Physiotherapy always seems to be in crisis. If it’s not the crisis of funding or the threat from competition, it’s the loss of professional identity or the lack of high quality clinical evidence. And yet, in recent years a number of physiotherapists have read these threats as an opportunity to radically rethink our practice. These people offer some radical and exciting ways to think about the physical therapies and the theories that underpin them. In this talk I want to give a brief guided tour of these new emerging fields and lay a breadcrumb trail for you to follow. Starting by acknowledging some of the many problems being faced by the profession, I show why the four main ways the profession is responding are understandable but inadequate (including our spurious current claim to be biopsychosocial). I then talk about some of the new emerging ideas in physiotherapy that are now pushing the boundaries of our practice. Many of these are radical and challenging, but they all derive from people within the profession looking for exciting ways to think about future physiotherapy. As Deleuze said, “There is no need to fear or hope, but only to look for new weapons”.

Description
This focused symposium will highlight the need to discuss the best care for patients with musculoskeletal [MSK] pain conditions, in a world of global increase in persistent MSK pain. Some practitioners of manual therapy [MT] got stuck in myths, biases and unsubstantiated beliefs. Also, the value of MT does not seem to be best evaluated by using RCTs. In the last two IFOMPT congresses we have become increasingly aware of the need to discuss and cross the bridge towards a fresh approach to MT practice and training, the needs of patients with MSK pain and MT research. In the focused symposium we hope to reflect on these, challenge existing paradigms, proposing ideas from contemporary research, and call on discussion from the audience.

Implications
Contemporary evidence suggests that MT techniques may not have much value in the treatment of patients with chronic musculoskeletal pain. However, while many manual therapists have invested time in developing their manual therapy skills, they may not have put the same effort in developing their ‘soft skills’ towards effective clinical communication, patient-centered therapy and a strong therapeutic alliance, which could optimize their therapy, patient experience and outcomes. Upon completion of this focused symposium, attendees will have knowledge and tools aimed at understanding the mechanisms of manual therapy outcomes, the value of understanding pain, the importance of patient-centered care, and a change in undergraduate and post-graduate MT training and research. The symposium will be interesting for clinicians, lecturers and researchers, and will contribute to the practice of manual therapy.

References
• 2016 Kongsted A, Kent P, Axen I, Downie AS, Dunn KM. What have we learned from ten years of trajectory research in low back pain? BMC musculoskeletal disorders. 2016 Dec;17(1):1-1.
• 2017 The future of orthopedic manual therapy: what are we missing? Cristiana K. Collins, Michael Masaracchio & Jean-Michel Brismée. Editorial. Journal of Manual & Manipulative Therapy, 25:4, 169-171, (2017)
• 2017 Martin Rabey, Toby Hall, Clair Hebron, Thorvaldur Skuli Palsson, Steffan Wittrup Christensen, Niamh Moloney. 2017. Reconceptualising manual therapy skills in contemporary practice. Musculoskeletal Science and Practice 29 (2017) 28e32
• 2017 Amarins J Wijma, Anouck N Bletterman, Jacqui R Clark, Sigrid C.J.M Vervoort, Anneke Beetsma, Doeke Keizer, Jo Nijs & C. Paul Van Wilgen (2017): Patient-centeredness in physiotherapy: What does it entail? A systematic review of qualitative studies, Physiotherapy Theory and Practice, DOI: 10.1080/09593985.2017.1357151
• 2018 Bialosky JE, Beneciuk JM, Bishop MD, Coronado RA, Penza CW, Simon CB, George SZ. Unraveling the Mechanisms of Manual Therapy: Modeling an Approach. J Orthop Sports Phys Ther. 2018 Jan;48(1):8-18.
• 2018 Rob Stenner, Shea Palmer, Ralph Hammond, What matters most to people in musculoskeletal physiotherapy consultations? A qualitative study, Musculoskeletal Science and Practice, Volume 35, 2018, Pages 84-89, https://doi.org/10.1016/j.msksp.2018.03.005
• 2018 Lin I, Wiles L, Waller R, Goucke R, Nagree Y, Gibberd M, Straker L, Maher CG, O’Sullivan PP. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. British journal of sports medicine. 1;54(2):79-86. doi:10.1136/bjsports-2018-099878
• 2020 Briggs, A. M., Shiffman, J., Shawar, Y. R., Akesson, K., Ali, N., and Woolf, A. D. (2020). Global health policy in the 21st century: challenges and opportunities to arrest the global disability burden from musculoskeletal health conditions. Best Pract. Res. Cli
• 2021. Providing value-based care as a physiotherapist. Chad E. Cook , Thomas Denninger5, Jeremy Lewis, Ina Diener and Charles Thigpen. Archives of Physiotherapy (2021) 11:12. https://doi.org/10.1186/s40945-021-00107-0
• 2021 Lewis JS, Stokes EK, Gojanovic B, Gellatly P, Mbada C, Sharma S, Diener I, O’Sullivan P. Reframing how we care for people with persistent non-traumatic musculoskeletal pain. Suggestions for the rehabilitation community. Physiotherapy. 2021 Sep 1; 112:143-9.
• 2021 Côté P, Hartvigsen J, Axén I, Leboeuf-Yde C, Corso M, Shearer H, Wong J, Marchand AA, Cassidy JD, French S, Kawchuk GN. The global summit on the efficacy and effectiveness of spinal manipulative therapy for the prevention and treatment of non-musculoskeletal disorders: a systematic review of the literature. Chiropractic & manual therapies. 2021 Dec;29(1):1-23.
• 2021 de Raaij EJ, Wittink H, Maissan JF, Westers P, Ostelo RWJG. Limited predictive value of illness perceptions for short-term poor recovery in musculoskeletal pain. A multi-center longitudinal study. BMC Musculoskelet Disord. 2021 Jun 7;22(1):522. doi: 10.1186/s12891-021-04366-7. PMID: 34098929;
PMCID: PMC8186079.
• 2021 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
• 2022 Our Musculoskeletal Treatments are More Similar than We Think: Shared Treatment Mechanisms. Chad E Cook JOSPT https://doi.org/10.2519/jospt.blog.20220524
• 2022 Albarqouni L, Arab-Zozani M, Abukmail E, et al Overdiagnosis and overuse of diagnostic and screening tests in low-income and middle-income countries: a scoping review BMJ Global Health 2022;7:e008696.
• 2022 O'Keeffe M, Ferreira GE, Harris IA, Darlow B, Buchbinder R, Traeger AC, Zadro JR, Herbert RD, Thomas R, Belton J, Maher CG. Effect of diagnostic labelling on management intentions for non‐specific low back pain: A randomized scenario‐based experiment. European Journal of Pain. 2022 Aug;26(7):1532-45.
• 2022 Reis FJ, Nijs J, Parker R, Sharma S, Wideman TH. Culture and musculoskeletal pain: strategies, challenges, and future directions to develop culturally sensitive physical therapy care. Brazilian Journal of Physical Therapy. 2022 Sep 15:100442.
• 2022 Verwoerd MJ, Wittink H, Goossens MEJB, Maissan F, Smeets RJEM. Physiotherapists' knowledge, attitude and practice behavior to prevent chronification in patients with non-specific, non-traumatic, acute- and subacute neck pain: A qualitative study. Musculoskelet Sci Pract. 2022 Feb;57:102493.
doi: 10.1016/j.msksp.2021.102493. Epub 2021 Dec 11. PMID: 34922256.
• 2022 Elbers S, Wittink H, Konings S, Kaiser U, Kleijnen J, Pool J, Köke A, Smeets R. Longitudinal outcome evaluations of Interdisciplinary Multimodal Pain Treatment programmes for patients with chronic primary musculoskeletal pain: A systematic review and meta-analysis. Eur J Pain. 2022 Feb;26(2):310-335. doi:
10.1002/ejp.1875. Epub 2021 Nov 5. PMID: 34624159; PMCID: PMC9297911.
• 2023 van Dijk H, Köke AJA, Elbers S, Mollema J, Smeets RJEM, Wittink H. Physiotherapists Using the Biopsychosocial Model for Chronic Pain: Barriers and Facilitators-A Scoping Review. Int J Environ Res Public Health. 2023 Jan 16;20(2):1634. doi: 10.3390/ijerph20021634. PMID: 36674387; PMCID: PMC9861865.
• 2023 Verwoerd MJ, Wittink H, Maissan F, van Kuijk SMJ, Smeets RJEM. A study protocol for the validation of a prognostic model with an emphasis on modifiable factors to predict chronic pain after a new episode of acute- or subacute nonspecific idiopathic, non-traumatic neck pain presenting in primary care. PLoS One. 2023 Jan 17;18(1):e0280278. doi: 10.1371/journal.pone.0280278. PMID: 36649242; PMCID: PMC9844852.
• 2023 Fullen BM, Wittink H, De Groef A, Hoegh M, McVeigh JG, Martin D, Smart K. Musculoskeletal Pain: Current and Future Directions of Physical Therapy Practice. Arch Rehabil Res Clin Transl. 2023 Feb 1;5(1):100258. doi: 10.1016/j.arrct.2023.100258. eCollection 2023
• 2023 Burns JW, Jensen MP, Gerhart J, Thorn BE, Lillis TA, Carmody J, Keefe F. Cognitive therapy, mindfulness-based stress reduction, and behavior therapy for people with chronic low back pain: A comparative mechanisms study. J Consult Clin Psychol. 2023 Mar;91(3):171-187.

