Learning Objectives

Participants will:
• identify behavioural, psychological and healthcare system factors affecting clinicians’ and patient’s readiness for recommending and adopting evidence-based non-pharmacological management strategies.
• understand how to identify people with MSK conditions at risk of a poor prognosis and how to implement clinical pathways of ‘right’ care.
• learn lessons from studies aimed at reforming primary care services towards effective de-medicalized options for MSK pain tailored to the individual.

Description

PROBLEM – MSK CONDITIONS are a GLOBAL DISEASE BURDEN
Leaders in musculoskeletal health services research from the US, UK and Australia will share real world perspectives on outcomes from their innovative translational research that connects consumers with clinicians, services and systems, to support musculoskeletal reform. Reform is critical: musculoskeletal (MSK) conditions attribute the HIGHEST global non-communicable disease burden (Global Burden of Disease Study, 2019). Underuse of high value care practices (e.g. behavioural management and physical activity) and overuse of low value care (imaging, medicines, surgery, inappropriate manual treatments; Foster et al 2018) are key issues discussed. We will present solutions showing how collectively we can nudge helpful behavioural change at clinical interface, and leverage services and system re-design to support integrated person-centred musculoskeletal care.

SOLUTION - CHANGING CLINICAN and PATIENT BEHAVIOUR
Dr Lynn DeBar will open by summarizing broad trends in treatment practice for MSK conditions, including historical practices misaligned with optimal provision of non-pharmacotherapy evidence-based care. She will discuss behavioural, psychological, and healthcare system factors that affect the readiness of clinicians and patients to partner to optimize adoption of non-pharmacotherapeutic strategies. Examples from NIH- and PCORI-funded studies (including multi-method evaluations of US policy initiatives; Smith et al 2022; DeBar et al 2022) evaluating patients’ uptake of evidence-based behavioural interventions will be utilized. Integrative health approaches for managing chronic pain in primary care in the US will be discussed. Following, actionable strategies to scale and sustain patient-centred approaches (encouraging patients’ active partnership in a biopsychosocial function-focused means of managing MSK conditions) will be proposed. Finally, methodologies considering how to effect broader systems of care will be reviewed.

SOLUTION – IMPLEMENTING CLINICAL PATHWAYS
Professor Trudy Rebbeck will discuss implementation of risk-based clinical pathways of care utilising expert MSK physiotherapists as a promising solution. First, validated tools that assist clinicians in identifying those at risk of a poor prognosis (e.g. Orebro, WhipPredict) will be discussed. Next, different clinical pathways of care (e.g. stratified and matched care) will be introduced. Common messages across MSK conditions suitable to manage those at low risk (likely to recover) will be identified (e.g. providing exercise and advice). Integrated roles of generalist and specialist MSK physiotherapists in managing people with MSK conditions at risk of a poorer prognosis will be explored. Results and lessons learnt from large Australian implementation trials testing these models of care for people with whiplash (Rebbeck et al 2023) and MSK disorders (Rebbeck et al 2021) will be discussed.

SOLUTION – SUPPORTING DELIVERY OF CARE
Professor Jonathan Hill will introduce some cutting-edge projects that are seeking to deliver innovative guideline-based clinical decision-support systems, to improve musculoskeletal primary care decision-making. For example, the Norwegian SupportPRIM project (www.ntnu.edu/supportprim) , the UK MSK Pathways trial, and the UK STarT MSK Trial (Hill et al 2022). In addition, he will talk about the Keele MIDAS and MSK research database projects in the UK which are designed to benchmark services against key care quality indicators.

AUDIENCE DISCUSSION
Prof Helen Slater, a world leader in development, implementation and evaluation of MSK Models of Care will conclude the session by leading a discussion on the opportunities and challenges for driving whole-of-system reform to improve MSK health outcomes and how we might achieve this in a rapidly evolving health landscape (Briggs et al 2019). Critical factors at the clinical (micro), service delivery (meso) and system (macro) levels will be considered. Helen will facilitate discussion between the panel and audience and invite conversation about the future to support MSK health reforms, including through the use of digital care models, and future roles for MSK physiotherapists.

IMPLICATIONS
Participants will understand key behaviours required to change and adopt new models of care. This is critical for not only professional survival but for musculoskeletal physiotherapists to have key roles in the future of health service delivery for people with these disorders.

REFERENCES
Briggs A, Slater H et al. Pain; 2019 160:1240-1244.
DeBar L et al. Ann Intern Med. 2022 175(1): 46-55.
Foster N et al. The Lancet, 2018; 391(10137): 2368-2383.
Global Burden of Disease Study 2019. The Lancet 396(10258): 1204-1222.)
Hill et al. Lancet Rheumatology 2022; 4:9 E 591- E602.
Rebbeck T et al. Pain 2023; in press.
Rebbeck T et al. BMJ Open 2021;11e057705.
Smith DH…….. DeBar L. Medical Care 2022; 60 (6).

Learning objectives
1. To describe the epidemiology and assessment of patients with suspected degenerative cervical myelopathy (DCM)
2. To describe the management and outcomes of patients with DCM
3. To learn from a patient’s experience of being diagnosed and living with DCM
Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord dysfunction in adults with an estimated prevalence of 2%.(1) DCM is most often caused by degenerative cervical stenosis, which can lead to chronic, non-traumatic spinal cord compression.(1) Degenerative cervical stenosis may be the result of degenerative disc disease (including disc herniation or spondylosis), facet joint degeneration (either arthropathy or instability), hypermobility or ligamentous degeneration.(2–4) DCM is a progressive condition, and if not diagnosed or treated timeously, can result in an incomplete spinal cord injury and neurological loss. DCM patients’ symptoms are thought to deteriorate over time,(5) therefore prompt recognition of any early decline in function is crucial for optimal treatment.
The incidence of DCM appears to rise with an ageing population, with most patients diagnosed in their 50s.(6) The global population is ageing, and therefore the rates of DCM are likely to be increasing. However, awareness of this condition in primary and secondary care specialties appears to vary with numerous case reports documenting delays to diagnosis and treatment.(1) Recent international guidance has recommended a treatment algorithm according to the severity of DCM, as judged by the Modified Japanese Orthopedic Score.(3,8) However, many of the initial presenting symptoms are subtle, and may not be identified without comprehensive neurological testing.(1,3,6) Further, patients may present with symptoms that do not fit neatly into the International Guidance algorithm.(7) Further, older age often results in overlapping symptoms such as peripheral joint osteoarthritis, age-related decline, lumbar spine pathology, as well as cardiovascular conditions. There is no consensus to date on the diagnostic criteria for DCM, which further challenges the management of these patients.(1,7,9) Awareness of this condition as a differential cause of spinal pathology appears to be lacking in primary care, with limited coverage in the UK and US medical curriculum.(10) It is unknown the degree to which physiotherapists screen for this condition, and there are no agreed pathways in place for physiotherapists managing this patient subgroup.
Early diagnosis of DCM is important as most cases appear to progress with time.(5) It is imperative to make every effort to reduce time to diagnosis by ensuring timely assessment, such as upper motor neurone sign assessment, and, where relevant, appropriate investigations, such as cervical spine imaging.(3) Timely treatment is therefore critical to preserving function. Surgical decompression is recommended for moderate and severe classifications of DCM,(7) and aims to prevent further deterioration of symptoms. Delays to diagnosis and treatment are common in this patient group and may have significant long-term impacts on future function and prognosis, especially when younger patients are affected. Myelopathy is an important differential diagnosis to consider in primary and secondary care, irrespective of age, given the potential impact on future productive working years. (1)
During this symposium, we will describe the epidemiology of DCM, and explore the possible initial presentations of patients in primary and secondary care. We will provide clear assessment guidance regarding differential or early diagnosis and management of DCM, using the international guidance for recommended management and triage. We will present and discuss pathways for the management of DCM (and results from an audit of our local pathway) and discuss surgical treatment, outcomes and prognosis. We will also learn from a patient’s experience, and reflect on their journey to diagnosis and treatment. We will engage attendees with a pre-symposium survey of understanding of the condition, assessment tools and current practice, to assess their understanding and current management of DCM. We will also explore current myelopathy pathways in place for attendees.
The planned impact is that all attendees will gain an increased awareness of DCM and the potential consequences of delayed diagnosis and treatment. The symposium will aim to educate physiotherapists on assessment and management of this condition, as well as reviewing current pathways in primary and secondary care for the management of suspected and confirmed DCM. This will hopefully provide improved pathways for future management of suspected and confirmed DCM, and reduce both time to diagnosis and to treatment. We will share current pathways implemented at NUH, discuss learning and future directions for improved management of this condition.

BACKGROUND
The effectiveness of physiotherapy to reduce low back pain depends on patient adherence to treatment. This requires effective strategies to facilitate but also tools to measure adherence to physiotherapy. Facilitators and barriers to patient adherence are multifactorial and include patient and therapist-related factors.

PURPOSE
This three-part research project aimed to identify strategies to facilitate adherence of patients with low back pain to physiotherapy.
A systematic review identified tools to measure and strategies to facilitate adherence.
The subsequent focus group study aimed to identify aspects of patients' experiences in their physiotherapy and physiotherapists' reflections that influenced adherence.
The final Delphi study aimed to reach an expert consensus on aspects influencing adherence.

METHODS
The three research studies were conducted sequentially and each built on the previous findings. The two-stage review study included a scooping procedure in stage one to identify tools for measuring adherence. Stage two included a systematic process that followed the PRISMA recommendations.
The focus group study included patients with low back pain (n = 10, 5 women) and physiotherapists (n = 11, 5 women). Data analysis was implemented using simple transcription with structured content analysis based on categorization (deductive/inductive) and coding.
In the final Delphi study, international experts were invited to participate in a three-round standard Delphi survey. The survey contained 49 items (32 original and 17 suggested by experts) which were rated on 5-point Likert scales. The items were assigned to six domains. The consensus level was defined as 60 %.

RESULTS
In the systematic review, 21 studies were included for stage one and 16 for stage two. Identified were six different tools to measure adherence. The most used tool was an exercise diary; the most common more multidimensional tool was the Sports Injury Rehabilitation Adherence Scale. The most promising strategies for facilitating adherence were based on cognitive behavioral principles.
The focus group study identified that patients with back pain requested more effective home programs, long-term rehabilitation management, and individualized therapy to achieve a higher level of adherence. Physiotherapists requested more time for patient education. Communication, quality of the therapist-patient relationship, and individualized therapy were identified as essential factors by both representatives.
The Delphi study experts agreed on the domains “Influence of biopsychosocial factors” (89%) and “Influence of cooperation between physiotherapists and patients” (79%) as major influencing aspects for patient adherence. Additional important domains were the “Influence of competencies of physiotherapists” (71%) and “Interdisciplinary congruence” (78%).

CONCLUSIONS
Biopsychosocial factors, therapeutic competencies, and patient-physiotherapist collaboration should be considered in physiotherapy practice to facilitate adherence in patients with back pain to physiotherapy. Future studies should prospectively evaluate the effectiveness of individual or combined identified aspects for their influence on patient adherence in longitudinal study designs.

IMPLICATIONS
The results of this three-part research provide recommendations for facilitating adherence of patients with back pain in physiotherapy. Future research is required to develop a multidimensional measurement tool for adherence and to evaluate the effectiveness of individual or combined strategies for long-term patient adherence.

Background
Evaluation of psychosocial aspects such as fear or catastrophizing have been increasingly included within physical therapy research and standards of practice. The implications have been an increased emphasis on screening for potential negative risk factors for outcomes and specifically addressing this within the treatment plan. The role of the patient or clinician's expectations has been increasingly found in the literature. Given this evolution in the understanding of the role of expectations, measurement, and treatment of patient expectations are less well defined. This is inconsistent with the large shift in practice patterns that focuses on the psychosocial factors in the overall management of the patient. Understanding expectations is the first step in approaching this topic. Knowledge translation into clinical practice is an area of need moving forward.

Purpose:
This project offers knowledge translation and clinical implementation strategies from our recent systematic reviews regarding patient expectations in musculoskeletal practice.

Methods:
Two systematic reviews were completed in accordance with PRISMA 2020 guidelines (pre-registration, PICO-guided searches in multiple databases, independent screening, appraisal and extraction, etc.) Both reviews linked musculoskeletal patient expectations (1- recovery expectations and 2- treatment expectations) to patient outcomes. Summarily asking, do patient outcomes differ between groups who 1- expect physical therapy to be of benefit compared to patients who do not expect physical therapy to help or 2- receive treatments they think will be of benefit versus receive treatments they do not think will be beneficial?

Results:
Recovery expectations were measured in 19 studies with 4,347 musculoskeletal patients while 1,855 patients’ treatment expectations were measured in 12 studies. The majority of studies were secondary analyses of randomized controlled trials or cohort studies with acceptable appraisal scores. Patient expectations were correlated with patient-reported outcomes in both reviews. The tools to measure expectations and outcomes were highly variable.

Conclusion(s):
Expectations should be measured at evaluation as part of a holistic examination process given their relationship to patient outcomes. There is greater evidence to support measuring recovery expectations than treatment-specific expectations. Future research to further investigate these and other expectations will serve to enhance patient outcomes.

Implications: The role of psychosocial factors in managing musculoskeletal conditions has been well established. The distinct area that is needed is knowledge translation into the clinical sector. Exploring the factors clinicians should consider related to expectations and discussing real-world applications is the focus of this presentation. This presentation will provide clinicians with a robust understanding of expectations to consider, tools and or approaches to assist in the assessment of these factors, and evidence-informed strategies to assist in the management of different expectations in the clinic. As a clinician, it is critical to both understand and apply this knowledge in the clinical setting to provide the best possible care for patients with musculoskeletal conditions.

Background: Belief is a powerful driving force in one’s behaviour. Health locus of control (HLOC) refers to a person’s belief of where responsibilities for his/her health condition lies. Evidence suggests that HLOC is associated with health attitudes, health behaviours and the key clinical elements of non-specific chronic low back pain (NSCLBP) such as pain and disability. These are the key areas musculoskeletal physiotherapists seek to address in their practice. However, it is not known whether a physiotherapy-led cognitive-behavioural chronic low back pain (CBCLBP) programme effects patient HLOC.

Purpose: To determine: (1) the effects of a six-week CBCLBP programme on patient HLOC, pain intensity, disability, fear-avoidance belief (FAB) and self-care attitude; (2) the association between changes in pain intensity, disability, FAB and changes in HLOC; and (3) the costs of producing any effect and healthcare utilization.

Methods: In an A-B-A same-subject design, patients with NSCLBP and high FAB were recruited. Patients completed a four-week course of 1:1 physiotherapy followed by a six-week CBCLBP programme. Outcomes were measured before and after the 1:1 physiotherapy, immediately after the CBCLBP programme, and 3- and 6-months later. Friedman’s ANOVA and Wilcoxon signed-rank tests determined changes between phases. Multiple regression determined the relationship between HLOC and outcome of interest. Significance was set at 0.05.

