0.27 to 1.54, n=48). For behavioural outcomes, mechanical allodynia was significantly less in the pre-injury exercise group (SMD -1.24, 95%CI: -1.87 to -0.61) whereas no overall effect was seen for sciatic function index. Post hoc subgroup analysis suggests that timing of outcome measurement may influence the effect of pre-injury exercise on mechanical allodynia. Risk of bias was unclear in most studies, as the design and conduct of the included experiments were poorly reported. Preventative exercise may have potential neuroprotective and immunoregulatory effects limiting the sequalae of nerve injury, but more research in this field is urgently needed., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Koop, Sleijser-Koehorst, Hooijmans, Tdlohreg, Lutke Schipholt, Scholten-Peeters and Coppieters.)

Background: Increasing pre-clinical evidence suggests that aerobic exercise positively modulates neuroimmune responses following traumatic nerve injury. However, meta-analyses on neuroimmune outcomes are currently still lacking. This study aimed to synthesize the pre-clinical literature on the effects of aerobic exercise on neuroimmune responses following peripheral nerve injury., Methods: MEDLINE (via Pubmed), EMBASE and Web of Science were searched. Controlled experimental studies on the effect of aerobic exercise on neuroimmune responses in animals with a traumatically induced peripheral neuropathy were considered. Study selection, risk of bias assessment and data extraction were performed independently by two reviewers. Results were analyzed using random effects models and reported as standardized mean differences. Outcome measures were reported per anatomical location and per class of neuro-immune substance., Results: The literature search resulted in 14,590 records. Forty studies were included, reporting 139 comparisons of neuroimmune responses at various anatomical locations. All studies had an unclear risk of bias. Compared to non-exercised animals, meta-analyses showed the following main differences in exercised animals: (1) in the affected nerve, tumor necrosis factor-α (TNF-α) levels were lower (p = 0.003), while insulin-like growth factor-1 (IGF-1) (p < 0.001) and Growth Associated Protein 43 (GAP43) (p = 0.01) levels were higher; (2) At the dorsal root ganglia, brain-derived neurotrophic factor (BDNF)/BDNF mRNA levels (p = 0.004) and nerve growth factor (NGF)/NGF mRNA (p < 0.05) levels were lower; (3) in the spinal cord, BDNF levels (p = 0.006) were lower; at the dorsal horn, microglia (p < 0.001) and astrocyte (p = 0.005) marker levels were lower; at the ventral horn, astrocyte marker levels (p < 0.001) were higher, and several outcomes related to synaptic stripping were favorably altered; (4) brainstem 5-HT2A receptor levels were higher (p = 0.001); (5) in muscles, BDNF levels (p < 0.001) were higher and TNF-α levels lower (p < 0.05); (6) no significant differences were found for systemic neuroimmune responses in blood or serum., Conclusion: This review revealed widespread positive modulatory effects of aerobic exercise on neuroimmune responses following traumatic peripheral nerve injury. These changes are in line with a beneficial influence on pro-inflammatory processes and increased anti-inflammatory responses. Given the small sample sizes and the unclear risk of bias of the studies, results should be interpreted with caution., (© 2023. The Author(s).)

Objective: 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≤0.20 moderate, and +LR≥10 and -LR≤0.10 high., Results: The history items 'arm pain worse than neck pain', 'provocation of symptoms when ironing', 'reduction of symptoms by walking with your hand in your pocket', the Spurling test and the presence of reduced reflexes showed high specificity and are therefore useful to increase the probability of cervical radiculopathy when positive. The presence of 'paraesthesia' and 'paraesthesia and/or numbness' showed high sensitivity, indicating that the absence of these patient interview items decreases the probability of cervical radiculopathy. Although most of these items had potentially relevant likelihood ratios, none showed moderate or high likelihood ratios., Conclusions: Several patient interview items, the Spurling test and reduced reflexes are useful to assist in the diagnosis of cervical radiculopathy. Because there is no gold standard for cervical radiculopathy, caution is required to not over-interpret diagnostic accuracy values., (Copyright © 2020 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.)

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 (ie, ≥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., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

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.

Purpose: To describe the clinical course and develop prognostic models for poor recovery in patients with cervical radiculopathy who are managed conservatively., Methods: Sixty-one consecutive adults with cervical radiculopathy who were referred for conservative management were included in a prospective cohort study, with 6- and 12-month follow-up assessments. Exclusion criteria were the presence of known serious pathology or spinal surgery in the past. Outcome measures were perceived recovery, neck pain intensity and disability level. Multiple imputation analyses were performed for missing values. Prognostic models were developed using multivariable logistic regression analyses, with bootstrapping techniques for internal validation., Results: About 55% of participants reported to be recovered at 6 and 12 months. All multivariable models contained 2 baseline predictors. Longer symptoms duration increased the risk of poor perceived recovery, whereas the presence of paresthesia decreased this risk. A higher neck pain intensity and a longer duration of symptoms increased the risk of poor relief of neck pain. A higher disability score increased the risk of poor relief of disability, and larger active range of rotation toward the affected side decreased this risk. Following bootstrapping, the explained variance of the models varied between 0.22 and 0.30, and the median area under the curve varied between 0.75 and 0.79., Conclusions: The clinical course of cervical radiculopathy appears to be long, with most of the reduction in symptoms occurring within the first 6 months. All prognostic models showed an adequate predictive performance with modest diagnostic accuracy and explained variance. These slides can be retrieved under Electronic Supplementary Material.