Learning outcomes:
• Develop awareness of the clinical presentation of axial spondyloarthritis, research evidence on diagnostic delays and impacts, and importance of screening for spondyloarthritis in musculoskeletal assessments.
• Develop knowledge of signs, symptoms and risk factors for axial spondyloarthritis, role of blood tests and imaging in suspicion, and guidance on referral to rheumatology.
• Gain practical skills in history-taking and clinical examination for suspected spondyloarthritis and associated extra-articular manifestations, skin and nail examination, and structuring a good referral.

Description:
Spondyloarthritis is a group of inflammatory conditions that mimic common musculoskeletal problems. Delays in diagnosis average up to 8-9 years for many people (1), because it is often not recognised in assessments(2,3). Screening for suspected spondyloarthritis (SpA) and when to refer onto rheumatology needs to be a core skill of musculoskeletal clinicians(4,5).
Musculoskeletal clinicians are key to early diagnosis and reducing the significant impacts of this inflammatory disease. Spondyloarthritis can be challenging to recognise and often mistaken as chronic mechanical low back pain or unrelated tendon and joint problems(4,5). Research shows that the inflammatory disease links between persistent back pain, peripheral problems and extra-articular inflammatory manifestations are often missed in clinical practice(2).
Knowing features that raise suspicion of spondyloarthritis and when to refer onto rheumatology is an important aspect of musculoskeletal practice. Research also indicates that musculoskeletal clinicians report a lack confidence and awareness in screening for axial spondyloarthritis (3,6), added to by a paucity of literature on axial SpA in musculoskeletal professional literature(7).
NICE (2017) has developed guidance to support earlier recognition, diagnosis, treatment and other important considerations with SpA. This is supported by increasing research, international campaigns and the development of increasing resources to support earlier diagnosis(8,9).
This course aims to enable clinicians to develop clinical knowledge and skills to screen for suspected spondyloarthritis within musculoskeletal assessments and when to refer to Rheumatology. It will also outline research and resources available to support their clinical practice in screening for these conditions.

Symposium format:
Chair – Dr Carol McCrum will introduce the symposium .and provide an outline of the sessions and practical activities.

Presenter 1- Will Gregory, Consultant Physiotherapist in Rheumatology, will introduce the and relevance of screening for Axial Spondyloarthritis in musculoskeletal assessment. Will then will discuss research showing the global issue of delayed diagnosis and the importance of early recognition of axial spondyloarthritis to enable early intervention and better outcomes. Patient perspectives on the impact of axial spondyloarthritis and of delayed diagnosis will be given through research on patient experiences and video accounts of experiences. The session will close with an overview of the Rheumatology Physiotherapy Specialist Capabilities Framework: Screening in Musculoskeletal Settings that outlines required inflammatory knowledge and skills of musculoskeletal clinicians.

Presenter 2- Eliza Steen, Advanced Practice Physiotherapist in Spinal Assessment Service, will discuss her research on the awareness, confidence and knowledge of physiotherapists of axial spondyloarthritis across a range of roles and settings. She will discuss findings on the lack of recognition of features of axial spondyloarthritis within back pain presentations, the consequences and need for supporting screening skills for this inflammatory disease in musculoskeletal clinical practice.

Presenter 3- Dr Carol McCrum, Consultant Physiotherapist in Rheumatology, will lead interactive talks outlining the latest research on signs, symptoms and risk factors for axial spondyloarthritis, features of inflammatory back pain, and when to suspect axial spondyloarthritis. She will discuss blood tests, imaging and interpretation concerning axial spondyloarthritis. Carol outline referral criteria provided by NICE Guidance on Spondyloarthritis (2017) and involve participants in using other resources to support when to refer for possible axial spondyloarthritis. There will be interactive quizzes and question and discussion time across the session.

Presenter 4- Hannah Chambers will lead practical sessions on screening for axial spondyloarthritis, including: history-taking, case studies and clinical-reasoning vignettes to support knowledge and skills on suspicion and referral through group workshops; practical session on questioning on extra-articular manifestations; skin examination; axial and peripheral physical examination skills; features of good referral letter. The session will close with post-workshop quiz on awareness, confidence and knowledge of screening for axial spondyloarthritis.

Chair- Dr Carol McCrum will host a panel Q&A and then summarize key learning and close.

Implications/Conclusions:
Axial spondyloarthritis has often been missed across multiple assessments of back pain, joint and tendon problems in people’s journey to diagnosis. Resulting impacts on disease outcomes, quality of life, complications, psychological health and workability can be devastating. Early recognition and referral is key. Screening for axial spondyloarthritis in back, tendon and joint problem presentations needs to be a core musculoskeletal skill.

References
1.Gregory WJ et al.(2022)Survey of Diagnostic Delay in Axial Spondyloarthritis Across Two National Health Service(NHS) Rheumatology Services.Cureus,30;14(3):e23670
2.McCrum C et al.(2019)Unrecognised Masquerader:Retrospective review of people presenting to musculoskeletal physiotherapy with undiagnosed spondyloarthritis.Physiotherapy,105,e102.
3.Stee, E, Cairns,M, McCrum,C(2021)Physiotherapist’ awareness, knowledge and confidence in screening and referral of suspected Spondyloarthritis:Survey of UK clinical practice.Musculoskeletal Care.
4.McCrum C(2019)Appraisal of Clinical Practice GuidelineJournal of Physiotherapy,65(4),242.
5.McCrum C(2019)Editorial -When to suspect spondyloarthritis.Musculoskeletal Science and Practice,41(iii),
6.McCrum, C.(2020)Delaying Diagnosis: inflammatory back pain and other features of suspected spondyloarthritis rarely featured in musculoskeletal health professions literature. Rheumatology,22(Supp_2)
7.MacMillan,A et al.(2021)Masterclass: Axial spondyloarthritis for osteopaths and manual therapists.IntJOsteopMed(41)45-56.
8.Rheumatology_Physiotherapy_Capabilities_Framework_vFINAL_Interactive.pdf (macpweb.org)

Learning objectives: By the end of this symposium, participants will be able to
1. Recognize the complexities of the use of spinal mobilizations and manipulations in the paediatric population in regard to harm and effectiveness.
2. Be aware that infants (0-2 years old) are a separate population with different rules, regulations and law in regard to the use of spinal mobilizations and manipulations.
3. Understand recommendations and the position statement on spinal mobilisations and manipulations in the paediatric population based on current available research and clinical reasoning.

The session will start with an introduction from the Chair of this panel explaining that IFOMPT and IOPTP (International Organization for Physiotherapy in Paediatrics) formed an international task force to develop a position statement to guide safe and effective use or non-use of spinal mobilisations/manipulations in the paediatric population across diverse conditions. The panel of experts will then present outcomes of completed work from the task force on mobilisations and manipulations in a paediatric population including the results of:
a. One Scoping review (3) with the aim of identifying and mapping the available evidence regarding effectiveness and harms of spinal manipulations and mobilisations for infants, children and adolescents. It also aimed to identify and synthesise policies, regulations, position statements and practice guidelines informing their clinical use;
b. Two systematic reviews (4, 5) which investigated the clinometric properties of outcomes measures identified in the scoping review;
c. One Delphi study of international expert physiotherapists, which aimed to describe current practice, perceived effects, and perceptions of peers in the field of orthopaedic manipulative therapy and paediatric physiotherapy regarding spinal mobilisations and manipulations appropriateness and usage in infants, children, and adolescents.

The information of the above will be used to inform a position statement on spinal mobilisations and manipulations in a paediatric population. Finally, the session will end with a panel discussion and questions and answers session regarding evidence informed practice benefits and harms, the types of studies that need to be conducted on the topic of paediatric spinal manipulations and mobilisations, the political milieu related to infants (0-2 years of age) including consenting and legal issues in various countries about spinal manipulations and mobilisations, the reasons physiotherapists should or should not manipulate or mobilize paediatric population and for which conditions, and some trends for the future.

Background
The CORKA trial (ISRCTN 13517704) was commissioned to investigate rehabilitation outcomes inn patients assessed as being at risk of poor outcome after knee arthroplasty (KA). The trial used a screening tool based on an analysis of factors associated with a poor outcome after knee arthroplasty to guide patient selection for the trial. The tool was not as sensitive as hoped and further work is required to develop factors based on individual level to predict patients requiring supervised rehabilitation as recommended in UK NICE guideline NG157
Purpose
To use simple physical performance tests, pre KA, to predict functional health outcomes, post KA, to try to identify patients at greater risk of poor outcomes and provide information on patients likely to benefit from targeted rehabilitation post KA.
Methods
Secondary analysis of data collected for the Community-based Rehabilitation after Knee Arthroplasty (CORKA) RCT. Physical assessments were measured at baseline and included the figure of 8 walk test, 30-second chair stand test (CST), single leg stance on the operated leg (SLS), and the Physical Activity Scale for the Elderly (PASE). The Late-Life Function and Disability Instrument (LLFDI) was used to assess community-dwelling older adult’s function. The LLFDI function score was measured at six months, one year and two years post–baseline assessment. Linear regression analysis was used to predict the LLFDI score from the physical assessments while adjusting for age, sex, BMI, and site of recruitment.
Results
A total of 621 participants (men n= 250, women n= 371) were recruited for this study with a mean age 70.4 ± 8.1 years, and BMI of 31.5 ± 4.7. Participants were recruited from 8 different NHS sites across the UK. SLS and PASE significantly predicted LLFDI function at six months (SLS B=0.14, 95%CI 0.06-0.22, PASE B=0.018, 95%CI 0.05-0.03) and two years (SLS B=0.21, 95%CI 0.11-0.31, PASE B=0.022, 95%CI 0.004-0.038) with the CST and SLS significantly predicting LLFDI function at one year (SLS B=0.18, 95%CI 0.09-0.27, CST B=0.36, 95%CI 0.04-0.68).
Conclusion
Single leg stance on the operated leg and the Physical Activity Scale for the Elderly consistently predicted LLFDI function from six months to two years after KA surgery. Further research should investigate how dynamic and static balance along with objective measures of physical activity may predict which patients are at risk of poor health outcomes following KA surgery.
Implication
If balance and general physical activity can provide a more accurate method to predict which patients are at risk of low health outcomes post KA surgery then pre-habilitation programmes could be used along with targeted post-op rehabilitation programmes to provide better health outcomes for those at greater risk.