Results: N=70 patients were recruited. N=55 patients entered the programme and completed the 6-month follow-up (79%). No significant improvement was seen after the 1:1 physiotherapy. Significant improvement in HLOC (p < 0.001), pain intensity (p < 0.001), disability (p < 0.001), FAB (p < 0.001) and self-care attitude (p < 0.001) was found immediately after the CBCLBP programme, with improvements sustained for 6 months. Changes in HLOC explained 6%, 0.5% and 31.9% variances in changes in pain, disability and FAB respectively, after controlling other variables. Increased internal locus of control (ILOC) was a significant predictor of reduction in FAB (p=0.002). HLOC had no predictive importance in the reduction of pain intensity or disability. The mean provider’s cost of the programme was £285.82 per patient. At 6-month, 25% of the participants re-visited their GP, and 16% consulted other therapy.

Conclusion: The CBCLBP programme significantly improved patients’ HLOC, pain intensity, disability, FAB and self-care attitude for 6 months. Increase in ILOC was a unique significant predictor of reduction in FAB, highlighting the potential importance of improving ILOC in attaining better FAB outcome, which in turn is related to reduction in pain intensity and disability. As a guide to stakeholders, £285.82 per patient is less costly compared to 1:1 physiotherapy.

Implications: HLOC should be targeted in CBCLBP programme to optimize treatment outcomes in NSCLBP. For this subgroup of NSCLBP patients, the CBCLBP programme was more effective in addressing the multi-dimensional nature of NSCLBP than 1:1 physiotherapy. It is recommended that policy makers and clinicians should routinely consider the CBCLBP programme as a first-line intervention rather than a last resort for this subgroup.

Background:
Many patients with musculoskeletal problems do not adhere to home exercises or self-management advice provided by physiotherapists. This is due to numerous factors, many of which can be targeted by Behaviour Change Techniques (BCTs).

Purpose:
For the physiotherapy management of people with musculoskeletal problems, the purpose of this systematic scoping review and mapping exercise was to 1) identify modifiable determinants (barriers and facilitators) of home exercise adherence and self-management, 2) for determinants with supporting evidence from ≥2 studies, map these to the Theoretical Domains Framework and BCTs and 3) provide examples of BCTs for clinical practice.

Methods:
The review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. Medline, Embase, CINAHL, and AMED were searched from inception to December 2022. Two independent reviewers carried out manuscript selection, data extraction, quality assessment, and mapping. Risk of bias (RoB) was assessed using the Quality in Prognosis Studies (QUIPS) tool. The Theory and Techniques Tool was used to map determinants to BCTs.

Results:
Thirty-two publications, describing 29 cohorts were included. Thirteen modifiable determinants were supported by ≥2 studies. Five of six studies reported a positive association between exercise self-efficacy and adherence, the only determinant supported by evidence from ≥2 cohort studies with low RoB. Patient understanding, being observed, receiving feedback, physiotherapists providing information, and a lower number of prescribed exercises were each investigated in 2-3 studies, all of which demonstrated a positive association with adherence and included one cohort study with low RoB. For physical activity, perceived treatment efficacy, social support, and task appreciation there was evidence from some studies of no association with adherence. These studies were of higher RoB and less or equal in number compared to those showing a positive association. Evidence of a positive association between coping and task self-efficacy with adherence was not consistent, with a greater number of studies reporting no association.

Determinants were mapped to 7 of 14 TDF categories. These mapped onto 42 of 93 BCTs, the most common being problem solving and instruction on how to perform the behaviour. The six most common categories of BCTs were goals and planning, feedback and monitoring, natural consequences, repetition and substitution, reward and threat, and antecedents.

Conclusions:
For people receiving physiotherapy for musculoskeletal problems, this review has identified modifiable determinants of exercise adherence and self-management and mapped these to evidence based BCTs. It has provided guidance and clinical examples to help physiotherapists select BCTs which specifically target the determinants of importance for individual patients. Research is needed to investigate the effectiveness of integrating BCTs into physiotherapy.

Implications:
The actions of both the patient and their physiotherapist are determinants of exercise adherence and engagement with self-management, indicating a joint responsibility. A wide range of BCTs mapped to the identified determinants, indicating that physiotherapist may need to upskill their knowledge in this field. Integrating behaviour change science into existing pre- and post-graduate physiotherapy curriculum will help cascade learning and promote a culture of behaviour change management into standard clinical practice.

Background: Chronic musculoskeletal pain (CMP) is a public health global epidemic that inequitably impacts minorities, immigrants, and females. CMP is often reported as an “invisible” disease by patients who encounter stigma and biases when seeking care. A socially-just neuroethics perspective encourages clinicians to contextually understand their patients’ pain experiences to minimize the risk of inadvertently providing stigmatized or implicitly biased care. Racial, ethnic, and cultural differences have been previously demonstrated for pain severity, pain beliefs and coping. However, few studies have looked at a linguistically diverse population’s perceptions about CMP. Purpose: The primary aims of this mixed method study were to: 1) describe the self-reported pain experiences in people living in the Piedmont Region of North Carolina (United States) who have CMP and speak Arabic, English, or Spanish and 2) interpret their experiences of living with CMP. Methods: A multi-modal, multi-language sequential explanatory mixed method study was implemented. This study design allowed for a broad survey sample and in-depth follow-up.The ethics of social justice support this design as it provided agency to community participants. The biopsychosocial model, the social ecological model, and Bronfenbrenner’s ecological model were the guiding theoretical frameworks. Descriptive statistics summarized the Phase 1 results and a one-way analysis of variance was used to explore differences in pain severity. Cross-tabulation analyses determined the relationship between languages concerns that day-to-day activities will increase pain, pain interference perceptions, and beliefs regarding the safety of physical activity when one is in pain. An interpretative phenomenological analysis lens was used in Phase 2. Results: The findings are from 909 survey respondents (Phase 1) and 10 Phase 2 participants. Significant differences were demonstrated between the languages for pain severity, pain interference perceptions, and concerns that day-to-day activities would increase their pain. While Arabic and Spanish speaking participants were evenly split as to whether physical activity was safe or not, English-speakers believed physical activity was safe at a two-to-one margin. The uniqueness of their individualized CMP experience, “only I live with my pains” resonated with all. Common strategies across all languages included staying active and using massage, creams, and heat. The preferred resources varied by language, and resource decisions were underpinned by polices related to access to health care and access to the internet. Conclusions: Similarities and differences were noted in the pain experiences of Arabic-, English-, and Spanish-speakers. Some of the differences may be attributed to cultural preferences. However, the results also indicate that disparate policies underpinned some of the findings. Implications: Increasing awareness of broad policies that impact a population’s health is an important first step to improving inequitable outcomes in CMP. Clinicians wishing to address health disparities in CMP can prioritize community engagement to learn from linguistically diverse populations about their priorities and needs.

Background:
Patients with non-specific chronic low back pain (NSCLBP) face a long-lasting, painful and potentially disabling condition. In the absence of visible damage and physical explanations for the origin of the pain, they may experience poor social recognition and disbelief. It is important to understand what they specifically expect from physiotherapists in this context, as the influence of expectations on clinical decision making, relationships and outcomes has previously been highlighted.
Purpose:
The aim of this study is to identify NSCLBP patients' expectations of physiotherapists prior to a 3-week rehabilitation programme and their perceived fulfilment 1 month after the programme.
Methods:
A purposive sample of 20 patients (9♀ , 11♂ , 41.0±10.5 years, 4.3±3.5 symptom duration, 3 on sick leave, 2 professional retraining) participated in semi-structured interviews conducted by anthropologists before and after the programme. The first and last individual sessions of 10 patients were also observed. The qualitative data were crossed with the clinical data. Coding was done with Atlas.tiR, crossed content analysis was done by two anthropologists and two physiotherapists.
Results:
The goals of the majority of patients were consistent with those of the programme. Patients mainly expected an active programme. Although pain reduction was the most expected outcome, strengthening, return to valued activities and improved well-being were also expected. Patients expected physiotherapists to deal mainly with physical problems and to provide a functional diagnosis of their problem. They also expected advice, explanations and skills development to help them cope with NSCLBP. Technical, gestural and relational individualisation was strongly expected in individual sessions, while social support was expected in group sessions. Relational expectations mainly included listening, mutual trust, support and personalisation. However, patients' opinions differed on whether or not physiotherapists should address emotional issues. Most patients felt that their expectations were met during the programme. However, they were not met when rehabilitation goals and patient goals diverged. Physiotherapists were generally not held responsible for unmet outcome expectations as long as they showed personal involvement and attention to the patient. Observations showed that expectations and responses given were often formulated indirectly.
Conclusion(s):
Expectations are specific to a sample of experienced patients enrolled in an NSCLBP rehabilitation programme. Patients' adherence to programme goals was fundamental to the fulfilment of expectations. Patients' expectations converged towards notions of patient-centred care and the development of a personalised therapeutic alliance with the physiotherapist. Patients differentiated the fulfilment of expectations towards the programme outcome from those towards the physiotherapist. In the case of a mitigated rehabilitation outcome, they considered their expectations of the physiotherapist to be met if he/she showed commitment and adaptation to their person and situation. Further research is needed to understand the factors that shape and influence patients' expectations.
Implications:
Awareness and discussion of patients' expectations could help to optimise the mutual therapeutic and relational fit between patient and physiotherapist. Physiotherapists need to help clarify expectations as they are often expressed indirectly. Consideration of expectations could help to improve the patient's sense of recognition and rehabilitation achievement.

“The pain is not necessarily less, but I experience it differently”: A qualitative study about how people with persistent pain experience physiotherapy care blended with a biopsychosocial digital intervention.

Poolman EYa,b, Vorstermans Lc, Donker MHd, Coppieters MWa,e, Cuijpers Pb, Scholten-Peeters GGMa, de Wit LMb

a Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences - Program Musculoskeletal Health, The Netherlands.
b Amsterdam Public Health Research Institute, Department of Clinical Psychology, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, The Netherlands.
c Master Musculoskeletal Rehabilitation, HAN University of Applied Sciences, Nijmegen, The Netherlands.
d Department of Health Sciences, Faculty of Beta Sciences, Vrije Universiteit Amsterdam, The Netherlands.
e Menzies Health Institute Queensland, School of Health Sciences and Social Work, Griffith University, Brisbane & Gold Coast, Australia.


ABSTRACT
Background: A blended intervention consisting of face-to-face therapy and psychologically informed digital care was developed to optimise the management of people with persistent spinal pain who also have psychosocial risk factors associated with the development or maintenance of persistent pain. This study aimed to gain insights in how participants experienced this blended intervention.

Methods: An interpretative qualitative study using semi-structured interviews was conducted. Eleven people with persistent non-specific spinal pain who received the blended intervention within a randomised clinical trial were included. All interviews were recorded, transcribed verbatim and analysed independently by two researchers. Data were analysed using a thematic inductive approach.

Results: The analysis identified four themes: (1) Experiencing a better understanding of the relationship between own physical and mental health, which also highlights the variations in preferences for receiving such psychologically informed care; (2) Importance of the physiotherapist’s active involvement in biopsychosocial blended care, which describes the crucial role of physiotherapists in supporting participants in this; (3) Appreciation of digital care, to better understand persistent pain and make meaningful lifestyle changes; and (4) Trials and triumphs, revealing gains such as reduced suffering, but also challenges with implementation of changes into long-term routines.

Conclusion: Participants of the blended intervention experienced positive changes in thoughts and behaviours, which highlights the feasibility and acceptability of the blended intervention as a more holistic treatment within pain management. The differences in personal preferences for receiving psychologically informed digital care poses challenges for implementation of blended biopsychosocial care in evidence-based practice.

Background: Non-specific neck pain (NSNP) contributes substantial socio-economic burden internationally. Up to 50% people experience NSNP annually. Patients with NSNP can experience physical (e.g., pain and disability) and psychological (e.g., fear avoidance, anxiety and depression) problems, leading to reducing quality of life. Furthermore, recurrent symptoms and chronicity are frequently reported. Thus, an effective intervention is still required to manage the multiple components of NSNP. An active behavioural physiotherapy intervention (ABPI), a complex intervention delivered within a flexible framework addressing both physical and psychological aspects, may be feasible to manage patients with acute NSNP to prevent chronicity based on the findings of a previous pilot and feasibility trial in acute whiplash-associated disorders.

Purpose: To evaluate feasibility and procedures of the ABPI to prevent the transition to chronicity in patients with acute NSNP in order to inform design of a future adequately powered definitive trial.

Methods: An external pilot and feasibility cluster-randomised double-blind (assessors and participants) parallel two-arm clinical trial (ABPI versus standard physiotherapy intervention [SPI]) was performed based on a pre-specified published protocol to minimise potential biases. Six physiotherapy departments in six public hospitals in Thailand were recruited and cluster-randomised to either ABPI (n=3) or SPI (n=3) using computer-generated randomisation with block sampling. Sixty participants (30 each arm, 10 per hospital) with acute NSNP (< 4 weeks) were recruited. Participants were assessed at baseline and 3-months follow-up post baseline (planned primary endpoint definitive trial). The planned primary outcome measure was the Neck Disability Index (NDI). The Numerical Pain Rating Scale (NPRS), Fear-Avoidance Beliefs Questionnaire (FABQ), Cervical Range of Motion (CROM) and EuroQol 5-dimension 5-level (EQ-5D-5L) were planned secondary outcome measures. Data were analysed descriptively consistent with the nature of a pilot and feasibility trial. Fully recovered status was evaluated using an NDI cut-off ≤ 4/50. Treatment session details and costs of management were collected to explore feasibility of cost-effectiveness analyses.

Results: All procedures worked well. All participants attended in person assessments at baseline and 3-month follow-up. The median age of participants was 36.5 years (range 21-59, interquartile range: 20.75). Considering the median of difference between intervention arms, the findings suggest that the ABPI could improve all physical (NDI [12/50:9/50], NPRS [5/10:4/10] and CROM all directions) and psychological (FABQ [17/66:6/66] and its sub-scores) outcomes including quality of life rather than the SPI. The exceptions were the EQ-5D-5L dimensions of mobility, self-care, pain/discomfort and anxiety/depression which were similar for both interventions. The number of fully recovered participants following ABPI (27/30, 90.00%) was higher than SPI (16/30, 53.33%) with fewer treatment sessions and lower costs of management. No adverse or serious adverse events were reported.

Conclusions: The findings suggest that the ABPI is feasible and valuable (e.g., high number of fully recovered participants, fewer treatment sessions and reduced management costs compared to the SPI). Conducting a future definitive trial to evaluate effectiveness of the ABPI is supported without modifications based on the a priori criteria.

Implications: A definitive trial is feasible to evaluate effectiveness of the ABPI to prevent chronicity for acute NSNP patients.

A critical role of the advanced practitioner is to act as a shepherd for the profession, keeping a strategic eye toward the future and preparing for it as technologies emerge, society evolves, and the evidentiary basis of the profession matures. To that end, this session is a look into the future of OMPT education, exploring the intersection of technologies like AI, traditional manual therapy education, person-centered care, health justice, and educational standards. A brief lecture will give way to a guided panel discussion with members of the research community, futurists, and individuals from the IFOMPT standards committee.

This one hour interactive / participatory presentation will allow the participants to get a first-hand working knowledge of how to use motivational interviewing (MI) with their patients. There will be three (3) specific “real play” interactive sessions where the participants in this workshop will pair-up with another participant and practice interviewing and being interviewed about real-life issues.

The concepts and skills discussed and practiced in this session will be as follows:

1. Present the four basic elements of MI. Discussion (5 min.)
a. MI Spirit
b. OARS
c. Change Talk
d. MI Principles

2. Practice the Spirit of MI through “real play” scenarios of participants. (15 min.)
a. This practice session will help each participant to become more collaborative in their interviewing skills within their own style.
b. Learning how to evoke change within or patients’ sessions will be performed.
c. Allowing autonomy in the decision-making process will be studied.