Background: Exercise is considered the cornerstone of effective management for lateral elbow tendinopathy. While exercise is known to induce an analgesic response in healthy populations, this response is less clear in pain populations, such as chronic lateral elbow tendinopathy (LET). Manual therapy is also known to induce an analgesic response. For example, Mobilisation-with-Movement (MWM) has been shown to increase pressure pain thresholds (PPT) and pain-free grip strength in people with LET. People with chronic LET have also demonstrated altered pain processing, including widespread mechanical hyperalgesia, cold hyperalgesia and increased pain facilitation as measured through temporal summation. The effects of exercise, both alone and in combination with manual therapy, on sensory outcomes is unknown. Furthermore, the association of pain processing characteristics and changes in pain and function following exercise (with and without manual therapy) is unknown.
Purpose: The primary aim of this study was to examine the effects of exercise alone and in combination with manual therapy on sensory characteristics, pain and function in individuals with LET. The secondary aim was to evaluate the association of pain processing characteristics and changes in pain and function following exercise, with and without manual therapy. Design: Within-subject, single-blinded, randomised study.
Methods: Twenty-four participants (age 49.7 ±8.2 years, duration elbow pain 15 ±25 months) with a clinical diagnosis of LET underwent three experimental conditions in random order: Control, Exercise (6 x 10-seconds isometric gripping to pain threshold) and Exercise with concurrent Mobilisation-with-Movement (Exercise+MWM). A blinded assessor measured PPT and temporal summation (over the elbow, and tibialis anterior), and resting pain intensity (11-point scale) before, immediately after and 10-minutes after each condition. Grip force was recorded during the Exercise conditions. Repeated-measures ANOVAs were used to compare between conditions and over time (p < 0.05). Conditioned pain modulation (CPM), temporal summation, Patient-Rated Tennis Elbow Evaluation, Tampa Scale of Kinesiophobia and Hospital Anxiety and Depression Scale were measured at baseline. Results: Resting elbow pain significantly increased following the Exercise-only condition (0.8, 95%CI 0.4 to 1.1) compared to other conditions. Exercise+MWM significantly increased average grip force compared to Exercise alone (mean difference 42 N, 95%CI 10 to 74). PPT at the elbow (p = 0.001) and tibialis anterior (p = 0.016) significantly improved following Exercise+MWM compared to Exercise alone. There was a significant correlation between the net CPM effect and the net effect of adding manual therapy to Exercise on PPT (p < 0.01). Conclusion: There was no evidence of exercise-induced analgesia in people with LET. Adding manual therapy to exercise produced an analgesic response and a greater exercise output compared to exercise alone. Descending inhibitory control of nociceptive stimuli (as measured by conditioned pain modulation) may be associated with the analgesic effects of adding manual therapy to exercise.
Implications:
• Combining manual therapy with exercise provides an analgesic response
• Combining manual therapy with exercise increases exercise output, which is known to be important for stimulating a biological response within the tendon
• Exercise alone increases resting pain levels, potentially negatively impacting adherence to an exercise program.

Background: Clinical guidelines recommend exercise as a core treatment for hip and knee osteoarthritis (OA). Other non-pharmacological therapies are commonly delivered as adjuncts to exercise. A Cochrane systematic review published by the author team found no clinically meaningful effect of various adjunctive therapies used with land-based exercise therapy, compared to the placebo equivalent and exercise, or exercise only for hip or knee OA.

Purpose: This subgroup analysis reports the results on the effects of adjunctive manual therapies used in combination with land-based exercise therapy for hip or knee OA.

Methods: A systematic review and meta-analysis was performed. Searches were completed across six databases up to June 2021. Studies included randomised controlled trials (RCTs) or quasi-RCTs of people with hip or knee OA comparing adjunctive therapies alongside land‐based exercise therapy (experimental group) versus 1) placebo adjunctive therapies alongside land‐based exercise therapy, or 2) land‐based exercise therapy (control groups). Exercise had to be identical in both groups. Major outcomes were pain, physical function, participant‐reported global assessment and adverse events. We evaluated short‐term (< 6 months), medium‐term (6-12 months) and long‐term (≥ 12 months) effects. Risk of bias was assessed using the Cochrane Risk of Bias tool v1. Certainty of evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluations (GRADE). Statistical heterogeneity was assessed using the I2 statistic. Findings from analysis of the manual therapies subgroup is reported using pooled Standardised Mean Differences (SMD). Effect sizes were categorised as small (0.2-0.5), medium (0.5-0.8) and large (> 0.8).

Results: Of the 62 trials included in the review, seven investigated manual therapies, including joint mobilisations and massage, combined with exercise against exercise only. None compared against placebo manual therapy and exercise. Six trials included people with knee OA and two included hip OA. The number of treatments delivered varied between 8 and 15, delivered over 6-12 weeks. Two trials delivered manual therapy over 11 months, with inclusion of booster sessions (at months 5, 8 and 12). Medium-term effects were evaluated in five trials, and three assessed long-term effects. Adverse events were reported in one trial. There was no short-term difference in pain severity (SMD 0.01 [-0.30, 0.31], n= 608, I2 = 68%), physical function (SMD -0.13 [-0.45, 0.20], n=669, I2 = 75%), or patient global assessment (Risk Ratio (RR) 1.19 [0.97, 1.46], n=235, I2 = 0%). Based on one trial (n= 101), there was a significant improvement in pain (SMD 0.55 [0.15, 0.94]) in favour of exercise only (vs manual therapy and exercise), but not in function (SMD 0.33 [-0.07, 0.72]. There was also no long-term difference in pain (SMD -0.27 [-0.72, 0.18], n=286, I2=68%), or physical function (SMD -0.07 [-0.49, 0.36], n=286, I2=65%). Certainty of evidence using GRADE was rated as low for all comparisons.

Conclusions/Implications: Current evidence does not support manual therapies used adjunctively with exercise therapy for short-term, medium-term or long-term improvement in pain, function or patient global assessment for hip or knee OA compared to exercise therapy only. Caution should be applied in interpreting results due to low-certainty evidence.

Background
Persistent shoulder pain is a common problem and people with this condition are often referred for orthopaedic specialist management in tertiary care. Protracted waiting times for a consultation occur frequently within these services, yet surgical conversion rates remain relatively low. Developing models of care that can distinguish between prospective surgical candidates and people who may benefit from an alternative care pathway could improve service efficiency, optimise healthcare expenditure, and enhance patient outcomes. Altered sensory processing may be present in this patient group and influence treatment outcomes, however the current evidence regarding this is limited. Furthermore, the sociodemographic, clinical, general health and lifestyle, and psychological characteristics of this group are yet to be comprehensively explored. Investigation of these characteristics could provide insight into factors that may impact the experience and trajectory of shoulder pain in this population.

Purpose
The primary objective of this study was to compare sensory processing measures in people attending tertiary care for shoulder pain with control participants. A secondary objective was to compare the groups’ sociodemographic, clinical, general health and lifestyle, and psychological characteristics.

Methods
Participants with shoulder pain ≥ 3 months attending a tertiary orthopaedic clinic (n = 119) and community participants without shoulder pain (n = 44) underwent a standardised quantitative sensory testing protocol, measuring pressure pain threshold (PPT), temporal summation (TS), and conditioned pain modulation (CPM). Sociodemographic, clinical, general health and lifestyle, and psychological characteristics were assessed via a participant interview, self-report questionnaires, and a physical assessment. All measures were conducted in a single session.

Results
Participants with shoulder pain demonstrated significantly lower PPTs at all sites (i.e., local, and widespread mechanical hyperalgesia) and significantly decreased CPM effect during the cold pressor test (i.e., descending inhibition of nociception) than the control participants. There was no significant difference between groups for TS. Participants with shoulder pain displayed decreased general health and function, less healthy lifestyles, and poorer psychological health compared with the control group.

Conclusion
Features of impaired sensory processing were evident in people attending a tertiary care orthopaedic clinic for management of shoulder pain compared with a control group. The impact of sensory function on treatment outcomes in similar patient cohorts requires investigation.

Implications
Pain mechanisms in people with persistent shoulder pain appear more complex than being an isolated musculoskeletal (i.e., nociceptive) complaint. The value of a multidisciplinary approach to care should be considered, with a view to improving an individual’s physical and psychological wellbeing in addition to any relevant biomechanical or medical interventions.

Background:

The shoulder is the most frequently dislocated joint, in 95% of cases the shoulder dislocates forwards. After a shoulder dislocation has occurred emergency treatment is required to reduce the dislocation and to support the arm in a sling. Rehabilitation has a key role in restoring a functional, painless shoulder. However there is limited evidence comparing different rehabilitation methods after the initial support in a sling. Current guideline recommendations internationally range from advice only to advice and an additional programme of supervised physiotherapy.

The choice of rehabilitation offered following a shoulder dislocation has large resource implications for the person and health care provider. Consequently, if a single advice session were all that is required, it would lessen the burden on patients and the healthcare resources required.

Purpose:

We aimed to compare the clinical effectiveness of a single session of advice with a single session of advice and a programme of physiotherapy.
 
Methods:

We completed a pragmatic, superiority, multi-centre randomised controlled trial, funded by the National Institute for Health and Care Research (NIHR; 16/167/56). Trauma research teams at 41 UK NHS Trust sites screened adults with a first-time traumatic anterior shoulder dislocation confirmed radiologically, being managed non-operatively.

Four hundred and eighty two participants were eligible and consented from 40 UK NHS sites between 14th November 2018 and 14th March 2022. All participants received an initial single session of advice to aid self-management. This lasted for up to one hour and included education on the injury, common complications and how to prevent them, pain relief and suggested exercises. Following this single session of advice all participants were randomly allocated (stratified by participant age, hand dominance and recruiting site) to this advice session alone or additional physiotherapy over a four month period.

The primary outcome was the Oxford Shoulder Instability Score, measured six months after treatment allocation. Secondary outcomes included the QuickDASH, EQ-5D-5L and complications.

Results:

There was no statistically significant difference between advice compared to advice and a programme of physiotherapy at the primary six-month time point, for the primary intention to treat adjusted analysis (favours physiotherapy: 1.5; 95% CI -0.3 to 3.5) or at earlier three month and six week time points.

Conclusion:

Until ARTISAN there was no strong evidence to guide rehabilitation management following an initial two-weeks support in a sling. We now know an additional programme of physiotherapy is not superior to advice alone.

Implications:

An individually tailored programme of physiotherapy is not superior to advice, however, people who are not experiencing recovery as expected could self-refer for a supervised programme of physiotherapy after the initial self-management period. This will provide a balance between best use of health care resources, empowering patients and reducing unnecessary appointments for those who can self-manage.

Background: Joint motion assessment informs diagnosis, interventions, and assessment. Hip range of motion (HROM) measures are included in Clinical Practice Guidelines for hip management. To optimize patient outcomes, we need to bridge between research, education, and clinical expertise to deliver refined and precise patient management. Purpose: Present hiption as the natural plane of motion of the hip that allows for maximal hip flexion and greatest ease of movement. 1) identify if hiption is clinically measurable and reproducible, 2) compare normative values for HROM as measured in cardinal planes vs. hiption plane, and 3) determine if HROM in hiption as reliable as cardinal HROM in both experienced and novice raters. Secondary aims: assess functional squat between planes and assess potential impact of hypermobility. Methods: Exploratory cohort model, supine HROM flexion (F), external rotation (ER), internal rotation (IR) in cardinal and hiption planes. Hiption determined as plane of maximal hip flexion with least resistance and greatest comfort. Hip IR/ER at 90 degrees hip flexion both planes. Beighton scale completed for joint laxity. Maximal squat depth in cardinal, hiption plane and self-selected position. Data analyzed with paired t-test for HROM between planes, and squat depths. ICC for inter-tester reliability, and correlation analysis for HROM and Beighton scale. Results: 121 subjects, ages 20-65 (28.4, +/- 8.0) (female 61%, male 38%, non-binary 1%). Hip ROM 121 subjects (mean values degrees): Cardinal: F left 126.0 (8.08), R 126.9 (7.42), IR L 32.7 (9.33), R 29.9 (9.42), ER L 46.3 (11.49), R 48.4 (11.39). Hiption: F L 132.2 (8.09), R 132.9 (7.52), IR L 33.7 (10.46), R 31.2 (9.79), ER L 48.5 (11.31), R 50.4 (10.63). Adjusted hiption ROM based upon a transverse plane determination of hiption: IR L 52.3 (10.59), R 49.4 (9.91), ER L 29.5 (10.59), R 32.3 (9.59). Paired t-tests between planes, positive for all (p < .000): F L (t= -18.7; CI -6.9, -5.5), R (t= -16.1; CI -6.6, -5.2), IR L (t= -24.1; CI -21.1, -17.9), R (t= -26.2; CI -20.9, -17.9), ER L (t= 23.1; CI 15.3, 18.2), R (t= 21.9; CI 14.7, 17.6). Reliability: HROM cardinal - good; F L (ICC .83), R (ICC .76), IR L (ICC .79), R (ICC .74), ER L (ICC .80), R (ICC .78). Hiption – moderate to good; F L (ICC .83), R (ICC .81), IR L (ICC .86), R (ICC .77), ER L (ICC .83), R (ICC .79). Adjusted IR L (ICC .66), R (ICC .49), ER L (ICC .66), R (ICC .50). Mean squat (cm/SD) cardinal 105.8 (9.8), self-selected 98.9 (8.8), hiption plane 97.5 (11.0). Difference significant cardinal/self-selected (p < 0.000) (95% CI= 5.0, 8.7), and cardinal/hiption (p < 0.000) (95% CI= 5.5, 11.1). Self-selected/hiption not significant (p= 0.167) (95% CI= -0.6, -3.5). Discussion: HROM in hiption greater for flexion, internal rotation; not external rotation. Findings all significant. Reliability good for hiption vs cardinal plane except adjusted IR and ER (moderate). Squat deeper in hiption. Future research should assess impact of hiption on manual interventions, exercise prescription, and rehabilitation for hip/pelvic impairments.

BACKGROUND: Plantar fasciitis (PF) is characterized as the inflammation and possible degeneration of the plantar fascia, often presenting as pain and stiffness in the morning and with weight bearing activities. With non-surgical treatment, about 80% of patients improve within 12 months, however, some individuals go on to have a failed healing response and develop chronic heel pain. Extracorporeal shockwave therapy (ECSWT) has been identified as a minimally invasive, effective treatment for the treatment of chronic PF but less is known when this is used in combination with manual therapy and/or exercise.

PURPOSE: The purpose of this study was to examine the effects of ECSWT alone, ECSWT in combination with joint mobilizations to the talocrural, subtalar, and first metatarsophalangeal joints, and ECSWT in combination with exercise on heel pain and lower extremity function in individuals with chronic PF.

METHODS: Participants (n=108) with chronic heel pain secondary to PF were randomly assigned to one of the three treatment groups. Participants were asked to: i.) rate their heel pain at rest, after activity, and ii.) improvement using the visual analog scale (VAS) and function using the Lower Extremity Functional Scale (LEFS) before and 12-weeks following treatment. Two one-way ANOVAs were conducted to examine baseline and post-intervention pain and functional outcome measures between the three treatment groups to determine differences in the change scores. A dependent samples t-test also examined significant differences from pre- to post-intervention within each treatment group for the outcome measures.

RESULTS: There was a statistically significant difference between groups for heel pain at rest with a small effect size, F(2,102)=4.902, p=.009, ŋ2=.088. Bonferonni post-hoc comparisons revealed that heel pain after activity was lower in the ECSWT and joint mobilizations group (-19.46 on the VAS, p=.016) and in the ECSWT group alone (-17.39 on the VAS, p=.036) compared to the ECSWT and exercise group. There were no statistically significant differences between the ECSWT and joint mobilizations and ECSWT group on heel pain after activity. No other significant differences were found between each of the treatment groups comparing change scores from pre- to post-scores for the other outcome measures (p>.05). Significant differences post-treatment were found, however, in the VAS scores for heel pain at rest and overall improvement in heel pain and in LEFS scores. The ECSWT and joint mobilization group demonstrated the greatest reduction in heel pain at rest and after activity, reported the greatest overall improvement, and improved function compared to the ECSWT alone or ECSWT and exercise groups.

CONCLUSION: ECSWT alone and in combination appears to improve heel pain and function but when combined with joint mobilizations of the talocrural, subtalar, and first metatarsophalangeal joints, greater improvements post treatment and in overall heel pain at rest and after activity and in lower extremity function are present. The beneficial findings of ECSWT as a consideration for treatment is consistent with previous research but combining ECSWT with joint mobilizations may result in greater benefits in pain and function.

Background: Manual therapy (MT) is an effective intervention for treatment of people with knee osteoarthritis (OA). Dose is a well-recognised aspect of any treatment approach and is known to affect clinical outcomes. Treatment frequency is an aspect of MT dose that has not been thoroughly investigated. Existing studies show large variability and lack of rationale to support selection of treatment frequency. Variation in provision of treatment makes it difficult to directly compare results from different studies, or for physiotherapists to translate findings into clinical practice. Therefore, there is a clear need for research to investigate the optimal frequency of MT for people with knee OA.
Study Aim: The primary aim is to investigate whether frequency of treatment with MT for people with knee OA affects clinical outcomes at 6-month follow-up. A secondary aim is whether MT is superior to a best practice exercise and advice intervention.
Method: We conducted a fully powered, 3-arm, randomised controlled trial (RCT), comparing participants receiving six MT treatments at a frequency of once per week (MT1), those receiving six treatments at a frequency of twice per week (MT2), and a control group (UC) who did not receive MT. All groups received a standardized best-practice package of care incorporating an individually tailored exercise programme, advice, and education.
We analysed clinical outcomes using linear mixed models across the trial period with the primary outcome being functional outcome at 6-months (KOOS). Secondary outcomes included pain, quality of life (QOL), and physical performance measures (PPMs).
Results: We recruited 154 participants with mild to moderate knee OA with only 4 withdrawals (2.6%). At 6-months there was no between group difference for MT1 and MT2. The primary outcome (KOOS function) was 2.24 lower in MT2 (95%CI -7.89, 3.40) p=0.432. This result was repeated for all secondary outcomes except MT2 were quicker on the timed up-and-go, 1.41 secs (95%CI 0.28, 2.53) p=0.015 and the 40-metre fast paced walk, 3.35 (95%CI 0.06, 6.64) p=0.046. For the secondary analyses the MT groups combined were superior to UC for KOOS function, 5.68 (95%CI 0.57, 10.79) p= 0.03, and three of the four PPM. Graphical trends suggest that MT2 improved faster, but MT1 continued to improve and sustained this improvement at 6-months.
Conclusions: Adding MT to UC gives a superior functional outcome at 6-months, but the frequency of treatment does not impact this substantially.
Implications: Clinicians and patients with knee OA can reach a shared decision on how often to attend for treatment with MT.