3. Demonstration and practice “real play” the concept of OARS + 1. (15 min.)
a. Open-ended questions
b. Affirmations about the patients’ abilities, strengths, and efforts
c. Reflections
d. Summarize the big picture & highlighting the change talk.

4. Demonstrate and practice “real play” the skills of evoking Change Talk. (15 min.)
a. Engaging techniques taught
b. Focus through negotiating the agenda.
c. Evoking by assessing the patient’s readiness to make a change.
d. Planning by asking about “next steps”

5. Summarize and offering advice for your patients. Discussion (5 min.)
a. +1 is offering up advise and planning for the next session.

6. Principles of MI. Discussion (5 min)
a. R – Resist the righting reflex
b. U – Understand your patient’s motivation
c. L – Listen to your patient
d. E – Empower your patient

This one-hour session is dedicated to empowering early career researchers in the manual therapy and musculoskeletal (MSK) community. This panel discussion, led by experienced researchers, offers insights and practical advice for developing a research career while balancing person life, clinical practice, and teaching. The panellists will share their journeys, highlighting key strategies for success and common pitfalls to avoid in academic and research careers. This interactive session encourages questions and open dialogue, ensuring participants leave with clear guidance and inspiration to advance their careers.

Background: Bone fractures generate high healthcare costs and are one of the leading causes of disability worldwide. According to data from the 2019 Global Burden Disease Study, fractures are among the musculoskeletal conditions that require the most rehabilitation worldwide. Evidence-based practice (EBP) is the recommended approach to ensuring quality and consistency of care. However, studies on physiotherapeutic fracture treatment seem scarce and lack better methodological quality.

Purpose: To analyse the profile of fracture studies indexed on the PEDro platform regarding study designs, investigated body segments, publication decade, and geographical distribution.

Methods: Two researchers independently analysed studies indexed on the PEDro platform using the term "fracture" associated with the filters "musculoskeletal" and "orthopaedics." Studies with unavailable abstract or whole article, even when searched on other platforms, and studies not focusing on fractures as their central theme were excluded. Studies were categorised by body segments: spine, shoulder, humerus shaft, elbow, radius and ulna shaft, wrist and hand, hip, femur shaft, knee, tibia shaft, ankle and foot, elderly/fragility, and general fractures. The studies were analysed concerning their designs, investigated body segments, publication decade, the continent of publication of the clinical trials (CT), and the average PEDro score.

Results: 699 articles were selected for analysis, and 617 were included. The majority were found under the "orthopaedics" filter (597), accounting for 19.56% of studies in this filter. The remaining studies were found under the "musculoskeletal" filter (62), accounting for 0.65% of publications in this filter. Studies on lower limbs were more common (317), with a focus on hip fractures (221), followed by ankle and foot (60), tibia shaft (22), femur shaft (8), and knee (6). For the upper limb, a total of 193 articles were selected, including wrist and fingers (143), shoulder (37), elbow (10), radius and ulna shaft (3), and humerus shaft (0). The remaining articles (107) were allocated to general fractures (42), elderly/fragility(33), and spine (32). Clinical trial production was concentrated in European (232), Asian (95), North American (93), and Oceanian (51) continents, with fewer studies in South American (5), Central American (2), and African (0) continents. The CT´s average score on the PEDro scale was 4.8. There were many studies, peaking in the 2011-2020 decade.

Conclusion: Fracture studies indexed on the PEDro platform represent a small amount related to the analysed filters. Most segments lack clinical practice guidelines; some do not have systematic reviews or clinical trials. Additionally, they have an average methodological quality below five points on the PEDro scale. There is a geographic disparity in scientific production, led by continents with developed countries such as Europe, Asia (China and Japan), North America, and Oceania. This is also reflected in the studied segments, which mainly cover the hip and wrist, the most recurrent fractures in these countries.

Implications: These results highlight clinical physiotherapists' barriers in practising evidence-based treatment for patients after fractures.

Background: A positive therapeutic alliance between patients and their primary health care professionals (PHCP) is associated with improved health outcomes in musculoskeletal conditions including low back pain and whiplash. An important component of therapeutic alliance is patients’ perceived trust in their PHCP, where trust is thought to be related to perceptions of both competence and warmth. Measures of therapeutic alliance are usually administered after care has been provided but impressions of trust have been found in medical professionals to be formed early in the interaction. Factors influencing early impressions of trust may not only be related to the interpersonal skills of the PHCP but also the profession of the PHCP and their perceived level of expertise. However, early impressions of trust have not been evaluated in allied health professionals. Whether there is an association between early impressions of trust, therapeutic alliance and health outcomes for people with musculoskeletal conditions is unknown.
Purpose: (i) Determine the relationship between early impressions of trust and patient health outcomes and therapeutic alliance at 3 months. (ii) Explore factors associated with primary health care professional trustworthiness such as profession and expertise.
Methods: Prospective-cohort study embedded in a multi-centre randomized controlled trial investigating pathways of care for people with musculoskeletal conditions. Participants presenting with low back pain, neck pain and knee osteoarthritis within 4 weeks of seeking care were eligible. Participants completed baseline questionnaires (demographics, clinical, pain, disability and psychological measures). They then rated early impressions of trust with their nominated PHCP, on a 7-point Likert scale which included constructs of competence and warmth. Participants were randomized to receive care as usual from their PHCP or, to a clinical pathway that included care from their PHCP plus a specialist musculoskeletal health professional (SHCP). At 3-months they completed pain-related disability (Neck Disability Index (NDI), Oswestry Disability Index (ODI) and WOMAC) and therapeutic alliance outcomes and re-rated impressions of trust with their PHCP (and SHCP if relevant). Associations between early trust, 3-month trust and therapeutic alliance were assessed using Spearman's correlation coefficient. Multiple regression models were used to determine if trust provided an additional benefit to predicting health outcomes than known predictors. Kruskal-Wallis H test was used to compare mean-ranked trust scores between professions and between PHCP and SHCPs.
Results: 766 people with MSK conditions (LBP n=331, NP n =171, KOA n=264) participated. Early trust predicted therapeutic alliance (Adjusted R2=0.19, p < 0.001**) and pain-related disability at 3 months (Adjusted R2=0.01, p=0.003). Perceptions of PHCP trustworthiness were significantly higher for allied health professionals (AHPs) compared with medical professionals (MPs) (χ2(2) = 8.609 p = 0.003). There was no difference between perceptions of trust between specialist and primary health care professionals.
Conclusion: Early impressions of PHCP trustworthiness predict disability and therapeutic alliance at 3 months. AHPs demonstrate higher trust scores than MPs.
Implications:
1.Clinicians should consider that their early interactions with patients impact their perceived trustworthiness and patient health outcomes. 2.Researchers could use simple measures of trust instead of traditional longer questionnaires to measure this construct.

Background: The Disabilities of the Arm, Shoulder and Hand (DASH) and its shortened version (QuickDASH) are two patient-related outcome measures (PROMs) widely used for the assessment of individuals with musculoskeletal disorders of the upper limb (UL). These measures have been extensively studied and translated into multiple languages, making them suitable for use across diagnoses and practice settings in subjects with any or several musculoskeletal disorders. Interpreting PROMs requires understanding whether changes in patients' scores represent trivial, small but important, moderate, or large changes, i.e., assigning qualitative meaning to quantitative scores. To interpret the scores, the most informative index is the minimal clinically important difference (MCID), which represents the smallest difference in score that informed patients perceive as necessary, either beneficial or harmful. Interpretation of change scores for DASH and QuickDASH has become problematic given the increasing number of published -and sometimes conflicting- MCID estimates. Therefore, there is a growing need for guidance in identifying the optimal MCID ranges for DASH and QuickDASH.
Purpose: To perform a systematic review and meta-analysis of the MCID ranges of DASH and QuickDASH.
Methods: MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, Cochrane Library, and Scopus databases were searched up to June 2022. Studies on subjects with upper limb musculoskeletal disorders that calculated MCID by anchor-based methods were included. Descriptive and quantitative synthesis was used for MCID and minimal detectable change (MDC). Fixed and random effect models were used for the meta-analysis. I2 statistics was computed to assess heterogeneity. Risk of bias of studies was assessed with the Bohannon & Glenney and COSMIN checklists for MCID and MDC, respectively.
Results: Out of 7,734 retrieved articles, 12 studies (n=1,677) were included, producing 17 MCID estimates ranging from 8.3 to 18.0 DASH points and 8.0 to 18.1 QuickDASH points. The pooled MCIDs were 11.00 DASH points (95% CI=8.59-13.41; I2=0%) and 11.97 QuickDASH points (95% CI=9.60-14.33; I2=0%). The pooled MDC90 were 9.04 DASH points (95% CI=6.46-11.62; I2=0%) and 9.03 QuickDASH points (95% CI=6.36-11.71; I2=18%). Great heterogeneity was identified among the primary studies along with important methodological problems in the calculation of MCID and MDC. 

Conclusions: A reasonable MCID range of 12 to 14 DASH points and 12 to 15 QuickDASH points was established. The lower boundaries represent the first available measure above the 95%CI of pooled MDC90, while the upper limits represent the upper 95%CI of the pooled MCID. In future researches, it will be necessary to establish shared rules in the calculation of MCID to reduce methodological heterogeneity and make the results of primary studies more comparable.
Implications: The thresholds proposed in this study will enhance the use of DASH and QuickDASH in clinical practice, guiding decision-making in individuals with UL disorders, and facilitate more precise sample selection and interpretation of research findings.

Background
The presence of spatiotemporal alterations in the cervical muscles of patients with chronic neck pain, assessed by surface electromyography, during postural perturbations is well established in the literature. However, to the best of authors´ knowledge, no study has analysed cervical kinematics motor behaviour during such perturbations in any type of patient. Furthermore, it has not been analysed so far whether there are differences depending on the speed of reaction of upper limb movements.
Purpose
To compare neck kinematic analysis in the sagittal plane between patients with chronic whiplash and healthy subjects at two different neck postural perturbation paradigms: 1) maximum speed reaction of the upper limbs and 2) slow voluntary arms reaction movement.
Methods
A cross-sectional study design was carried out. Neck kinematics of eighteen chronic whiplash patients (31.11±6.44 years; 11 males) were compared to eighteen healthy subjects (36.44±8.03 years; 11 males) at two different neck postural perturbation paradigms.
An 8 optoelectronic Smart-DX system (BTS BioEngeneering. Milán, Italy) was used for 3D motion capture. The data were collected and processed using the software Smart Clinic (BTS BioEngeneering. Milán, Italy).
To analyse the association between a dichotomous independent variable and a parametrically distributed quantitative dependent variable, the Student's t-test (for independent samples) and the pairwise Student's t-test (for dependent samples) were used. Effect sizes (Cohen's d) were calculated for statistically significant results, considering 0.20-0.49, 0.50-0.79 and ≥0.80 as small, medium and large effect sizes, respectively.
Results
Maximum speed reaction paradigm: healthy controls had an extension mean range of 8.07° (±4.64), while the patients had a range of motion of 13.04° (±7.19). These differences were statistically significant (p=0.01), with a large effect size of d=0.82 (95% CI: 0.13-1.5).
Slow voluntary arms movement paradigm: healthy controls had an extension mean range of motion of 7.87° (±4.21), while patients had a path of 13.2° (±8.05). These differences were statistically significant (p=0.02), with a large effect size of d=0.83 (95% CI: 0.14-1.5).
There was no significant difference between both paradigms in neck kinematics in both controls (p=0.64) and patients (p=0.74).
Conclusion
Patients with chronic whiplash showed significantly greater extension range of motion compared to healthy subjects when exposed to postural perturbations requiring neck stabilisation, regardless of reaction and movement speed.
Implications
The results of this study show that patients with chronic whiplash have postural control or neck stabilization disorders. They have difficulty keeping their head in a stable position when moving their arms, regardless of their speed reaction and velocity. We suggest future studies including motor learning exercise programs at different speeds reaction (upper limbs coordination).

Background: Vascular pathologies of the head and neck are rare but can present as musculoskeletal pain and dysfunction. The International Federation of Orthopedic Manipulative Physical Therapists (IFOMPT) Cervical Framework aims to support students and practitioners in safe assessment and management of the cervical spine considering potential for vascular pathology by enabling evidence-based clinical reasoning.

Purpose: To 1) explore influence of the Framework on clinical reasoning processes, 2) explore perceptions of the value of the Framework to inform clinical practice, 3) compare clinical reasoning and perceptions between postgraduate and entry-level physiotherapy students.

Methods: COnsolidated criteria for REporting Qualitative research informed design and reporting of this two-staged qualitative study. First, think-aloud methodology explored use of the Framework to inform clinical reasoning through two cervical spine cases. Second, semi-structured interviews explored perceptions of the value of the Framework. Participants were students enrolled in Advanced Health Care Practice (AHCP; Comprehensive Musculoskeletal Physiotherapy or Sport and Exercise Medicine Fields) or Master of Physical Therapy (MPT) Programs at Western University, Canada. Students learned about the Framework though standardized delivery. Coding and analysis of transcripts was guided by Elstein’s diagnostic reasoning components (think-aloud), Postgraduate Musculoskeletal Physiotherapy Practice Model (think-aloud, semi-structured), and the four pillars of practice (semi-structured). One researcher coded transcripts. A second researcher challenged codes to enhance trustworthiness.

Results: For AHCP (n=8) and MPT (n=10) students, clinical reasoning processes reflected a novice expert continuum, using primarily hypothetico-deductive processes. The Framework informed hypothesis generation in the clinical history and selection of physical examination tests to evaluate potential for a vascular hypothesis. AHCP students demonstrated greater specificity in clinical history questions, focus and prioritization in the physical examination, to inform clarity and support for diagnosis and management. The clinical history section of the Framework held the greatest value informing assessment of the cervical spine for potential of vascular pathologies. For AHCP students, the Framework supported practice across all four pillars, with focus on the clinical practice pillar. Advanced use of knowledge from the Framework supported development of AHCP students’ personal characteristics (e.g., confidence) and aided a high level of clinical reasoning. For MPT students, value and use of the Framework was superficial and limited in scope.

Conclusion(s): The Framework supported clinical reasoning processes, knowledge and personal characteristics in postgraduate and entry-level physiotherapy students, while illustrating differences according to level of practice. The clinical history section of the Framework held the greatest value for all students, supporting identification of clinical history features to generate and evaluate a vascular hypothesis. Postgraduate students had deep knowledge of all sections of the Framework to support a broad range of personal characteristics which enabled high level clinical reasoning for diagnosis and management.

Implications: The Framework is a valuable physiotherapy educational resource to aid safe assessment and management of cervical spine presentations considering potential for vascular pathology. Results support using the Framework in physiotherapy educational curricula to support safe and effective clinical reasoning, enabling students to move along the novice expert continuum. Different approaches are required in educational delivery according to level of practice.