Background:
Headache and neck pain are closely related. Office-workers are regarded especially vulnerable for both conditions. The objectives of the study are, to examine the effects of a 12 month intervention, consisting of neck exercise and health promotion, on headache outcome variables in office workers in two public departments in Switzerland.
Methods: The study is a stepped-wedge cluster randomized controlled trial. One-hundred twenty participants were randomly allocated within their cluster (n=8 per cluster) to the time point for entering the intervention phase. Five of 15 clusters were randomized to either the intervention or control phase at each time point (t0, t2, t3). At t1, the trial had to be suspended for 3 months, but outcomes had been sampled. Secondary outcomes were headache occurrence (Yes/No), headache frequency (days/4 weeks) and the "headache impact test-6 (HIT-6) questionnaire. For each outcome variable several regression models had been calculated, to test for the effect of treatment (intervention /no intervention), period (four time periods) and calendar time (time being in the intervention phase), and their interactions.

Results: For the occurrence of headache (Yes/No) the simplest model fitted best the data, showing a 54% reduction in headache occurrence (95% Confidence interval: 26 to 84% reduction). For headache days within the last 4 weeks, the model including the interaction effects (intervention *period) best fitted the data. At t1, the intervention effect was largest with a reduction in headache days per four weeks of 43% (95% CI: 26 to 54%), while at later time points effects could not be maintained. For the HIT-6, also the model accounting for the period of the intervention best fitted the data. There was no effect found for any contrast, when accounting for the intervention period (-0.84 points on the HIT-6, 95% CI: -2.4 to +0.7 points).

Discussion: The NEXpro intervention had some effect on headache outcomes in office workers. The strongest effect had been found for the occurrence of headache, with an average reduction of 54% in reporting headaches in the last 4 weeks. As the other outcome variables showed, the strongest effect had been found during the first intervention period, while later on effects were smaller. Positive effects attenuated over time, even though participants were encouraged to continue their exercise programme. No effects were found for the HIT-6 questionnaire. Exercise and health promotion programmes have positive effects on headache, but they may need periodic refreshment to maintain the effects.

Introduction: Concussion has been associated with a range of subsystem impairments persisting beyond expected recovery time. Regardless of the nature of subsystem impairments, patients post-concussion often present with similar symptom profiles which can challenge management decisions. Cluster analyses may be used to identify patient subgroups with similar physical impairments post-concussion, as previously used to identify neck impairment subgroups in headache phenotypes. Subgrouping may aid in the development of more streamlined post-concussion assessment and management processes.
Aims: To identify how healthy individuals and those who present both asymptomatically and with persistent symptoms 4 to 26 weeks post-concussion group, based on their performances across cervical musculoskeletal and sensorimotor (cervical, vestibular, oculomotor, balance) assessments.
Methods: This secondary exploratory study utilised data from a previous cohort study, conducted in a Tertiary Teaching Hospital and University setting. Participants included 72 adults aged 18-60 years who were 4 to 26 weeks post a diagnosed concussion (35 asymptomatic and 37 symptomatic) and 39 healthy controls with no concussion history. Those with history of cervical spine or vestibular disorders were excluded. Results from measures of cervical musculoskeletal (flexor endurance, segmental joint dysfunction, kinematics) and sensorimotor function (joint position sense, smooth pursuit gain, ≥2 oculomotor indicators of dysfunction using video nystagmography, near point convergence, single-dual tandem walk test time difference, postural sway) were included in a Ward’s hierarchical agglomerative clustering analysis. Dissimilarities were calculated using Gower’s Distance and Agglomerative Coefficients (AC) examined strength of clustering structures.
Results: Four clusters (AC=0.96) including minimal or nil impairments (Cluster 1), vestibulo-ocular (Cluster 2), cervical spine musculoskeletal/ sensorimotor (Cluster 3), and multi-subsystem impairments (Cluster 4) were identified. Each cluster was characterised by either an absence or presence of clinically relevant assessment findings. Most healthy controls (71.8%), and a minority of symptomatic individuals (7.7%) grouped in Cluster 1, whereas the opposite occurred in Cluster 4 (43.2% symptomatic, 5.1% healthy controls). Asymptomatic individuals post-concussion were distributed across all four clusters.
Conclusion: Individuals post-concussion, including those not reporting ongoing symptoms, may present within physical impairment subgroups potentially underpinning persistent cervical and or sensorimotor dysfunction. Future research should aim to identify and manage these individuals to better inform decisions related to recovery and return to pre-injury activities post-concussion.

Background: Work ability is of utmost importance to investigate after treatment for individuals with chronic Whiplash-Associated Disorders (WAD). There is current lack of information about work related factors for individuals with WAD. More efficient, flexible ways of delivering neck-specific exercises with fewer visits are needed, especially for working individuals with WAD. In a randomized controlled trial, a neck-specific exercise programme in combination with four physiotherapy visits (NSEIT) was non-inferior to the same exercises performed at a physiotherapy clinic (NSE) twice a week for three months (24 visits). The results revealed sustained clinically important changes in disability and pain for approximately 50% of participants. However, work-related factors were not presented.
Purpose: To compare the effects of NSEIT to the same exercises performed at a physiotherapy clinic (NSE) regarding secondary outcomes of work-related factors.
Methods: This is a prospective, multicentre, randomized controlled trial regarding secondary outcomes of work-related factors in 140 individuals with chronic WAD grade 2 and 3, with 3- and 15-month follow-up. Protocol registered before data collection started: clinicaltrials.gov NCT03022812.
Results: There were no group differences between NSE and NSEIT in the Work Ability Scale or work subscales of the Neck Disability Index, Whiplash Disability Questionnaire or Fear Avoidance Beliefs Questionnaire (FABQ-work). Both groups improved in all work-related outcome measures, except for FABQ-work after the 3-month intervention and results were maintained at the 15-month follow-up.
Conclusions: Despite fewer physiotherapy visits for the NSEIT group, there were no group differences between NSEIT and NSE at 3- and 15 months follow-up. The improvements in most work-related measures at 3-month follow-up were maintained at the 15-month follow-up.
Implications: A neck-specific exercise program with an internet support improves work ability to the same extent as several visits to a physiotherapy clinic. In addition, the internet-support may provide individuals a more flexible way to adhere to the program. The results of the present study are promising, showing that NSEIT and NSE can improve work ability after a whiplash injury.

Background
Persistent pain and disability after whiplash injury constitutes a substantial personal and societal burden. A whiplash injury can alter neck muscle function, which remains years after the injury and may explain why symptoms such as persistent pain and disability occur. There is limited knowledge of dynamic neck muscle function in chronic whiplash-associated disorders (WAD), and to what extent altered muscle function can improve after rehabilitation. Methods to improve the diagnostic of neck muscle function in WAD is therefore of high priority.

Purpose:
The aims of the present study were to; compare dorsal mechanical neck muscle function in chronic WAD versus age- and sex matched healthy controls during dynamic neck rotation and evaluate neck muscle function in WAD after three months of neck-specific exercises.

Methods:
This study included 34 individuals with chronic WAD grade II and III, and 34 pain-free controls, matched for age and sex. The neck muscles were recorded by real-time ultrasound and were analyzed with speckle tracking analyses. Thirty individuals in the WAD group completed a 12-week neck-specific exercise program. Mixed design analyses of variance (ANOVA) were used to evaluate between group (WAD and controls) and within group (WAD, baseline to 3-moths follow-up) change in five neck muscles: Trapezius, Splenius, Semispinalis capitis, Semispinalis cervicis, and Multifidus. Effect sizes was displayed as partial Eta squared (ηp2); 0.01 small effect, 0.06 intermediate effect, and 0.14 large effect.

Results:
The results showed significant altered neck muscle function in the three deepest neck muscles (Semispinalis capitis, Semispinalis cervicis, Multifidus) in cervical rotation to the most painful side in WAD compared to controls (F=12.4, p < 0.001, ηp2=0.17). After three months of neck-specific exercises, the differences between the WAD and control groups were no longer significant (F= 2.7, p=0.10, ηp2=0.05), and the WAD group showed significant improvements over time (F=5.1, p=0.03, ηp2=0.16).

Conclusion(s):
Real-time ultrasound with speckle-tracking analyses could detect differences in the deepest neck muscles in WAD compared to controls. In addition, after three months of neck-specific exercises were deformation in these muscles improved to a similar deformation pattern as controls, and the significant baseline group differences ceased. Moreover, these promising results included those with longstanding neurological signs after whiplash injury, WAD grade III.