Objectives: This study aimed to (1) investigate physiotherapists’ awareness and use of red flags for individuals with low back pain (LBP) in Saudi Arabia, and (2) identify factors that might be associated with their awareness and use of LBP red flags.
Design: A cross-sectional study.
Setting: Data were collected using an anonymous online questionnaire between December 2022 and March 2023.
Participants: Physiotherapists working in private and public hospitals in Saudi Arabia were included.
Results: A total of 643 participating physiotherapists (26.2 ± 3.8 years) completed the survey; 63.8% were females. Most physiotherapists (94.4%) had adequate awareness and few had fair awareness (5.6%) towards LBP red flags. Although more than half of physiotherapists (61%) had good utilization of red flags when assessing individuals with LBP, some (39%) had poor utilization of LBP red flags. Physiotherapists who had a previous training in the use of red flags for LBP assessment were more likely to have a better awareness towards LBP red flags and use them in practice than those who had no previous training. There was a positive correlation between physiotherapists’ awareness and use of LBP red flags.
Conclusions: Most physiotherapists in Saudi Arabia were aware about LBP red flags and many reported to have good use of red flags in clinical practice when assessing individuals with LBP. Although most physiotherapists had adequate awareness towards LBP red flags, some of them did not use red flags for LBP assessment in clinical practice. Physiotherapists are recommended to engage in training courses regarding the documentation and use of red flags for the management of individuals with LBP as current results showed more use of red flags in practice for those who had previous training.

Learning objectives :
1. Understand beliefs about back pain, how these influence pain, movement and recovery, and ways in which these can be influenced.
2. Understand psychological and sensorimotor mechanisms through which fear and avoidance can be managed clinically
3. Understand how treatment can be adapted to support an individual to reduce their fear of movement and build their engagement in movement and activity.

General description
Low back pain (LBP) is a major global health problem with multidimensional contributing factors. Unhelpful beliefs, pain-related fear and movement avoidance have been shown to be important drivers of pain and disability in patients with LBP. Exercise-based or exposure-based interventions, together with education, have been recommended for the management of LBP and to target beliefs, pain-related fear and movement avoidance. Yet, their effects on pain and disability are only small to moderate. Recent evidence suggested that considering the interrelations between affective, cognitive and sensorimotor factors is critical to improve the care of people with LBP. Understanding and exploring individual differences in these domains is central to developing a person-centred management plan. These recent theoretical advances have brought new insights into assessment and management principles to develop beliefs that support recovery and reduce pain-related fear, and build engagement in movement and activity in patients with LBP.

Understanding and influencing beliefs about low back pain:
This section will summarise beliefs about LBP common in communities around the world and ways in which these are reinforced and perpetuated. It will discuss how patient beliefs can be explored in clinical settings through actively engaging with the person’s story. It will highlight the importance of understanding beliefs, and the evidence on which these are based, to enable the provision of effective and meaningful reassurance. It will conclude with consideration of opportunities to gather additional evidence as a mechanism to help co-construct beliefs that support recovery.

The role of spinal motor behaviour alterations in patients with low back pain:
This section will first present evidence from the biomechanical field supporting an avoidance behaviour of spinal movement in patients with LBP. It will also discuss the relationships between spinal movement avoidance, psychological factors, pain and disability. Finally, it will review evidence discussing the role of targeting spinal motor behaviour in LBP rehabilitation to summarize key rehabilitation principles for clinical practice.

Understanding discrepancies in a person's fear of movement and avoidance behaviour:
This section will focus on how to reconcile discrepancies in fear of movement and avoidance behaviour observed in the same person with LBP, and how physiotherapy management can be adapted accordingly. Aspects of fear of movement and avoidance behaviour will be discussed considering relevant theoretical models. Exposure-based therapy, as an effective treatment for patients with fear of movement and avoidance behaviour, is discussed based on the latest insights on exposure-in-vivo in general anxiety literature, and participants are guided in how to translate these insights into exposure-based treatments for persons with avoidance behaviour and related musculoskeletal pain.

Reasoning and application of interventions targeting sensorimotor, affective and cognitive mechanisms in people with low back pain:
This section will present contemporary evidence for the beneficial effects of interventions that jointly target sensorimotor, affective and cognitive mechanisms. The practical application of these interventions will be discussed, with opportunity for audience contribution. The discussion will draw on principles presented earlier in the session, and the model that underpins one of the interventions co-developed by the presenter. A secondary focus will be on practical application of clinical techniques to assess and modulate nervous system function, given emergent evidence indicates these are an important element of the contemporary interventions aforementioned.

Implications/conclusions :
Based on recent evidence from multiple perspectives, this Focused Symposia will provide musculoskeletal clinicians evidenced-based information on the management of beliefs, pain-related fear and movement avoidance in patients with LBP. It will help bridge the gap between affective, cognitive and sensorimotor domains. Guidance will be presented to develop a person-centred assessment of the patient, including actively engaging with the person’s story, using appropriate questionnaires and completing behavioural and neurophysiologic assessments. Moreover, rehabilitation principles will be described to jointly target sensorimotor, affective and cognitive mechanisms to optimize care for people with LBP.

References:
Bagg 2022 doi:10.1001/jama.2022.9930
Wand 2023 doi: 10.1093/ptj/pzac151
Darlow 2013 doi: 10.1370/afm.1518
Hasenbring 2015 doi: 10.1097/AJP.0000000000000097
Bunzli 2017 doi:10.2519/jospt.2017.7434
De Baets 2023 doi: 10.2519/jospt.2023.
Christe 2021 doi: 10.1097/j.pain.0000000000002065
Christe 2023 doi: 10.1111/papr.13191

Background:
Musculoskeletal (MSK) ill-health is the greatest socioeconomic burden for the World’s healthcare systems to manage. Established in ancient history, manual therapy uses a hands-on approach (hereon in referred to as HODA-A, hands-on data acquisition and analysis) provides a safe, affordable, and environmentally convenient assessment and treatment of a person’s MSK system. HODA-A is used to palpate characteristics of a person’s anatomy, becoming the measurement instrument that underpins the majority of MSK investigations conducted by MSK professionals in both MSK medicine (theory, research, and practice) and MSK clinical practice, often a prerequisite that informs a person’s care in many healthcare disciplines.

Purpose:
The existing evidence-based research investigating HODA-A, or studies that have used HODA-A as part of the methodology, are flawed because HODA-A lacks the necessary developmental studies to determine its validity as a measurement instrument. For more than 70 years the evidence-based research has focused on reliability studies of HODA-A, concluding it is clinically unacceptable as a measurement instrument - further fuelling the hands-on/hands-off debate. However, according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) Risk of Bias (RoB) standards, validity studies must precede reliability studies on all proposed measurement instruments. Therefore, to conduct reliability studies without the necessary ‘first-step’ validity studies on HODA-A constitutes a methodological flaw, is a waste of resources and unethical. Worryingly, within the next 10 years, it is predicted an estimated 250 papers per annum will be published on HODA-A with the same fatal methodological flaws.

Methods:
Initially, a literature review exploring centuries of neurophysiological research, studying how to replicate the human hand for prosthesis and robotics sciences, provided strong evidence detailing five phases that occur when a person is tasked to interpret their active touch. This information supported a later phenomenographic study using sixteen international expert panellists to explore the Scientific Evaluation and Review of Claims in Health Care (SEaRCH™) of HODA-A when used as a measurement instrument in MSK healthcare. The information gained from these extensive studies was evaluated using the COSMIN RoB standards.

Results:
HODA-A uses eight constructs with associated items to conduct manual MSK assessments on a person, and HODA-A requires a complex system approach to understanding the relationships between the eight constructs and items underpinning HODA-A performance.

Conclusion(s):
For the first time in history HODA-A has been exposed to validity testing, offering substantial insights into the necessary measurement theories and conceptual framework needed for HODA-A to be used as a valid measurement instrument in MSK healthcare. Further research exposing HODA-A to COSMIN RoB standards continued.

Implications:
Reliability studies on HODA-A should only be conducted if the methodology of how HODA-A was applied met all the COSMIN RoB standards.

Background:
Spinal conditions are prevalent causes of pain and disability worldwide. Gaining insight into the comparative effectiveness of manual therapy interventions with alternative treatments can enlighten patients and healthcare professionals regarding the most suitable methods for effectively managing these conditions.

Purpose:
The purpose of this umbrella review was to summarize, synthesize, and integrate the evidence evaluating the effectiveness of manual therapy intervention(s) with other interventions for the treatment of different spinal conditions.

Methods:
This is an umbrella review of systematic reviews. We have searched seven databases (CINAHL, Cochrane, EMBASE, Epistemonikos, Medline (PubMed), SCOPUS, and Web of Science) and obtained systematic reviews that compare spinal manual therapy alone (mobilization, manipulation, and manual traction) with control, no treatment, or sham treatment. A pair of reviewers assessed the quality of the systematic reviews using A Measurement Tool to Assess Systematic Reviews (AMSTAR 2) tool. We extracted data related to study characteristics and the effectiveness of spinal manual therapy, categorizing by treatment technique, outcome measures, and condition. The corrected covered area (CCA) index had been calculated to identify duplicating randomized controlled trials.

Results:
A total of 3,918 citations were identified. We screened in 2,146 citations after removing duplication. 179 articles were reviewed in full text screening phase. In total, 21 systematic reviews met our eligibility criteria. The quality of the included systematic reviews was rated mainly as critically low (n = 14) or low (n = 6), while only one study was of high quality. Although manipulation may provide short-term relief for acute and chronic low back pain, its impact on functional improvement is uncertain. Similarly, the short-term effects of manipulation on pain levels in acute and chronic neck pain remain uncertain. Limited evidence exists comparing mobilization alone to other interventions, and the effects of manipulation and mobilization on pain and function are inconsistent. The CCA index was 3.97%, indicating a low overlapping of the included reviews.

Conclusion(s):
Due to the low-quality nature of the systematic reviews and meta-analyses included in this study, the findings should be interpreted with caution. No definitive recommendation can be made for the effectiveness of spinal manual therapy. Higher-quality systematic reviews and randomized controlled trials are needed to further support the use of spinal manual therapy in spinal pain conditions.

Implications:
These findings emphasize the need for caution in interpreting the effectiveness of spinal manual therapy due to the low-quality evidence available. As such, healthcare professionals should approach the use of manual therapy in managing spinal pain with careful consideration and individualized decision-making. The future implementation of higher-quality systematic reviews and randomized controlled trials is crucial to providing more robust evidence to support or refute the use of spinal manual therapy for spinal pain conditions.

Background: Spinal and peripheral joint manipulation (MAN) and mobilization (MOB) are clinically recommended interventions for the treatment of musculoskeletal conditions. Although adverse events (AE) have been reported following these interventions, there is considerable heterogeneity in the terms, definitions and classification systems used to describe such AEs. A universally accepted definition and classification system has not yet been established. Recording and reporting of such events to improve patient safety is dependant on having standardised terminology.

Purpose: To establish an inter-professional and international standardized definition and severity classification for AE following MAN and MOB for adults with musculoskeletal conditions.

Methods: This sequential mixed-methods study included an electronic Delphi process (e-Delphi) with a published protocol followed by virtual focus groups. Inter-professional and international expert stakeholders were invited to participate. Participants included international and multidisciplinary MAN and MOB practitioners, educators and researchers, patients, medical doctors, regulators and medico-legal representatives. The e-Delphi process comprised 3 rounds: round 1 included open-ended questions on participants’ working definition and severity classification of AE; in round 2, participants rated their level of agreement with statements generated from round 1 and a previous scoping review of the literature; and in round 3, participants re-rated their agreement with statements achieving consensus in round 2. Focus groups were conducted with e-Delphi participants to further explore e-Delphi findings. Quantitative data were analysed descriptively to evaluate consensus (defined a priori) and qualitative data were analyzed using a theoretical thematic analysis.

Results: E-Delphi rounds 1, 2 and 3 had 183 (response rate: 85%), 163 (77%), and 153 (73%) respondents respectively, representing most continents and 9 expert stakeholder groups. Consensus was reached for severity categories (i.e., mild, moderate, severe and catastrophic) and on 2 domains to differentiate these categories (i.e., symptom intensity and impact on patients). Consensus was not reached for a standardized AE definition. Focus group discussions centered on acceptability and inclusion of "unfavourable”, “unexpected” and “undesired” terms in the AE definition and differences between “serious” and “catastrophic” severity classification categories.

Conclusion: A standardized severity classification was established with detailed descriptors for each category. The lack of consensus on a standardized definition for AE demonstrates the complexity of this topic. Findings may contribute to advancing patient safety and AE knowledge across professions through implementation of a common classification system.

Implications: The here-established severity classification facilitates and streamlines inter-professional and international dialogue regarding the reporting of AE following MAN and MOB in clinical practice and research. A universally accepted classification and common language enhances inter-profession collaboration, precision and accuracy in recording and reporting adverse events in research and clinical practice.

Background
Treatment fidelity (TF) is the degree to which interventions adhere to a planned protocol. Its 5 domains include treatment design, provider training, treatment delivery, treatment receipt and treatment enactment. Higher treatment fidelity increases the statistical power of results as well as internal and external validity. Orthopedic manual therapy (OMT) studies would benefit from a validated treatment fidelity tool that improves research design and patient outcomes.

Purpose
The objective of this study was to validate an OMT TF tool using a Delphi method. TF has been lacking and has yet to be fully acknowledged or successfully addressed in OMT research. Despite the adoption of numerous checklists to help guide researchers (TIDieR, Consort, PRISMA) there remains a need for improvement of OMT research quality.

Methods
After IRB approval, a two-phase sequential Delphi method was used to determine the validity of specific criteria important to high quality OMT research. The Delphi approach involved obtaining consensus from a group of 20 experts across 8 countries using a series of surveys which incorporated controlled feedback.

Results
The criteria that did not meet a 75% agreement after the first round were disregarded. Criteria that met the inclusion of 75% agreement after the second round were included in the tool. The response rate was 100% in round 1 and 91% percent in round 2. Agreement included 13 criteria in the 5 TF domains.

Conclusions
We completed a Delphi study to determine the appropriate criteria for a TF tool to enhance OMT research. Use of this tool by researchers will lead to improved TF and clinical validity of OMT techniques.

Implications
Higher TF increases the confidence that the outcome of interest is correlated to the OMT intervention performed. Using this tool may improve TF leading to higher quality OMT studies with more reliable results and potentially more efficient and effective clinical OMT interventions and improved patient outcomes.

Background:
Spinal manipulative therapy with an impulse of high velocity and low amplitude (HVLA-SMT) is clinically effective, most probably via an interplay between neurophysiological and biomechanical mechanisms. Previous systematic reviews reported positive effects for cervical and thoracic HVLA-SMT on cervical range of motion (ROM), but no systematic review focused on other biomechanical effects, apart from ROM. Furthermore, information on a possible link between the effects of HVLA-SMT and the purported clinical benefits is missing.

Purpose:
The aim of this systematic review was to assess the level of knowledge on the biomechanical effects of spinal HVLA-SMT in asymptomatic and symptomatic humans, as well as on the possible link between biomechanical effects and clinical effectiveness.

Methods:
A professional information specialist conducted a systematic literature in six databases (Medline (OvidSP), Premedline (PubMed), CINAHL, EMBASE, Cochrane, and Biosis). Two authors selected the studies according to predefined criteria (only randomized controlled trials included) and classified them into ‘low risk’, ‘some concerns’ or ‘high risk’ using the revised Cochrane risk-of-bias tool for randomized trials (RoB 2). Studies with high risk of bias (N=10) were excluded from the narrative synthesis.