Implications: The non-invasive ultrasound method with speckle-tracking analyses can be used in the assessment and diagnosis of patients following whiplash trauma.

Background: Evidence suggests that manual therapy combined with therapeutic exercise is superior to routine physical therapy for neck pain. However, its underlying mechanisms remain unknown. Changes in structural brain following interventions may provide valuable insights into underlying mechanisms of chronic neck pain and treatment effectiveness.

Purposes: The primary aim was to investigate the effects of manual therapy combined with therapeutic exercise (MT+Exs) compared to routine physical therapy (RPT) on cortical thickness and volume in patients with chronic nonspecific neck pain (NSNP). The secondary objectives were to assess changes in clinical features, cervical range of motion (CROM) and cranio-cervical flexor (CCF) strength after the interventions.

Methods: This study was a single-blinded, randomized controlled trial. A total of 52 participants with chronic NSNP (> 3 months) were recruited. Participants were randomly allocated to either the MT+Exs group (n = 26) or RPT (n = 26) group as control in a 1:1 ratio. The MT+Exs group received cervical mobilization and specific cervical and scapular training for 10 weeks (2 visits/week). The RPT group received routine physical therapy (e.g., modalities and stretching exercise). The primary outcome was cortical thickness and volume of regions of interest (ROIs) including primary somatosensory cortex (S1), precuneus, insula, prefrontal cortex (PFC) and anterior cingulate cortex (ACC). The secondary outcomes were clinical features (neck pain intensity, disability and psychological symptoms), CROM in all directions and maximal CCF strength. All outcome measures were taken at baseline and post-intervention. The cortical thickness and volume were computed using FreeSurfer analysis and a general linear model.

Results: There was no loss to follow-up. Compared to baseline, the MT+Exs group showed decreased cortical thickness in the left and right S1, left and right precuneus and left PFC as well as increased cortical thickness in the left and right ACC at post-intervention (p < 0.05). The RPT group showed decreased cortical thickness in the left S1 and right precuneus at post-intervention (p < 0.05). After the 10-week interventions, the MT+Exs group showed increased cortical thickness in the left and right ACC compared to the RPT group (p < 0.05). There were no within- and between-group differences in cortical volume (p > 0.05). The secondary outcomes were improved in both groups at post-intervention (p < 0.05). The MT+Exs group had greater improvements in pain intensity, disability and CROM compared to the RPT group (p < 0.05). No adverse events were reported.

Conclusion: A 10-week intervention of manual therapy combined with exercise and routine physical therapy induced structural changes (thickness) in various pain-related regions of the brain in patients with chronic NSNP. A change in the ACC thickness was greater with manual therapy in combination with exercise than routine physical therapy. The results suggest that both interventions can influence neural plasticity in the brain regions related to pain modulation, with the effects varying according to the specific intervention.

Implications: Understanding changes in structural brain following interventions can further advance knowledge of pain mechanisms, potentially leading to the development of more effective treatment strategies to alleviate chronic NSNP.

Background
More than half of migraine patients experience motion sensitivity and report symptoms of kinetosis and postural instability. Given the high prevalence of neck pain in this population, sensorimotor integration impairments of cervical afferents could be related to these symptoms. However, this topic is relatively unexplored among patients with migraine.
 
Purpose
The aim of this cross-sectional study was to investigate the influence of head movements on motion sensitivity and its association with balance alterations.
 
Method
Patients with migraine (n= 15) and healthy controls (n=15) reported presence and severity of kinetosis symptoms during the modified Cervical Torsion Test (CTT) and the Head Neck Differentiation Test (HNDT) using a Visual Analog Scale (0-100) and the Simulator Sickness Questionnaire (SSQ). Furthermore, their quiet standing balance was assessed over a foam with eyes closed for 30 seconds and the the postural sway (area and total sway) was calculated.
 
Results
Patients with migraine (66.7%) experienced greater motion sensitivity especially during the neck components of the HNDT and CTT tests, and also more often than healthy controls (20%), (Chi2= 6.65, p=0.01). SSQ scores reflecting severity of symptoms were higher in migraine than in controls (U=56.0, p=0.004). SSQ scores correlated moderately and positively with balance total sway (r=0.54, p=0.020) and sway area (r=0.50, p=0.029).
 
Conclusion
The higher frequency of triggered symptoms in migraineurs during the neck components of the tests and its association with balance impairment provides a first indication of involvement of cervical afferences and dysfunctional sensorimotor processing among migraineurs.
 
Implications
The understanding of the susceptibility of migraineurs to cervical provoked symptoms could improve clinical decision making for physiotherapists considering the impact of neck dysfunction on vestibular symptoms and kinetosis in migraine patients. Future research is required to evaluate the potential of the CTT and HNDT as valuable diagnostic tools for evaluating the neck as a source of dizziness and motion sensitivity in this population.

Background
People with whiplash associated disorders (whiplash) have poor outcomes and those with poor outcomes contribute to the highest rehabilitation costs in many countries. In Australia, despite two decades of guideline development and implementation, gaps remain in the assessment of people at risk of poor outcome and providing care matched to risk profile. Many stakeholder groups assess risk based on personal opinion, their experience or simply guess. Clinical guidelines developed using robust methods will allow clinicians to make informed and accurate choices about assessment of prognosis for people with whiplash.

Purpose
This project aimed to develop new multi-disciplinary guidelines for both acute and chronic whiplash associated disorders by i) following a robust process recommended by the National Health and Medical Research Council (NHMRC) in Australia and ii) following the GRADE process to develop recommendations for prognosis. The multi-disciplinary process aimed to ensure key stakeholders likely to implement recommendations were involved from the commencement of the project.

Methods
Following the NHMRC guidelines, an 18 member multidisciplinary committee was convened comprising key stakeholders from clinical professions (e.g. Physiotherapy, General Practice, Physicians, Psychology, Chiropractic, Exercise Physiology), research experts, insurer, legal, government regulator and consumer representatives. A systematic review was performed to identify prospective longitudinal cohort studies or secondary analysis of randomised controlled trials that have assessed both prognostic tools and prognostic factors predicting outcome for people with acute and chronic whiplash. Inclusion criteria were based on the PICOTS (Population, Index Prognostic factor, Comparator prognostic factors, Outcome, Timing, Setting) criteria. Studies meeting these criteria were meta-analysed where possible. The GRADE “certainty of evidence” and “evidence to decision frameworks” were followed by the guideline committee to determine prognosis recommendations. Guidelines then underwent both public consultation and external review before submission to the NHMRC for endorsement.

Results
From 2417 titles screened, recommendations were made from 5 prognostic tool studies, 57 acute whiplash prognostic factor studies and 6 chronic whiplash prognostic factor studies. Two prognostic tools were recommended (WhipPredict and SF-Orebro) to identify those at risk of poor prognosis. Individual prognostic factors with strong recommendations to determine poor outcome in people with acute whiplash were symptom factors (initial pain intensity, initial neck related disability, number of painful body areas number of painful symptoms) and psychological factors (post-traumatic stress symptoms and expectations of recovery). For people with chronic whiplash similar symptom factors were conditionally recommended (initial neck pain intensity and neck disability) to identify those likely to have ongoing poor outcome. Factors that are not recommended to assess to determine prognosis include crash related, imaging and socio-demographic factors.

Conclusion(s):
Clinicians are primarily recommended to administer a prognostic tool early after injury to identify both those with a good (likely to recover well) and poor prognosis. Stratified care, where care is matched to the risk profile is then recommended to be chosen from the guideline treatment recommendations.

Background: The clinical criteria and grading system for nociplastic pain involves the presence of (1) chronic symptoms; (2) regional pain distribution, (3) predominantly non-nociceptive or neuropathic pain origin, and (4) clinical signs of pain hypersensitivity (i.e., mechanical hyperalgesia) in the pain region. People with chronic whiplash-associated disorders (WAD) may demonstrate features of nociplastic pain. One of the possible co-morbidities of nociplastic pain is increased light sensitivity, which shifts the nociplastic pain classification from possible to probable. Light sensitivity can be measured via the Pupillary Light Reflex (PLR). Light sensitivity has not previously been evaluated in chronic WAD. It is unknown if light sensitivity is a feature of chronic WAD and if it is associated with clinical measures of nociplastic pain.

Purpose: To determine: (1) there is a significant difference in PLR measures between a healthy cohort (HC) and people with chronic WAD, and (2) if clinical measures of nociplastic pain are correlated to PLR measures in both HC and WAD cohorts.

Methods: Asymptomatic people (HC) from the community and an age/sex-matched cohort with chronic WAD and nociplastic pain (Cervical and tibialis anterior PPTs were reduced by more than 2 standard errors of measurement from the HC = mechanical hyperalgesia) attending a multidisciplinary chronic pain centre were recruited for the study. Clinical measures of nociplastic pain were collected, inclusive of pain intensity, Central Sensitisation Inventory – CSI, Pressure Pain Thresholds – PPTs, Temporal Summation – TS and Conditioned Pain Modulation – CPM. Measures of PLR were collected using a validated iPhone app in a standardized room environment. Independent t-tests evaluated group differences and Pearson’s correlation analyses measured the relationship between clinical measures of nociplastic pain and PLR.