Results:
The 33 included studies were heterogeneous in terms of participant characteristics, intervention and outcomes. The majority (27/33) reported on the effects of HVLA-SMT on spinal ROM. Evidence points towards an effect of thoracic HVLA-SMT on cervical range of motion (ROM) (all eight studies with a positive effect) and of cervical HVLA-SMT on cervical ROM (nine studies with a positive and six studies with no effect), while the effect on the respective ROM was less clear for lumbar (one large study reporting an effect, one small study reporting no effect) and thoracic (two studies with conflicting results) HVLA-SMT. The four studies on facet joint gapping (all conducted by the same research group) showed some effect of HVLA-SMT compared to side-posture positioning, and the single study on stiffness showed no effect of HVLA-SMT. Only a single study linked the biomechanical outcomes to pain or disability measures.

Conclusion(s):
HVLA-SMT, either applied to the cervical or the thoracic spine, appears to have a positive effect on cervical ROM. For all other outcomes, the included studies were too heterogeneous and too few for any sound conclusion. Future studies on biomechanical effects of HVLA-SMT should link the biomechanical to clinical outcomes such as pain and disability..

Implications:
HVLA-SMT either to the cervical or thoracic spine is an evidence-based tool to improve cervical range of motion. However, whether HVLA-SMT it leads to enhanced clinical outcome, such as reduction in pain and disability, is not clear.

Background:
Clinical guidelines recommend spinal manipulative therapy (SMT) as a treatment for spinal pain. Traditionally, SMT involves applying a specific thrust technique to a spinal target. However, previous systematic reviews of SMT suggest that the target site may not be significant for clinical outcomes. In addition, although there are multiple systematic reviews regarding SMT, none have examined whether the overall impact depends on the application procedures, such as where (the target) and how (the thrust) it is delivered.
Purpose:
We conducted a systematic review and network meta-analysis to identify the most effective SMT application procedures for reducing short-term pain and disability in patients with spinal pain. We compared a range of SMT interventions directly and indirectly with other guideline-recommended treatments and controls.
Methods:
Relevant RCTs comparing SMT to no-treatment controls, SMT sham, recommended and non-recommended therapies, or other types of SMT were identified through three search strategies: i) systematic, ii) explorative, and iii) known sources. Pairs of reviewers independently screened titles, abstracts, and full texts, extracted data, and assessed risk of bias using the revised Cochrane Risk of Bias Tool (ROB2). We conducted a frequentist network meta-analysis for the application site (e.g., symptomatic vs. non-symptomatic region) and the site rationale (e.g., clinician-selected vs. generic)
Results:
We included 151 trials (11,388 participants), with 84% rated high within-study risk of bias. Most SMT procedures were comparable to other recommended therapies and were slightly better than controls. However, inter-SMT procedure effects were small and statistically insignificant. Non-specific thrusts and generic targets provided the largest effects. Networks were consistent, with ~10% of direct comparisons showing inconsistency. Comparisons were based on low/very low confidence.
Conclusion:
Our findings suggest that a non-specific SMT approach may provide the largest effects for spinal pain and disability, albeit with minor differences compared to specific SMT approaches.
Implications:
We find ourselves amid a paradigm shift in how we understand SMT applications. Despite prior beliefs, clinicians should not concern themselves with specific thrust procedures or precise targets, as the clinical effects of SMT appear similar across these parameters. Consequently, clinicians should select SMT procedures factoring in patient and clinician safety, comfort, preferences, and body characteristics.
We encourage educational settings to de-emphasize teaching of target site specificity and specific techniques. Instead, we encourage students to explore different techniques in a safe environment while emphasizing psychomotor skills to facilitate safe and comfortable delivery of SMT.

Background
Manipulations or mobilizations are commonly used interventions in patients with mechanical neck pain. The treatment effects have often been studied in randomized controlled trials (RCT) which are generally considered the gold standard in evaluating the treatment effects, mainly due to its high internal validity. External validity is defined as the extent to which the effects can be generalised to clinical practice. An important prerequisite for this is that interventions used in clinical trials can be replicated in clinical practice. It can be questioned if interventions utilized in randomized controlled trials can be translated into clinical practice.

Objectives
The overall aim of this study is to examine whether the quality of the description of manipulation and mobilization interventions is sufficient for to replication of these interventions in clinical practice.

Methods: A comprehensive literature search was performed. Two independent researchers used the Template for Intervention Description and Replication (TIDieR) which is a 12-item checklist for describing the completeness of the interventions.

Results:
Sixty-seven articles were included that used manipulation and/ or mobilization interventions for patients with mechanical neck pain. None of the articles describe the intervention e.g. all the items on the TIDieR list. Considering item 8 (a-f) of the TIDieR checklist only one article described the intervention completely.

Conclusion:
Manipulation or a mobilization interventions are poorly reported in RCTs, which jeopardize the external validity of RCTs, making it difficult for clinicians and researchers to replicate these interventions.

Background: Low back pain (LBP), associated with spine, pelvis, and hip mobility impairments, can be caused by tight muscle contractions to protect sensitized tissues. Fascia tissue manipulations like myofascial release, soft tissue mobilizations, and elastic tape application are used to treat lumbar fasciae in LBP. The effect of fascia tissue manipulations through lumbodorsal skin displacement (SKD) on mobility is inconclusive, likely depending on the location and displacement direction of the manipulation. To indicate whether or not a patient would benefit from fascia tissue manipulations, a fascial diagnostic test procedure has been proposed (i.e., The Dynamic ArthroMyofascial Translation® Test). Although changes in joint mobility through SKD seem to be clinically effective, the basal effects of SKD on healthy subjects have not been objectively tested.

Purpose: This study aimed to assess whether lumbodorsal SKD affects the flexion and extension range of motion (ROM) in healthy subjects. Furthermore, the study tested the effect of SKD at different locations and directions. Finally, it assessed the intertester and intratester reliability of SKD.

Methods: Sixty-three healthy participants were randomly assigned to either the SKD or sham group. The SKD group was subjected to either mediolateral-directed SKD at the height of either L5 or L3 during a flexion or extension movement, while the sham group underwent displacement without SKD. The SKD was performed by two trained physiotherapists. Changes in range of motion (ROM) were assessed using motion capture to measure thoracic, lumbar, and hip angles, as well as finger-floor distance.

Results: Statistics indicated that flexion and extension ROM were affected by SKD (p < 0.05) and not by sham displacement. Flexion ROM decreased, whereas the extension ROM increased, depending on SKD location and displacement direction (p < 0.05). The ICC indicates good intertester and intratester reliability (ICC3, k = .81-.93; ICC3,1 = 0.70-0.84).

Conclusions: SKD at the lower back substantially affects the flexion and extension range of motion in the spine, pelvis, and hip. The effects of SKD are direction and location-dependent, as well as movement (flexion/extension) specific. Further research is warranted to gain insight into the mechanisms by which SKD affects the spine, pelvis, and hip range of motion, muscle activation, and force transmission in healthy, asymptomatic, and low back pain subjects.

Implications: SKD during flexion and extension may be useful to determine whether a patient would benefit from fascia tissue manipulations, which is an ongoing study at this moment. The ongoing study aims to ascertain if SKD affects the spine, pelvis, and hip range of motion, back muscle flexion relaxation, and relative tissue displacement (ultrasound speckle tracking) in LBP and matching healthy subjects. Preliminary results of these studies are expected to be presented.

Abstract:
Background
Manual therapy has been an approach in the management of patients with various disorders dating back to ancient times and continues to play a significant role in current health care.1 The meaning of manual therapy is widely varied, ranging from a hands-on technique, and a hands-on approach to a structured and skillful hands-on clinical management approach within a biopsychosocial framework.4 The future role of manual therapy in health care is an important area of research.1 Over the last decade, there has been an increased focus on and expansion of orthopedic manual physical therapy (OMPT) clinical practice and research.2 Along with this focus have come numerous research studies assessing the effectiveness of OMPT, a dramatic increase in the number of orthopedic residency and manual therapy fellowship programs, and an increased emphasis on OMPT in entry-level Physical Therapy academic programs.2 Orthopaedic manual therapy residence program has a positive influence on the residents’ ability to perform musculoskeletal examination and evaluation and to determine a treatment diagnosis.5 However, there are very few opportunities for long-term, comprehensive postgraduate clinical education in developing countries because of fiscal and human resource constraints.3 Therefore, physiotherapists have little opportunity to improve clinical reasoning and treatment skills.3


Rationale

We argue that Orthopaedic Manual Physiotherapy is one of the most important specializations in the physiotherapy profession for physiotherapists in low-resource settings with the potential to strengthen rehabilitation and support the healthcare system. However, very little is known about the development and advancement of Orthopaedic Manual Physiotherapy in low- and middle-income countries. There are questions about the implementation of Orthopaedic Manual physiotherapy in these countries including what does Orthopaedic manual therapy practice mean for low-resource settings? How are low-resourced Orthopaedic Manual Physiotherapy countries advancing their practice based on their local context (e.g., level of physiotherapy entry-to-practice education, availability of resources, and support from the healthcare system)? How can physiotherapists within low-resource countries support their healthcare system and strengthen rehabilitation by advancing their practice in different specialties?

Aims and Objectives
This debate/discussion aims to address these questions by providing practical examples of advancement in Orthopaedic Manual Physiotherapy practice in low-resource settings drawing on examples from Africa, Asia, and Parts of North America (the Caribbean). The specific objectives of this session are to:

1. Discuss what Orthopaedic Manual Physiotherapy practice means to countries with low resources and describe the importance of developing and advancing Orthopaedic Manual Physiotherapy practice as a specialization to strengthen physiotherapy and rehabilitation in developing countries.

2. Provide practical examples of how countries with low resources have developed and implemented Orthopaedic Manual Physiotherapy practice as a specialization to strengthen physiotherapy and rehabilitation within their countries with examples from Africa, Asia, and parts of North America (the Caribbean).

3. Stimulate discussion on the barriers, facilitators, and strategies for developing, implementing, and advancing Orthopaedic Manual Physiotherapy practice in developing countries and discuss the next steps.

Method
This session will use a combination of presentation and interactive discussion to engage with the audience. This Debate/discussion will present practical approaches to the implementation of OMPT practice in low-resource settings. This focused symposium will present important information that is currently not available in the literature and the practice of OMPT. The information will be additional valuable knowledge to OMPT practice.



Implications/conclusions
Orthopaedic Manual Physiotherapy practice is a specialization in the physiotherapy profession with the potential to strengthen physiotherapy and rehabilitation and improve healthcare systems in low-resource settings. This debate/discussion will enable the physiotherapy profession to better understand what Orthopaedic Manual Physiotherapy practice means in different contexts and the strategies for developing, implementing, and advancing OMPT in low-resource settings with examples from African, Asia, and parts of North American countries. The examples from this debate/discussion can be applied to many low-resource countries (the Caribbean) and have the potential to have a broader impact on the development, implementation, sustainability, and advancement of OMPT and on strengthening rehabilitation. The presentation and discussions from this session will be published in different formats (Conference publication and opinion paper). The outcome of the session will also lead to the formation of a team of researchers, clinicians, and physiotherapy leaders who will further design research projects to support OMPT in low-resource settings.

References
1. Manual Therapy: The Historical, Current, and Future Role in the Treatment of Pain A. Russell Smith, Jr. Department of Athletic Training and Physical Therapy, Brooks College of Health, University of North Florida, Jacksonville Received October 3, 2006; Revised December 11, 2006; Accepted December 11, 2006; Published February 2, 2007
2. Cristiana K. Collins, Michael Masaracchio & Jean-Michel Brismée (2017): The future of orthopedic manual therapy: what are we missing? Journal of Manual & Manipulative Therapy, DOI: 10.1080/10669817.2017.1358249
3. Shala Cunningham1, Richard Jackson2, Daniel Kangutu Muli3, McFelea4 The development of postgraduate Orthopaedic Manual Therapy Residency Program in Nairobi, Kenya: 1Department of Physical Therapy, Radford University, Roanoke, VA, United States2The Jackson Clinics Foundation, Inc., Middleburg, VA, United States3Department of Physiotherapy, Kenya Medical Training College, Nairobi, Kenya4Department of Physical Therapy, University of Evansville, Evansville, IN, United States. Published June, 2017
4. Chad E. Cook, Megan Donaldson & Elaine Lonnemann (2021) ‘Next steps’ for researching orthopedic manual therapy, Journal of Manual & Manipulative Therapy, 29:6, 333-336, DOI: 10.1080/10669817.2021.2008010
5. The Influence of an Orthopedic, Manual Therapy Residency Program on Improved Knowledge, Psychomotor Skills, and Clinical Reasoning in Nairobi, Kenya: Shala Cunningham1, Joni McFelea2 1Department of Physical Therapy, Radford University, Roanoke, VA, USA2Department of Physical Therapy, University of Evansville, Evansville, IN, USA. Published March, 2017

The purpose of this session for attendees is:
1. To consider multiple mechanisms and their interactions in persistent pain
2. To critically understand the difference between mechanistic descriptors and neurophysiological mechanisms (e.g., nociplastic pain vs sensitization)
3. To critically understand the background rationale, causation and prognosis regarding the association between different mechanisms and how this influences treatment options
Description
At the beginning of the session, Morten Hoegh will present the three mechanistic pain descriptors (nociceptive, neuropathic and nociplastic) and continue with a presentation of the neurophysiological mechanisms related to the central sensitization-phenomena (wind-up, classical central sensitization and long-term potentiation). Afterwards, he will discuss the overlap between mechanisms and descriptors.
Sean Gibbons will present persistent pain within the disease pathogenesis framework. He will discuss low grade systemic inflammation mechanisms, his research on how to identify immune dysregulation and strategies for subgrouping. He will also discuss the importance of addressing functional mechanisms in the clinical reasoning of intervention strategies. Following this he will highlight tissue mechanisms and how they may be influenced by immune dysregulation.
Susanne Becker will present results on factors that can induce endogenous pain modulation in humans, focusing specifically on the perception of reward, and related motivation and learning. In particular, she will present recent evidence highlighting the importance of these factors in the modulation of pain, including persistent pain. Recent research convincingly shows the relevance of reward processing as a pathogenetic factor in chronic pain. This presentation will discuss this evidence and link it to potential novel intervention strategies in patients with chronic pain.
Ashley Smith will present an overview of the evidence investigating both conservative and medical options to modulate the clinical features of central sensitization in a variety of chronic pain disorders. In particular, he will summarize his research investigating the role of nociception and its influence on various forms of endogenous analgesia. This presentation will also cover testing paradigms of central sensitization, including temporal summation, conditioned pain modulation and exercise induced hypoalgesia. Through a clinical reasoning framework, Ashley will provide a rationale for appropriately directing patient care, based on a patient’s pain modulation profile.
In the following discussion, the presenters together answer questions from the audience in a panel discussion format.
Implications/conclusions
Persistent pain involves multiple mechanisms. By understanding the mechanisms contributing to the persistent pain, physiotherapist could optimise treatment (e.g., lifestyle, manual therapy, therapeutic exercise, behavioral, education) and prognosis in various pain conditions. Effective recognition of the factors associated with this clinical presentation and the options available to modulate such allows physiotherapists to assist patients’ recovery trajectories.

Learning objective:
Upon completion of this focused symposium, attendees will have knowledge and tools aimed at including person-centered self-management support in OMPT practice.