Results: Twenty-six HC (15 female; mean age = 41.2 ± 12.7 yrs) and 26 people with chronic WAD (15 female; 43.2 ± 12.8 yrs) of median [interquartile range] 21 [12, 31] months duration of symptoms and mean pain (SD) of 6.5 (± 1.4)/10 were enrolled in the study. Participants demonstrated elevated CSI, reduced local and distal PPTs (as per inclusion criteria), and facilitated TS when compared to the HC. There were no differences in CPM. Chronic WAD demonstrated significantly reduced maximum constriction amplitude and quicker time to return to 75% of resting pupil diameter. PLR measures were not correlated to measures of nociplastic pain in either the HC or chronic WAD cohorts.

Conclusion(s): The between-group differences in PLR support other research in chronic WAD demonstrating autonomic nervous system dysfunction; with altered pupil constriction amplitude suggestive of changes in parasympathetic, and increased responsiveness of pupil re-dilatation suggestive of altered sympathetic nervous system function. There was no relationship between PLR and clinical measures of nociplastic pain, suggesting that altered nociceptive input is not driving this aberrant response in chronic WAD. Other comorbidities are required to establish that chronic WAD is a probable nociplastic pain condition.

Implications: Clinical utility of PLR is not currently warranted until research establishes parameters associated with clinical manifestations. Further research is also warranted to evaluate autonomic nervous system in chronic WAD.

Introduction: Manual joint mobilization and manipulation are recommended therapeutic interventions for people with neck pain. High-velocity thrust and sustained techniques have an uncertain association with serious arterial trauma. The validity of pre-manipulative tests of the cervical spine is often questioned, and the understanding of the effect of head/neck position on blood flow is still incomplete. Most of the evidence concerning hemodynamics in this area relates to extracranial flow (vertebral and carotid artery). Less is understood about the effects on intracranial flow while performing pre-manipulative tests and sustained positions like end of range cervical rotation mobilization. The aim of the study was to assess the influence of commonly used evaluation and treatment positions on intracranial hemodynamic
parameters.
Method: A randomized, cross-over observational study using ultrasonography on healthy subjects (n = 19) was conducted to measure hemodynamic parameters (peak systolic velocity and end diastolic maximum) of intracranial arterial systems. Two test positions (sustained premanipulative thrust C0-1 and sustained cervical end of range rotation) were compared with a sham position for each test position.
Results: Neither the sequence of tests performed nor an independent variable (the two positions) had a significant effect (p < 0.05) on peak systolic velocity (PSV) or end diastolic maximum (EDM).
Discussion: No effects from commonly used assessment and treatment of neck positions on hemodynamic parameters were found. This is consistent with previous studies. Further study is indicated on people with symptoms and known pathologies.

Background: Neck pain (NP) is a significant health problem that can lead to pain persistence. Identifying predictive variables in acute NP might assist in alleviating persistent pain and disability. Psychosocial factors appear to be adverse solid prognostic factors. Among them, avoidance and overactivity mediated pain persistence and disability. Stress takes a central role in the context of persistent pain. Pain and stress are intricately interconnected processes, both adaptive mechanisms for protecting the organism from harm. In cases of chronic pain, it can be seen as a form of stress overload, indicating a close relationship between the two and the potential for allostatic overload of the body and brain. However, stress and activity patterns have yet to be studied as predictors of pain persistence states over one year in subjects with acute NP.
Methods: This longitudinal inception cohort study recruits subjects with acute NP (< 4 weeks since the onset of pain) aged 18-65 years in clinical praxis, hospitals, and universities. Activity patterns (Avoidance-Endurance-Fast Screening (AE-FS)) and stress (Stress and Coping Inventory (SCI)) are collected at four different time points. Additionally, Hair cortisol concentrations (HCC) are measured to assess stress levels objectively. An online pain diary is maintained, providing information on the progression of pain over a year. In the initial phase, the prevalence of baseline activity patterns and HCC levels are determined using a cross-sectional design. As a subsequent step, the pain course over one year is observed. A linear mixed regression model calculates the time at which activity patterns, stress, and pain demonstrate the best predictive value for persistent pain and disability.
Discussion: To the best of our knowledge, this study represents the first investigation of activity patterns in acute NP and the predictive power of activity patterns, stress, and pain for the persistence of pain and disability in acute NP at different time points over one year.
Trial registration: Registration published 07/22, identifiers: NCT05468684
Keywords: Neck pain, activity patterns, stress, pain, disability

Introduction: Clinicians commonly assess cervical range of motion (ROM) in patients with neck pain. Recently, a new instrument has been developed, the Senscoordination 3D Cervical Trainer (SCT), designed to measure neck ROM in addition to joint position error, static and dynamic balance performance, and performance on a ‘neuro muscular control test’. The SCT incorporates a 9 degrees of freedom sensor which combines signals from a 3-axis accelerometer, a 3-axis gyroscope and a 3-axis magnetometer and then translates the 9 separate data points to an orientation vector in x, y and z coordinates and an angle of rotation around the direction of the vector. The sensor communicates with the computer and automatically displays the results on the screen after assessment.
This study aims to assess the interrater reliability, concurrent validity, and responsiveness of the SCT using the CROM device as a comparator.
Methods: One hundred patients with non-specific neck pain were included and their active cervical ROM was measured in a random order by two raters in succession using both devices simultaneously at baseline and after personalised physiotherapy management, at 12 week follow up. Convergent validity and responsiveness were quantified by a Pearson correlation coefficient. The intraclass correlation coefficient (ICC) was used to calculate the test–retest reliability of the SCT. The smallest
detectable change (SDC) was calculated per movement direction and for the total range of motion.
Results: The correlation between the measures obtained with the CROM device and the SCT was high (0.97 or 0.98 depending on direction of movement). Interrater reliability was high for all directions (ICC ranging from 0.81 to 0.97). The SDC ranged from 6.9 for left cervical rotation to 12.2 for right cervical rotation. At the follow up, correlation between the change score on the CROM device and the SCT was high (0.86–0.94 depending on the direction of movement).
Conclusion: The SCT is a valid, reliable and responsive instrument for measuring cervical ROM.

Background
The symptoms of hypermobility vary widely and can change across the lifespan. Whilst pain, joint instability and soft tissue injury are most commonly reported, many individuals report manifestations extending beyond the musculoskeletal system. Without routine screening, these multisystemic symptoms may go undetected and, if suboptimally managed, can significantly impact quality of life. The Spider, a 31-item self-report questionnaire, was developed to identify the presence and impact of the symptoms of hypermobility across eight domains: pain, fatigue, neuromusculoskeletal, cardiac dysautonomia, gastrointestinal, urogenital, depression and anxiety. Face and content validity of this new screening tool have been tested, and construct validity of the individual Spider domains has been established in adolescents.

Purpose
The aim of this study was to determine if the total Spider score, aggregated across all domains, provides a valid measure of the magnitude of symptom impact in adolescents and to explore which symptoms have the strongest associations with perceived functional ability in daily life. Convergent validity of the Spider’s total score was examined using an established measure of daily functional ability, the Paediatric Quality of Life Inventory (PedsQL). Known group validity testing determined whether the total score could differentiate between those with and without hypermobility. Finally, the strength with which each multisystemic manifestation (Spider domains) were associated with poorer functional ability relative to one another were explored.

Methods
This was an observational, cross-sectional study. Ethical approval was granted by the UCL Research Ethics Committee. Participants aged 13 to 18 years with and without symptomatic hypermobility were invited to complete the Spider and PedsQL questionnaires online via advertisement through 3 hypermobility charities (EDS UK, The ED Society, HMSA) and a private physiotherapy hypermobility unit. Data was analysed using descriptive and inferential statistics in SPSS.

Results
441 adolescents completed the study. Convergent validity testing, using Pearson’s correlation coefficient, demonstrated a strong inverse correlation between the Spider and PedsQL scores. As Spider scores increased, indicative of greater symptom impact, PedsQL scores decreased accordingly (r=-0.750, p < 0.001). Known-groups validity was evidenced by the significant between-group differences in Spider scores for those without and without hypermobility (median difference 42.34, p < 0.001). Multiple linear regression analysis of the domain scores revealed that the fatigue, cardiac dysautonomia and depression domains were the mostly strongly associated with poorer functional ability in adolescents.

Conclusion(s)
Results support the aggregation of scores from the eight Spider domains as a valid measure of the overall impact of hypermobility on functional ability in daily life in adolescents. Prioritising the management of fatigue, cardiac dysautonomia and depression, where present, may alleviate more of the burden associated with this condition.

Implications
The total Spider score can be used by clinicians to indicate the magnitude of symptom burden of hypermobility in adolescents, whilst the domain scores detail how a person is impacted to facilitate more directed management. Where fatigue, cardiac dysautonomia and depression predominate, clinicians may anticipate a greater level of disability in daily life and prioritise interventions accordingly to prevent further decline.

Background
Restoring agility post lower limb injury is pivotal in facilitating safe direction changes during sports activities, thereby minimizing the risk of re-injury. Standardized return-to-sport tests, including agility assessments such as the modified agility t-test (MAT), are commonly recommended. However, the psychometric properties of the MAT remain unestablished.

Purpose
This study aimed to ascertain the construct validity and test-retest reliability of the MAT.

Methods
In a single-center, cross-sectional study, we recruited 30 participants with an equal gender distribution and a mean age of 25.7 ± 1.5 years. We compared MAT performance against the Illinois agility test (IAT) to assess MAT’s construct validity by calculating Pearson’s correlation coefficient. The absolute and relative were gauged through the standard error of measurement, the 95% limits of agreement, the smallest detectable change and the intraclass correlation coefficient 2,1 (ICC 2,1) derived from test-retest results, setting statistical significance at α = 0.05.