Description
Musculoskeletal pain conditions are one of the leading contributors to disability worldwide. Orthopedic Manual Physical Therapy (OMPT) is a specialized area of physical therapy for the management of neuro-musculoskeletal conditions, based on clinical reasoning, using highly specific treatment approaches including manual techniques and therapeutic exercises (www.ifompt.org). Contemporary evidence suggests that musculoskeletal practice should incorporate a person-centered approach, including support to self-manage the condition (Lin et al., 2019; Caneiro et al., 2019; Lewis & O’Sullivan, 2018; Hutting et al., 2022-1, Hutting et al., 2022-2, Diener, 2021). Principles of person-centered care include 1) affording people dignity, compassion and respect; 2) offering coordinated care, support or treatment; 3) offering personalized care, support or treatment; and 4) supporting people to recognize and develop their own strengths and abilities to enable them to live an independent and fulfilling life (The Health Foundation, 2016).

Recently, a framework to support clinicians to deliver person-centered care in musculoskeletal was published. This framework consists of three overarching key principles: 1) a biopsychosocial understanding of the person’s experience; 2) person-focused communication; and 3) supported self-management (Hutting et al., 2022-2).

Physical therapists, including OMPT clinicians, are ideally positioned to support people with musculoskeletal conditions in their self-management, and this support is considered important and contributes to the management of musculoskeletal pain conditions (Hutting et al., 2019; Diener 2021). However, it has been reported that physical therapists do not always follow evidence based guidelines (Zadro et al., 2019) and experience difficulties with integrating patient-centered care principles and self-management support into their clinical practice (van den Heuvel et al., 2021; Hutting et al., 2020; Brunnekreef et al., 2022, Monk et al., 2023). Moreover, physical therapists lack confidence and ability in identifying psychosocial factors (Henning & Smith, 2023).

Self-management support is the help given to people that enables them to manage their health on a day-to-day basis. Self-management support can help and inspire people to learn more about their conditions and to take an active role in their health care (Agency for Healthcare Research and Quality, 2020). Self-management support should be provided as part of routine healthcare (Hopkins et al., 2022) and physical therapists should use a self-management approach to personalized treatment for patients with musculoskeletal pain conditions whenever possible (Hutting et al., 2019).

In the 2016 Educational Standards of the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT), patient-centered management, shared decision making and integrating biopsychosocial factors are important components (IFOMPT, 2016). The patient is recognized as an equal partner in their management and is encouraged to actively participate in their treatment and management (IFOMPT, 2016). This implies that, to provide contemporary OMPT, knowledge and skills about providing person-centered care (including a biopsychosocial understanding of the person’s experience, person-focused communication and supported self-management) is needed. Such an approach also complies with a recently proposed new evidence-guided framework for teaching and practice of OMPT. Within this framework, OMPT is based on three fundamental humanistic dimensions common in all aspects of healthcare: safety, comfort, and efficiency. These practical elements are contextualized by positive communication, a collaborative context, and person-centered care (Kerry et al., under review).

Therefore, contemporary knowledge about providing person-centered self-management support in OMPT practice will be provided in this focused symposium. The content of this focused symposium will be largely based on recent important publications about this topic (Hutting et al., 2019; Kongsted et al., 2021; Diener, 2021, Hutting et al., 2022-1, Hutting et al., 2022-2) supplemented with the latest available evidence.

In four linked presentations, evidence based practical recommendations to providing person-centered self-management support will be presented. Topics will include: a framework for delivering person-centered care in musculoskeletal practice, the current state of evidence of self-management for musculoskeletal pain conditions, characteristics of self-management support and suggestions for techniques to make this part of clinical practice, and recommendations to optimize communication and shared-decision making throughout the clinical interaction. Moreover, recently developed tools (e.g. the Self-Management Identification Tool and the Musculoskeletal Self-Management Questionnaire) will be discussed and clinical examples will be provided.

Implications/conclusions
Contemporary evidence suggests that person-centered self-management support should be a cornerstone of musculoskeletal practice, including OMPT. However, while many OMPT clinicians have invested time in developing their manual therapy skills, they may not have considered the adjunctive person-centered self-management support needed in their practice to optimize delivery, patient experience and outcome. Upon completion of this focused symposium, attendees will have knowledge and tools aimed at including person-centered self-management support in OMPT practice. This symposium will be interesting for clinicians, researchers and policymakers and will contribute to the practice of contemporary OMPT.

Background: Current evidence for cervical radiculopathy (CR) management has prioritised chronic CR, which creates a challenge for care of people with recent onset (less than 12 weeks) CR, presenting in primary care. Purpose: To investigate the effectiveness of conservative management available in primary care for adults with recent onset CR. Methods: We conducted a systematic review of randomised controlled trials investigating any conservative management involving adults with recent onset, single level CR of any aetiology, including one or more relevant outcome: pain, disability, overall improvement or satisfaction with intervention, quality of life or participation restriction. Exclusion criteria were chronic, multilevel or bilateral CR or radiculomyelopathy, major or systemic pathology, post-surgery interventions, or studies not in the English language. Electronic searching of Medline, CINAHL, EMBASE and the Cochrane Central Register of Controlled Trials (Central) was performed from database inception and completed by 12/01/22. Grey literature was searched using Open Access Theses & Dissertations (OATD) and Web of Science and SCOPUS was used for citation searching of included studies. Risk of bias (RoB) assessment using the Cochrane RoB tool 2.0 (Sterne et al., 2019) and certainty assessment using GRADE (Hultcrantz et al., 2017), was performed by two reviewers. Synthesis was planned for conservative management versus no treatment / sham / placebo, other conservative treatment, or surgery / spinal injections, for primary outcomes of pain and disability. The protocol was registered (INPLASY protocol 202220047) (Keating et al., 2022). Results: Seven studies (n=552 participants, mean age 43.4yrs) from 6 countries in Europe, Africa and North America were included. Interventions ranged from passive (collars, manual therapy, traction & electrophysical agents) to active (exercise). Three studies exhibited high RoB (Aksoy et al., 2018, Jellad et al., 2009, Ragonese, 2009) and only one exhibited low RoB (Langevin et al., 2015). Meta-analysis involved two studies with n=191 participants, comparing passive conservative management strategies to placebo or wait & see control (Konstantinovic et al., 2010, Kuijper et al., 2009). With moderate certainty, significant differences in the pooled effect estimate were found in favour of passive treatment (semi-rigid collar or LLLT) versus placebo or no treatment at short-term follow up (mean 4.5 weeks) for arm pain (SMD = -0.50 (95% CI -0.78, -0.21); I2 = 0%; p=0.0007), neck pain (SMD = -0.64 (95% CI -0.93, -0.35); I2 = 0%; p < 0.0001) and disability (SMD = -0.34 (95% CI -0.62, -0.05); I2 = 51%; p=0.02). Narratively, exercise was superior to no treatment in the short term with moderate certainty, but only for pain. Comparing conservative interventions against each other, alone or in combination, was of low to very low certainty resulting in less clarity for optimal multimodal inclusions. Conclusion: Offering passive (semi-rigid collar or LLLT) or active (exercise) interventions leads to immediate benefit in pain and disability, with no benefit over natural history within three to six months. Future trials of higher certainty, involving longer follow ups, may impact this assessment. Implications: Conservative management strategies improve short term outcomes only, compared to placebo or natural history.

Background: Neural mobilisations (NM) have been advocated for the treatment of nerve related cervicobrachial pain (NCBP), however, it is unclear what types of patients with NCBP (if any) may benefit.

Purpose: The primary aim of this systematic review was to assess the effectiveness of NM in patients with NCBP. The secondary aim was to explore if the effectiveness of NM varies between NCBP subgroups.

Methods: Databases were searched until December 2022. Randomised controlled trials were included if they assessed the effectiveness of NM in NCBP and outcome measures were pain intensity and/or disability. Studies were classified according to their inclusion/exclusion criteria as painful radiculopathy (signs of conduction loss), Wainner cluster (at least ¾ of: positive neurodynamic test, ipsilateral cervical rotation < 60°, positive distraction test, positive Spurling test), Hall and Elvey cluster (active/passive cervical movement dysfunction, positive neurodynamic test, sign of local cervical dysfunction) or other. Methodological quality was assessed using Cochrane Rob2 tool, and GRADE was used to rate the certainty of evidence.

Results: Twenty-six studies were included. For pain and disability reduction, NM was found more effective than no treatment (pooled pain MD= -2.81, 95%CI= -3.81 to -1.81; pooled disability SMD= -1.55, 95%CI= -2.72 to -0.37), increased the effectiveness of standard physiotherapy as an adjuvant when compared to standard physiotherapy alone (pooled pain MD= -1.44, 95%CI= -1.98 to -0.89; pooled disability MD= -11.07, 95%CI= -16.38 to -5.75 ), but was no more effective than cervical traction (pooled pain MD= -0.33, 95%CI= -1.35 to 0.68; pooled disability MD= -10.09, 95%CI= -21.89 to 1.81). Compared to exercise, NM was found more effective in reducing disability (pooled MD= -18.27, 95%CI= -20.29, -17.44). Fifteen studies were classified as Wainner cluster, four as Hall and Elvey cluster, one as radiculopathy and six as other. In most meta-analyses, there were significant differences in the effectiveness of NM between subgroups. NM was more effective than all alternative interventions (no treatment, traction, exercise, and standard physiotherapy alone) in 13 out of 15 studies (one reported no difference) classified as Wainner cluster. NM was more effective than varied alternative interventions in three out of 4 studies (one reported no difference) classified as Hall and Elvey cluster. In studies classified as other, findings differed. NM was not effective in the only study classified as radiculopathy. Evidence was only of moderate quality and GRADE revealed high uncertainty.

Conclusions: NM was found more effective than varied alternative interventions in most studies classified as Wainner cluster and Hall and Elvey cluster, but not in those classified as others or radiculopathy. Uncertainty of evidence is high.

Implications: NM may be a treatment of choice for those patients with NCBP that meet Wainner cluster. There is some evidence for its use in patients that fulfil Hall and Elvey cluster. Evidence is overall of moderate quality and is still highly uncertain. Research to establish the preferential effect of NM in different NCBP subgroups is required.

Background:

Cauda equina syndrome (CES) is a serious spinal pathology where dysfunction of the S2–S5 spinal nerves results in various combinations of bladder, bowel and sexual dysfunction and/or saddle anaesthesia. CES is rare, but its symptoms are not, and musculoskeletal physiotherapists frequently encounter persons with suspected CES. Given that delayed diagnosis of CES can result in devastating consequences for the affected person and costly litigation for healthcare organisations, it is imperative that a person presenting with suspected CES is well managed. There have been substantial changes to guidelines for the management of suspected CES in the past decade. Implementation of these in practice have been associated with a number of challenges for physiotherapists.


Purpose:

The aim of this study was to explore physiotherapists' experiences of managing persons with suspected CES.


Methods:

In this interpretive study, semi‐structured interviews were conducted with eight musculoskeletal physiotherapists. Verbatim transcripts were analysed by the first author using reflexive thematic analysis. An inductive approach to analysis was taken by the first author and followed the steps outlined by Braun and Clake (2012). During each step of the analysis, she entered into a dialogic discussion with the second author to probe and consider alternative interpretations.


Findings:

Five interlinking themes were generated. Two themes conveyed the challenges of clinical practice; Worry in relation to risk management and communication difficulties. Participants expressed a ‘fear-driven’ desire to avoid delayed diagnosis, which was related to panic, worry, sleepless nights and anticipation of ‘horrendous guilt’ if they were to miss anything. There were also accounts of self-doubt, frustration, power struggles and lack of mutual understanding in communications with persons with suspected CES and with other healthcare professionals.

The remaining three themes were described as antidotes to these challenges; Lightening the load with teamwork and shared responsibility, the usefulness of a clear pathway, and perceptions of improved confidence and competence with experience and training.

These findings will be presented in an interactive session which uses technology to explore the experiences of audience members. The resonance of their quotes with the research findings will then be explored.


Conclusions:

Findings suggest that it is important to be aware of and address the challenges faced by physiotherapists, in order to ensure a safe and smooth journey for persons with suspected CES and to care for clinicians' wellbeing.


Implications:

This study resulted in a number of practical implications for clinical practice. Clinicians and organisations should work to develop clear pathways for the management of persons with suspected CES, including access to other clinicians for advice. Supervisors should be aware of the potential for management of suspected CES to cause stress, anxiety and worry to physiotherapists, and mechanisms to support staff wellbeing should be integrated into the working schedule. Use of pre-existing communication aids and training tools for assessment and management of suspected CES is advocated. New resources will be presented to support translation of this research in to practice. Reference will be made to the United Kingdom’s national CES pathway (GIRFT, 2023).

Background:

The expanding scope of physiotherapists worldwide has come with an increased responsibility to identify serious pathologies such as fracture, infection, tumour and cauda equina syndrome (CES). Guidelines recommend a low threshold for emergency MRI to avoid the potentially devastating consequences of CES, but a balanced approach is required to prevent excessive strain on emergency resources.

The international framework for red flags for potential serious spinal pathologies (Finucane et al., 2020) offers support for clinical reasoning relating to CES and in some countries, national pathways have been developed. It is important to evaluate how these guidelines are implemented in clinical practice, at local level.


Purpose:

This study aimed to evaluate the management of patients presenting to an outpatient physiotherapy service with suspected cauda equina syndrome.


Methods:

This study was a service evaluation with an embedded case series of patients with radiological CES. The records of patients who were identified by their outpatient physiotherapists as having suspected CES (n=231) over a 27-month period were included. Data was extracted from patients’ medical records by a team of Advanced Clinical Practitioners (ACPs). The lead author further analysed the records of patients with clinical and radiological CES, in order to present the embedded case series.


Results:

In 79% of cases, it was decided that emergency referral was not required. The remaining 21% (n=49) of patients were referred to the emergency department and 49% (n=24) of these had an emergency MRI. Seven of these patients had MRI-confirmed CES and were included in the case series. Of these, four had a disc bulge and underwent emergency surgery, one had non-emergency surgery for a disc bulge combined with anterolisthesis and scoliosis and two patients with stenosis decided against surgical intervention. Five of these seven patients with MRI-confirmed CES had reported leg pain which predated the onset of their CES symptoms.


Conclusion(s):

The results of this service evaluation suggest support for an effective communication chain to facilitate escalation of concerns and appropriate use of emergency resources within local CES pathways. The case series showed that five of the seven patients with confirmed CES had experienced back and leg pain prior to developing bladder and/or bowel and or saddle anaesthesia symptoms. This reinforces the importance of considering provision of safety netting information for patients presenting with sciatica without other CES symptoms.

Future research could include long term follow up of patients who were not referred for consideration of MRI and qualitative inquiry might provide further insight into the clinical reasoning processes which inform decision making surrounding suspected CES.


Implications:

Local implementation of national guidelines and pathways for CES should include safety netting and a robust communication chain to support escalation of concerns and management of available resources. Practical tools to support safety netting are already available in many languages. Following this service evaluation, the lead author developed a downloadable CES handover tool and a perianal sensation testing prompt card to support clinicians in assessment and management of patients with suspected CES.

Background Whiplash associated disorder 2 (WAD2) is defined by the Quebec task force as neck pain and musculoskeletal signs, with no nerve injury. However, neuropathic pain has been demonstrated in a number of studies (Fundaun et al., 2021). Additionally, people with persistent pain and WAD2 show signs of elevated T2 signals on MRI scans, consistent with brachial plexus inflammation(Greening et al., 2018). It is not known whether similar signs of nerve inflammation are present in acute whiplash, or if there is a relationship between these findings and clinical measures. This analysis is part of an ongoing cohort study which aims to establish the contribution of peripheral nerve pathology to WAD2 and assess its role in prognosis (Ridehalgh et al., 2022). Purpose: To establish if the brachial plexus becomes inflamed acutely after a WAD2 injury, and to establish if such signs of inflammation relate to clinical measures. Methods: Ninety-five participants were recruited from emergency departments of 2 NHS trusts in the South East of England within 4 weeks of WAD2. Thirty healthy age/sex matched controls were also recruited. All participants completed the painDETECT and neck disability questionnaires. Quantitative sensory testing was performed at the index finger on the most affected side, and clinical tests including neurological integrity and heightened nerve mechanosensitivity were undertaken. All participants underwent a T2-weighted, fat supressed, MRI scan of the brachial plexus. Data was checked for normality using visual inspection and Kolmogorov-Smirnov tests. Wilcoxon and Mann-Whitney U tests or t-tests were used to look for differences between variables. Pearson’s and Spearman’s Rank correlation were used to assess the association between nerve signal intensity and clinical measures. Results: The T2 signal intensity for all roots of the brachial plexus was greater on the most symptomatic side in people with WAD2 compared to healthy controls (C5, C7, C8: p < 0.05, C6: P < 0.01). There was a significant correlation between cold pain thresholds (CPT) and C5 (p < 0.05, r= 0.24, 95%CI 0.03 to 0.43) and C6 T2 signal intensity (P < 0.01, r = 0.30, 95%CI 0.09 to 0.48). There were no significant correlations between T2 signal intensity and NDI and painDETECT questionnaires or tests for heightened nerve mechanosensitivity. Conclusion(s): The increase in T2 signal intensity in the roots of the brachial plexus in people with WAD2 is consistent with the presence of nerve inflammation. The relationship between C5 and C6 T2 signal intensity and CPT suggests that nerve inflammation may contribute to cold hypersensitivity. However, it is not yet known if such changes are important in prognosis of the condition. Implications: Nerve inflammation of the roots of brachial plexus may contribute to the pathophysiology of acute whiplash in those with no obvious sign of nerve injury and may be in part responsible to a decreased tolerance to cold pain. We are currently analysing data to establish if increased T2 signal is a predictor of poorer outcome. Acknowledgements: We would like to acknowledge Jane Greening for her considerable contribution to this study.

Objective: To explore indicators that predict whether patients with extremity pain have a spinal or extremity source of pain.

Methods: The data were from a prospective cohort study (n = 369). Potential indicators were gathered from a typical Mechanical Diagnosis and Therapy (MDT) history and examination. A stepwise logistic regression with a backward elimination was performed to determine which indicators predict classification into spinal or extremity source groups. A Receiver Operating Characteristic (ROC) curve was constructed to examine the number of significant indicators that could predict group classification.

Results: Five indicators were identified to predict group classification. Classification into the spinal group was associated with the presence of paresthesia [odds ratio (OR) 1.984], change in symptoms with sitting/neck or trunk flexion/turning neck/when still (OR 2.642), change in symptoms with posture change (OR 3.956), restrictions in spinal movements (OR 2.633), and no restrictions in extremity movements (OR 2.241). The optimal number of indicators for classification was two (sensitivity = 0.638, specificity = 0.807).

Discussion: This study provides guidance on clinical indicators that predict the source of symptoms for isolated extremity pain. The clinical indicators will allow clinicians to supplement their decision-making process in regard to spinal and extremity differentiation so as to appropriately target their examinations and interventions.

Background
Individuals with low back pain may have sinister or specific pathology necessitating appropriate neurological examination. Failure to adequately identify neurological compromise can have serious consequences for the patient and health service alike.

Accelerated by the global COVID-19 pandemic, there has been a recent shift towards telehealth. While experts have provided their perspectives regarding how individual neurological examination tests can be modified to a telehealth environment, no studies have established the accuracy of performing these tests via telehealth.

Purpose
The overarching aim of this study was to address concerns regarding the accuracy and appropriateness of performing a neurological examination via telehealth (specifically video-conferencing) for individuals with back pain.

Specifically, objectives were to:

1. Establish agreement between telehealth and in-person (reference standard) for a battery of physical tests routinely performed as part of a lumbar spine neurological examination.

2. Determine inter-rater reliability when performing individual physical tests of a lumbar spine neurological examination in-person.

Methods
A repeated-measures agreement study was undertaken at a hospital physiotherapy outpatient setting (Brisbane, Australia). Participants were current patients of the service ≥18 years of age with symptoms necessitating a lower limb neurological examination.

Participants completed an identical, structured neurological examination in-person and via telehealth, by two independent assessors, within a single session. A sub-group of participants completed a second in-person assessment, performed by a third assessor, within the same session to establish inter-rater reliability. Tests included lumbar dermatomes (light touch), myotomes, deep tendon reflexes (DTR), neural mechanosensitivity (SLR), and tests for long tract signs. Outcomes were recorded as either binary or categorical responses where relevant agreement and reliability statistics were undertaken.

Results
Data from 33 participants indicate variable exact agreement between modes of delivery (telehealth, in-person) across dermatomes (70% to 97%), myotomes (38% to 75%) and DTRs (57% to 75%). Agreement between delivery modes for long tract signs ranged from fair to almost perfect. Fifteen participants completed the second in-person examination. Inter-rater reliability of the in-person examination also demonstrated a wide variation in agreement across tests. Results provide some insight as to which neurological tests appear suitable for assessment via telehealth and which may need confirmation in-person. Additional resources, including video-recordings of all tests performed both in-person and via telehealth, has been developed for educational/training purposes.

Conclusion
Variable agreement was observed when comparing individual tests of a lumbar spine neurological examination between telehealth and in-person. Inter-rater reliability of tests performed in-person also yielded wide variation in agreement, suggesting that factors external to the delivery medium influence outcomes. Due to the low prevalence of long tract signs observed in this study, further research is required that specifically targets this sub-population.

Implications
This is the first known study that has sought to modify a lumbar spine neurological examination to a telehealth environment and investigate concurrent validity, as well as establish inter-rater reliability of an in-person physiotherapy examination. Findings can be used by a wide range of health professions to aid their decision-making towards the appropriateness of telehealth for their patients.

Background
Headache and neck pain are common presentations to primary care, and many patients may present with concerning symptoms in otherwise benign conditions. Limited information exists about red flags in headache and neck pain, but early recognition of serious pathology is critical to expedite medical evaluation and treatment and prevent mismanagement.
Purpose
This study aimed to identify, categorise and characterise cases of headache and neck/throat pain presenting to a metropolitan emergency department to improve recognition of serious pathology.
Methods
Cases were gathered from patients presenting to the Emergency Department of a Brisbane hospital with primary presenting complaint of headache or neck/throat pain. Hospital records were used to classify patients according to condition and identify common characteristics in serious pathologies. Patients were excluded if notes were unavailable, or the resultant diagnosis was not relevant to the study, such as respiratory conditions.
Results
10,165 cases were collected between January 2019 and January 2023, 4,235 were excluded. Headaches comprised approx. 80% of cases, with 76% of these being primary headache. Of the 5,0930 eligible cases of head and neck pain, 286 cases (4.8%) of serious pathology were identified, 1-2 cases per week. Of these, 56% were related to cerebrovascular conditions, most commonly haemorrhagic stroke, 22.5% to tumours/ space occupying lesions, 11% were related to infection such as meningitis and 3% to orthopaedic injuries e.g., cervical fracture/dislocation. Cervical arterial dissection (CAD) was identified in 33 cases (10%). Cerebrovascular pathologies showed higher proportions of sudden onset, unusual, severe headache (p = 0.015) and neurological symptoms (p < 0.001) than benign primary headaches. Tumours were generally known diagnoses, presenting with ongoing or worsening pain, dizziness, visual disturbance and altered neurology. Meningitis typically presented with fever, neck stiffness into flexion, photophobia, nausea and vomiting and were generally unwell. Orthopaedic injuries generally followed trauma.
Conclusions
Most patients presenting to emergency departments with acute onset headache are benign primary headaches or can be attributed to known conditions such as migraine. Serious pathology is uncommon but may be differentiated by typical features such as the presence of unusual headache with presenting or progressing neurological symptoms, fever, general unwellness, worsening pain. In comparison to other serious pathology. CAD cases were infrequent and less obvious to recognise.
Implications
Clinicians need to understand the possible types of serious pathology causing headache and their indicative presenting signs and symptoms as red flags. Clinicians should be especially vigilant in their history taking and objective examination for new or unusual headaches and subtle or transient neurological features and consider all possible underlying causes. If concerned, immediate referral on for imaging and medical evaluation is imperative before treatment is commenced. More specific screening tools are needed to identify for CAD.

Background
Temporomandibular disorders (TMDs) are characterised by pain and restricted jaw mobility, often associated with comorbidities like neck or low back pain. Physical therapy, particularly manual therapy (MT), is widely used to address TMD symptoms, showing positive effects in reducing pain and improving joint mobility. However, past systematic reviews on physical therapy investigated combined approaches, limiting specific insights into individual MT effectiveness targeted to specific areas. Although MT generally includes different approaches in different body regions, the effectiveness of techniques targeted on specific regions (e.g., neck, trunk, TMJ) is essential information for manual therapists planning TMD treatments. To date, there has not been a systematic review investigating the effects on pain and TMJ range of motion following MT applied specifically to the craniomandibular structures (Cranio-Mandibular Manual Therapy (CMMT)).

Purpose
This systematic review aims to evaluate the effectiveness of CMMT on pain and TMJ range of motion in people with TMD.

Methods
This systematic review adhered to a pre-determined published protocol, registered with PROSPERO (CRD42019160213). A comprehensive search of databases, including MEDLINE, Embase, CINAHL, ZETOC, Web of Science, SCOPUS, PEDro, PubMed, Cochrane Library, Best Evidence, EBM reviews–Cochrane Central Register of Controlled Trials, Index to Chiropractic Literature ChiroAccess, and Google Scholar, was conducted from inception until October 2020. Only randomized controlled trials comparing the effects of CMMT on pain and maximum mouth opening to other types of treatments for TMDs were included. Two independent reviewers screened articles, extracted data, assessed risk of bias using the revised Cochrane risk of bias tool for randomized trials, and evaluated the overall quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations.

Results
Among the 2720 records screened, only six studies (involving 293 participants) met the inclusion criteria. All included studies demonstrated a significant improvement in pain and maximum mouth opening after CMMT compared to baseline in the mid-term. However, only two studies indicated CMMT's superiority over other interventions. Several studies exhibited concerns regarding the risk of bias, with one study being deemed high risk. The overall quality of evidence was rated as very low for all outcomes due to high heterogeneity and small sample sizes. For the same reasons, a quantitative synthesis could not be performed.

Conclusion
The findings of this systematic review shed light on the potential benefits of CMMT for managing pain and improving maximum mouth opening in individuals with TMDs. However, the limited number of high-quality studies and the presence of heterogeneity highlight the need for further research to establish more robust evidence. Future research endeavors should prioritize large-scale, well-designed randomized controlled trials to enhance the evidence base and provide more conclusive recommendations for clinical practice. Moreover, exploring the long-term effects of CMMT on TMD outcomes would be crucial in optimizing treatment strategies and ensuring lasting benefits for patients.

Implications
Physiotherapists planning treatment of patients with TMD may consider CMMT, in addition to other treatment modalities, as one effective, low-cost, conservative option to manage pain and improve TMJ range of motion in the mid-term.

Background: Neck pain is one of the most common musculoskeletal disorders, with a prevalence rate (age-standardized) of 27.0 per 1000 population in 2019. Approximately 50%–85% of individuals with acute neck pain do not experience complete resolution of symptoms and some may go on to experience chronic pain. Manual therapy is a widely employed treatment approach for non-specific neck pain (NP), cervical radiculopathy (CR) and cervicogenic headaches (CGH). The existing body of evidence supporting manual therapies for individuals with neck disorders consists of an array of randomized clinical trials, systematic reviews and clinical practice guidelines. Purpose: The purpose of this umbrella review was to provide an updated synthesis of manual therapy (MT) interventions for individuals with cervical disorders. Methods:We followed the preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered in Prospero (CRD42022327434). PubMed, CINAHL, and EMBASE databases were searched from August 2016 to May 2023 for systematic reviews with or without meta-analysis on manual therapy for individuals with NP. We included acute, subacute, and chronic stages of non-specific NP, CGH and CR. Interventions included any manual therapy of the cervical or thoracic spine and could include joint mobilization/manipulation or soft tissue mobilization. We also included neuromobilization/neurodynamics of the upper quarter. Outcomes included any measurement of pain, and/or disability/function. Two authors independently reviewed the title and abstract for eligibility. A third reviewer settled disagreements. The full-text screening was handled in the same manner. Two review authors independently extracted data from the included studies. Data were summarized as reported in the included studies. Discrepancies in data reporting were handled through discussion. Two reviewers independently assessed the methodological quality using the Assessment of Multiple Systematic Reviews (AMSTAR 2) tool. A third reviewer settled disagreements. Quality of evidence was rated with the Grading of Recommendations Assessment, Development and Evaluation approach. Results: A total of 41 systematic reviews containing 561 trials were included. Manual therapy + exercise (4 reviews), manual therapy broadly (8 reviews), cervical mobilization (6 reviews), cervical manipulation (10 reviews), thoracic spine mobilization/manipulation (2 reviews), neuromobilization (2 reviews), and other types of manual therapy (6 reviews) were supported as being effective in the management of pain and disability for individuals nonspecific neck pain, cervicogenic headache, or cervical radiculopathy. Two reviews had AMSTAR-2 quality ratings of low confidence, while all others were moderate to high quality. Conclusion(s): Manual therapy is recommended to decrease pain and disability in individuals with NP, CGH and CR in the short term. Implications: The results of this umbrella review will be utilized to inform an update to the 2017 Clinical Practice Guidelines for Neck Pain Linked to the International Classification of Functioning, Disability and Health From the Orthopaedic Section of the American Physical Therapy Association.

Background: Concussions are prevalent in pediatric populations, often leading to post-concussion symptoms (PCS) including dizziness, one of the most reported PCS. Initial vestibular/ocular and neck-related impairments are known to be related to the future development of PCS. However, it is unclear if neck-related impairments are associated to vestibular/ocular impairments.
Purpose: This prospective cohort study aimed to identify recovery trajectories of vestibular/ocular impairments as measured by the Vestibular/Ocular Motor Screening (VOMS) assessment tool in pediatric concussion and assess baseline clinical markers including neck physical impairments findings that would predict trajectories.
Methods: Seventy-three children (8 to 17 yo) with a diagnosis of acute ( < 21 days) concussion were recruited. Participants took part in 3 evaluation sessions over 6 months (initial post-injury, 3-month, and 6-month). Sociodemographic data were recorded. All evaluation sessions included the primary outcome, the VOMS. Independent variables included symptom severity [Post-Concussion Symptoms Index (PCSI)], and quality of life [Pediatric Quality of Life Inventory (PedsQL)] as well as the flexion rotation test (FRT), neck pain, headache, global range of motion of the neck including pain at movement. A group-based multi-trajectory modelling analysis was performed. Each of the independent variables was compared between the trajectories.
Results: A Low Score on the VOMS (LSV) trajectory (n=53, 73%), and a High Score on the VOMS (HSV) trajectory (n=20, 27%) were identified. The PCSI (Odds Ratio (OR):82.91, 95% Confidence Interval (CI): 2.05 – –), neck pain at movement (OR:7.73, 95%CI: 2.01 – 29.75), positive FRT (OR: 5.11, 95%CI: 1.37 – 19.06), and having at least one cervical findings (OR:7.98, 95%CI: 0.93 – 68.29) were the strongest predictors of belonging to the HSV group (P < 0.05).
Conclusions: Following a concussion, 27% of children had a HSV trajectory over a 6-month period with general symptoms intensity, and cervical findings including pain at movement, and the FRT being the strongest predictors. Having at least one cervical finding was also a strong predictor of having a high score on the VOMS. Further research is needed to refine predictions and enhance personalized treatment strategies for pediatric concussions.
Implications: The study's implications for clinical practice in managing pediatric concussions and PCS highlight the importance of early identification and assessment of the vestibular/ocular impairments using tools like the VOMS. The study underlines the significance of incorporating neck evaluations in concussion assessments, given the strong link between neck impairments and vestibular/ocular impairments. Tailoring treatment plans to individual recovery trajectories, with a particular focus on evaluation of the neck and vestibular/ocular impairment, is recommended. The study also calls for further research to validate findings and explore additional factors affecting recovery trajectories. By implementing these recommendations, healthcare providers can enhance the management of pediatric concussions, particularly regarding vestibular/ocular and neck impairments, to improve patient outcomes.

Background:
Impaired balance and dizziness have been reported in migraine and causes of these may be central vestibular or cervicogenic. Neck pain is common in migraine and cervical musculoskeletal dysfunction has been identified in some individuals with migraine. However, it is unknown if balance performance is associated with dizziness, neck pain, and presence of cervical musculoskeletal dysfunction. Identifying any associations may help elucidate underlying mechanisms of impaired balance to direct management.

Purpose:
To identify i) impaired balance in participants with migraine as compared to pain-free participants, and ii) any associations between impaired balance and frequency of dizziness during migraine attacks, neck pain features, and presence of cervical musculoskeletal dysfunction.

Methods:
This is a secondary analysis of a previous study investigating cervical musculoskeletal dysfunction which identified dysfunction akin to mechanical neck pain in 39% of individuals with migraine. This present study included unpublished data on balance performance in pain-free participants (n=32) and participants with migraine (n=110 with, n=14 without neck pain). Balance in comfortable stance with eyes closed was measured by total root mean square (rms) amplitude of centre of pressure displacement. Neck pain intensity, frequency, history and disability (Neck Disability Index), as well as frequency of dizziness during migraine attacks, were surveyed. Frequency of dizziness during migraine attacks was rated by participants as “never”, “sometimes”, “often” or “always”. Balance was categorised as impaired when values exceeded the upper limit of 95% confidence intervals of total rms amplitude in pain-free participants. Associations between presence of impaired balance and frequency of dizziness, presence of cervical musculoskeletal dysfunction and neck pain features were individually explored using logistic regression with age and height as covariates.

Results:
Neck pain was reported in 89% of migraine participants, the majority (75%) of whom experienced neck pain at least weekly, for a duration of 10 years (median) interquartile range (IQR) [14], with average neck pain intensity of 4/10 (median) IQR[3/10], and Neck Disability Index Score of 24% (median) IQR[17]. The majority (44%) did not experience dizziness during migraine attacks, but dizziness “always” accompanied attacks in 9% of participants with migraine. Impaired balance was identified in 42% of participants with migraine and was not significantly associated with frequency of dizziness, presence of cervical musculoskeletal dysfunction nor any neck pain features (all p>0.05).

Conclusions:
Not all individuals with migraine in this study had impaired standing balance. Balance performance does not necessarily relate to dizziness, cervical musculoskeletal dysfunction or neck pain. Therefore, causes of impaired balance may be different within individuals. Findings may be different in the subgroups poorly represented in this study such as those with vestibular migraine.

Implications:
Specific assessments are needed to identify individuals with migraine who require intervention to improve balance. Clinicians should look beyond neck pain and cervicogenic proprioceptive dizziness as the potential cause to also consider central mechanisms when assessing for and addressing balance impairments in migraine.

Background
Neck pain is common in tension type headache (TTH). However, the origin of this neck pain is still ambiguous. Neck pain may be associated with cervical musculoskeletal (MSK) impairments and individual cervical MSK impairments have been demonstrated in TTH. However isolated impairments may not reflect a true cervical MSK disorder which typically presents with patterns or multiple cervical MSK impairments as demonstrated in patients with neck pain. Alternatively, neck pain may be a feature of pain hypersensitivity. Further study is needed to delineate the origin of neck pain in TTH to further inform clinical reasoning in the differential diagnosis of neck pain accompanying TTH.

Purpose
This study aimed to determine i) whether patterns of cervical MSK impairments are present in individuals with TTH which align with mechanical neck pain and, ii) the relationship between pain hypersensitivity and the presence or absence or frequency of MSK impairments.

Methods
This is a single-blind cross-sectional study. Participants included individuals with TTH (n=22), neck pain (n=11) and pain-free controls (n=16). Tests of pressure pain threshold (PPT), cold pain threshold (CPT) and temporal summation (wind-up ratio, WUR) were performed at the cervical spine to assess pain hypersensitivity. Assessments of cervical musculoskeletal impairments included range of motion (ROM), movement velocity and accuracy, joint position sense error (JPE), manual segmental examination, and neck flexor and extensor endurance. Shapiro-Wilk test was used to determine normality of data. Cluster analysis was used to determine how participants grouped based on cervical MSK impairments across all measures. Nonparametric tests were used to illustrate differences in cervical MSK impairments and pain hypersensitivity between clusters.

Results
Two clusters were found. Cluster 1 (n=33) included all pain-free controls and was characterised by no or isolated cervical MSK impairments. Cluster 2 (n=16) included the majority of individuals with mechanical neck pain and was characterised by multiple impairments across all measures. Participants with TTH (64%) were allocated to cluster 1 and 36% were in cluster 2. Participants in cluster 1 demonstrated greater cervical ROM in extension and right rotation (p < 0.05) and better neck extensor endurance (p < 0.001) than participants in cluster 2. Participants in cluster 1 had fewer positive cervical joint signs (p < 0.001) than in cluster 2. WUR was higher in participants of cluster 1 (p < 0.05) but PPT and CPT measures were similar between clusters.

Conclusions
The majority of participants with TTH had normal cervical function, however 36% presented with a collection of cervical MSK impairments across multiple measures that supports a cervical origin/contribution to neck pain. Higher WUR may reflect pain hypersensitivity underlying neck pain in participants with normal cervical function.

Implications
These findings demonstrate heterogeneity in neck pain mechanisms in TTH. A MSK cause/contributor to the neck pain can be confirmed by a group of cervical MSK impairments. Neck pain may also reflect pain hypersensitivity associated with headache. Local treatment to the cervical spine may not be indicated for all TTH with the complaint of neck pain.

Background: Temporomandibular disorders (TMD) are a group of conditions affecting the stomatognathic system, in addition, TMD is also commonly associated with other symptoms affecting the head and neck. Different neck exercises, especially endurance training of the deep neck muscles, have been used to reduce pain and improve neck motor control in patients with neck pain-related disorders, cervicogenic headaches, and whiplash, among others. However, to our knowledge, none of the previous studies have evaluated in isolation the effectiveness of motor control exercises or manual therapy targeted to neck muscles in improving pain, orofacial function, and quality of life in patients with TMD.
Purpose: To test the effectiveness of an 8-week exercise program targeted to the neck muscles compared to manual therapy, and placebo treatments on orofacial pain intensity, jaw function, and oral health-related quality of life (OHRQoL), and in women with TMD.
Methods: In this RCT, fifty-four women (between 18-45 years old) with a diagnosis of myofascial or mixed TMD according to the Research Diagnostic Criteria for TMD (RDC/TMD) were randomized into three groups: Neck motor control training (NTG), Manual Therapy Group (MTG), and Placebo Group (PG). All patients were evaluated with the Visual Analog Scale, Mandibular Function Impairment Questionnaire, and Oral Health Impact Profile – 14 at baseline, immediately after treatment (after 8 weeks of treatment), one month, and three-month follow-up. For all outcomes, a mixed ANOVA with repeated measures was conducted with a Bonferroni post hoc test, following the intention-to-treat (ITT) principles with imputation of missing data.
Results: NTG was significantly better than the PG group on pain and jaw function at the end of the treatment (Effect Size (ES) 0.9 [95%CI= 0.2, 1.6]), one-month follow-up (ES 0.8 [95%CI= 0.1, 1.5]) and three-months follow-up (ES 0.7 [95%CI= 0.1, 1.4]). For jaw function, NTG presented better results than PG at the end of treatment, one-month follow-up, and three-months follow-up with a large ES (>0.8). And between NTG and MTG after three-months follow-up (ES 1 [95%CI= 0.3, 1.7]), favoring the NTG group. No difference was verified between MTG and PG. For OHRQoL, NTG was significantly better than MTG and PG at the end of treatment, one-month, and three-month follow-up, with a large ES (>0.7). None of the participants received any co-intervention and did not report any type of adverse event. On average the patients attended 95.8%, 88.2%, and 91% of the sessions, in the NTG, MTG, and PG respectively.
Conclusion(s): The results of this project are encouraging, and they could be used to guide clinical practice in this field. Exercises targeted to the neck (which require low therapeutic supervision) could be a simple and conservative way to improve pain and disability for women with TMD with neck involvement.
Implications: To our knowledge, this is the first study that tested a specific neck motor control exercise protocol alone in a group of patients with TMD. This study showed that exercises directed to the neck (which requires low therapeutic supervision) could be useful in the management of patients with chronic TMD.

Background: Migraine is a common disabling primary headache disorder with high prevalence and enormous personal and socio-economic impacts.
Recent advancements in pharmacotherapy have enabled successful treatment and shown a reduction of the burden of migraine. Nonetheless, a (substantial) proportion of individuals experience migraine that is unmanageable by pharmacological treatments alone. Current non-pharmacological treatments for migraine include biobehavioural therapy, physiotherapy, aerobic exercise, acupuncture, and educational interventions. A combination of medication and behavioural therapies is considered the best treatment for migraine attacks and/or prevention of attacks.

Purpose: The concept of multidisciplinary headache therapy in outpatient settings has not yet been well established in Switzerland. Therefore, this study aimed to assess the effects of the Headache Management Program, as developed at Inselspital, Bern University Hospital, on people suffering from migraine.

Methods: This was an open-label, single-arm interventional study designed to assess the effectiveness of the Headache Management Program at Inselspital, Bern University Hospital, on patient reported outcomes in people with migraine. Participants were aged 18 years or older and seen in the outpatient headache centre before the start of the program. Diagnosis was made by a headache specialist according to the International Classification of Headache Disorders 3. Participants followed a program consisting of seven lectures once a week. The primary outcome was headache-related quality of life measured by Headache Impact Test 6 (HIT-6) and Migraine Disability Assessment (MIDAS). Descriptive statistics were mean, median and standard deviation. Data before and after the program were compared using paired t test and Wilcoxon signed rank test as appropriate.

Results: There was significant improvement in HIT-6 (p= .012 d= 0.62, paired t test) from before to after the program and scores decreased by 3.3 points, 95% CI [0.14, 1.10]. Similarly, median MIDAS post-program (Mdn= 27) was significantly lower than the median (Mdn= 38) pre-program (z= -2.53, p= .011, r= 0.40, Wilcoxon signed rank test).

Conclusion(s): This study suggests that the Headache Management Program has clinically significant patient reported outcomes and would be a good addition to standard headache care. Avenues for further research should include a randomised controlled trial with a bigger heterogenic sample size and control groups.

Implications: So far, the physiotherapists involved in the program only perform progressive muscle relaxation (PMR) at the beginning of the lectures. However, in future groups, they could also be involved in the physical activity lecture and/or design an additional lecture in which they guide program participants on exercises they can do at home or at work. This could include mobility and stretching exercises. If this goes well, a further step could be to offer a course for physiotherapists in private practice and introduce them to the program so that they can implement their own program in their own work environment. This should be tailored to physiotherapy issues related to migraine and also include basic information on drug treatment in consultation with the medical profession.

Background
Further than headache, patients with migraine frequently present musculoskeletal comorbidities. To the best of our knowledge, assessment of musculoskeletal alterations in migraine rarely stratifies patients according to neck dysfunction, verified through manual palpation of the upper cervical spine.
Purpose
We aimed to investigate the cervical joint position sense (JPS) and the neck muscle endurance among migraineurs and controls following stratification according to pain response during manual palpation of the upper cervical spine.
Methods
Thirty-two headache-free subjects and 57 migraine patients were included. The sample was stratified according to the presence of pain during the manual palpation of the upper cervical spine as follows: no neck pain (P0, n=23), local neck pain (P1, n=37) and pain referred to the head (P2, n=29). Demographic data, headache features and neck disability (NDI) were collected. All subjects were performed the JPS test after active extension, right and left rotation. The mean error (cm) between the initial and final position of three trials was considered. They also underwent the muscle endurance test of the neck flexors and extensors and the time in seconds of three trials was recorded. The test order was randomized, and data was analyzed using MANOVA tests with diagnosis and neck dysfunction as independent variables, on SPSS version 26.0 with α=5%.
Results
Eleven migraine patients were stratified in the P0 group (mean age 37.3, SD 14.3), 21 in the P1 group (mean age 34.8, SD 13.5) and 25 in the P2 group (mean age 33.1, SD 14.1). A significant effect of neck dysfunction for the joint position sense error after maximum extension was found (P0 versus P2 mean difference=1.93 cm, F2=4.85, p=0.008). No diagnosis effect was verified for all movement directions (p > 0.39), and no neck dysfunction effect was verified for the remaining right (p > 0.83) and left (p > 0.46) directions. For the muscle endurance test, a significant effect was found for diagnosis (migraine vs no migraine) and neck dysfunction. Compared to migraineurs, controls exhibited greater muscle endurance of neck flexors (mean difference 15 sec, F1=10.54, p=0.001) and extensors (mean difference 48 sec, F1=4.93, p=0.02). According to the stratification, subjects of the P0 group exhibited greater muscle endurance compared to P1 for neck flexors (mean difference 27 sec, F2=16.21, p < 0.001) and extensors (mean difference 46 sec, F2=3.20, p=0.04). The P0 group also was different from the P2 group regarding flexion (mean difference 29 sec, F2=16.21, p < 0.001) and extension (mean difference 68.4 sec, F2=3.20, p=0.04) endurance. No differences between P1 and P2 groups were found.
Conclusions
The presence of neck pain referred to the head is related to a greater joint position sense error for neck extension. The presence of migraine and/or any neck dysfunction is related to reduced endurance of neck flexor and extensor muscles.
Implications
Since the presence of neck pain delays migraine treatment and it is related to migraine chronification, the identification of differences among patients’ presentation is out of importance due its potential influence on the assessment, treatment plan and prognosis.