Results
Pearson’s correlation coefficient revealed a substantial correlation between MAT and IAT performances (r = 0.89). Moreover, MAT demonstrated good test-retest reliability with a standard error of measurement of 0.18 seconds and an intraclass correlation coefficient 2,1 (ICC 2,1) of 0.84. The IAT mirrored this reliability with respective scores of 0.19 seconds and 0.97. Furthermore, we identified the smallest detectable change in MAT to be 0.71 seconds.

Conclusions
The study corroborates the construct validity and test-retest reliability of MAT as a credible agility assessment tool, thereby positing it as a viable alternative to IAT.

Implications
The MAT more accurately mirrors agility demands in sports with short displacements like tennis and basketball compared to the IAT and the standard T-test. However, for sports requiring longer sprints, the standard T-test remains more suitable. Moreover, it is recommended to compare an athlete’s MAT scores during the Return-to-Sport (RTS) process to those of healthy participants, using data from this study as a reference.

Understanding and predicting which patient will have the best outcomes or responses to a particular treatment has been a priority in physical rehabilitation. Although diagnostic findings have been the cornerstone of clinical decision-making for disease management by health care professionals, the literature now supports that targeting prognostic-related findings is a promising way for rehabilitation clinicians to improve treatment decision-making processes, personalize rehabilitation approaches, and ultimately enhance patient outcomes [1]. The biopsychosocial characteristics of the patient and clinical findings are prognosis-related when they influence the course of the disease. Considering that individuals with the same diagnostic label will have different clinical phenotypes [2], and might have different responses to the same treatment, the prognosis-related findings advise clinicians on the risk of poor/good outcomes for a patient, which is useful to guide management options [3]. For a given health condition, patients at greater risk of poor outcomes will benefit from treatment strategies that are not needed by patients that will recover promptly [4]. In the context of rehabilitation, this means giving the right treatment to the right patient at the right time. Hence, integrating prognostic-related information to improve management of musculoskeletal disorders is a promising way to improve patient outcomes and personalize care.

Specific learning objectives:
1. Understand the added value of prognostic-related information to diagnosis for musculoskeletal rehabilitation practice and how prognosis can serve to reduce overmedicalization and overutilization of health care.
2. Appraise the relevance of externally validated prognostic models to predict a patient’s health outcomes and direct treatment in the context of physical rehabilitation of musculoskeletal conditions.
3. Integrate prognostic-related information into clinical practice to different case study, in order to establish the “prognostic profile” of a patient.

CONTENT
Section #1: The marriage of Diagnosis and Prognosis (25 min)
To understand the added value of diagnostic versus prognostic-related information for musculoskeletal rehabilitation practice, we will address the distinctions between diagnosis and prognosis [5]. We will discuss the potential benefits of prognostic-based decision-making and ways to apply prognosis in clinical practice, along with their benefits and limitations [6, 7]. The different types of prognostic models will be presented [3]. Their clinical contributions will be discussed and illustrated (Dr Cook).

Section #2: The scientific and clinical value of Prognostic models (25 min).
To allow the participants to evaluate the relevance of externally validated prognostic models, we will present results from our most recent systematic review regarding externally validated prognostic models with potential clinical value [8]. We will take this opportunity to explain how prognostic evidence is best integrated into prognostic tools and provide the audience with criteria to highlight key elements to consider when selecting a prognostic tool for clinical practice (Florian NAYE).

Section #3: Establishment of a “prognostic profile” (25 min).
Numerous prognostic factors need to be taken into consideration in order to establish the “prognostic profile” of a patient with a musculoskeletal condition. We will present our most recent study where we develop and assess the acceptability and feasibility of a set of questionnaires to establish the “prognostic profile” of patients with work-related musculoskeletal disorders. Participants will be presented with different case study in order to facilitate the integration of prognostic-related information into practice (Dr Tousignant-Laflamme).

Panel Discussion (20 minutes): Each presenter will have 2 minutes to answer questions from the audience in a final interactive discussion. We will engage the audience and stimulate the interaction with the audience through web-based interactive Q&A (Kahoot®).

IMPLICATIONS
This focused symposium will provide rehabilitation professionals with a better understanding of prognosis, prognosis-related findings, and their contributions to their clinical practice. This new knowledge is essential to enhance the quality of care for people with musculoskeletal conditions. From the exposed prognostic models with potential clinical value, the participants will be able to apply their new knowledge as early as their first patient on Monday.

Through their interactive presentations, the panelists will address an expertise area that should be a core competency of physiotherapists, namely the integration of prognostic-related information to improve the management of musculoskeletal disorders, helping to provide the right treatment to the right patient at the right time. Finally, it will help identify patients who may need more intensive care, from those who are likely to improve with marginal engagement and discusses current evidence supporting this assumption.

References:
[1] https://doi.org/10.1093/ptj/pzz171
[2] https://doi.org/10.1002/ejp.1541
[3] https://doi.org/10.1093/ptj/pzac023
[4] https://doi.org/10.1136/bmj.e5793
[5] https://doi.org/10.1186/s12916-014-0265-4
[6] https://doi.org/10.1371/journal.pmed.1001380
[7] https://doi.org/10.1371/journal.pmed.1001381
[8] https://doi.org/10.1093/ptj/pzad021

Learning objectives (up to 3)
The overall aim of this symposium is to describe new developments implicating neuroimmune contributions to certain persistent pain conditions including whiplash-associated disorder (WAD), using cutting-edge techniques to identify peripheral nerve pathology and examine its relationship to the immune system.
At the end of the symposium, attendees will be able to:
1. Describe the relevance of peripheral nerve pathology to clinical practice in some common persistent MSK conditions.
2. Discuss research and clinical methods used to identify peripheral nerve pathologies.
3. Describe the growing evidence base for links between the immune system, nervous system, and symptoms in some common persistent MSK conditions.
• Description (this must be evidence based)
Persistent MSK conditions such as low back pain, neck pain, and WAD account for high numbers of days of work loss with resultant high financial losses. For example, in 2019/2020 in the UK, 480,000 employees presented with work-related MSK conditions which resulted in an estimated 8.9 million lost working days(1). Current treatments for persistent MSK pain conditions typically demonstrate modest effects(2, 3) and this may reflect our incomplete understanding of the underpinning mechanisms.
Despite not being traditionally considered neuropathic pain conditions, many of these musculoskeletal conditions have signs of nerve pathology (4-6). Such signs include abnormal sensory detection thresholds using quantitative sensory testing; signs of nerve inflammation on magnetic resonance imaging (MRI); and structural degeneration of small nerve fibres in skin biopsies (4-6).
Findings of nerve pathology in some persistent MSK conditions may result from a direct nerve injury (eg after WAD) but many could result from neuroimmune changes as has been previously demonstrated using animal models (7). For example, it is well established that stress is associated with increased inflammatory markers (8) and signs of nerve dysfunction. Posttraumatic stress found in some conditions such as WAD have been associated with persistent pain (9), and higher levels of stress have been demonstrated to mediate the trajectory of acute to persistent low back pain (10).
Overall, our symposium will explore pathophysiological neuroimmune involvement in certain persistent MSK conditions, with a particular focus on WAD. We will do this by describing new developments enabled by cutting-edge research methods, including:
1. Detailed assessments of nerve structure and function using a range of clinical and research methods. We will highlight quantitative sensory testing (11), histological analysis from skin biopsies (12), as well as validated bedside clinical tests (13, 14). This section will be presented by Dr Joel Fundaun.

2. Novel MRI sequences and analyses to measure signs indicative of nerve inflammation (5) and structural nerve changes (15) (e.g., demyelination and nerve degeneration). This section will be presented by Dr Colette Ridehalgh.

3. Characterisation of systemic and local inflammation using blood markers, genome-wide association studies and gene-expression analyses. We will explore evidence for raised inflammatory markers in WAD, persistent spinal and widespread pain based on clinical (16), biobank (17) and genetic (18) data, including relationships with clinical presentation. Links between nerve pathology and skin inflammatory cytokine gene expression will be reported. This section will be presented by Dr Scott Farrell.
The symposium will discuss each of the above methods within the context of people with persistent MSK pain. It will discuss the clinical implications of how knowledge of such pathophysiological mechanisms can influence patient management.
• Implications/conclusions
An improved understanding of the mechanisms related to persistent MSK pain is critical to improve patient outcomes. This symposium will explore the accumulating evidence for peripheral nerve pathology and links to the neuro-immune system in people with persistent MSK pain whilst detailing innovative interdisciplinary research methods. This session aims to provide a clear overview of these findings and explain their relevance to clinical management. Additionally, it will assist attendees to understand the application of simple bedside clinical tests and their important role in a detailed assessment of neurologic function in MSK persistent pain.

• References
1. Health and Safety executive. Work related Musculoskeletal Disorde Statistics (WRMSDs) in Great Britain. UK:HSE. 2020.
2. Sterling M, de Zoete RMJ, Coppieters I, Farrell SF. Best Evidence Rehabilitation for Chronic Pain Part 4: Neck Pain. J Clin Med. 2019;8(8).
3. Hayden JA, Ellis J, Ogilvie R, Malmivaara A, van Tulder MW. Exercise therapy for chronic low back pain. Cochrane Database Syst Rev. 2021;9(9):Cd009790.
4. Fundaun J, Kolski M, Baskozos G, Dilley A, Sterling M, Schmid AB. Nerve pathology and neuropathic pain after whiplash injury: a systematic review and meta-analysis. Pain. 2021.
5. Greening J, Anantharaman K, Young R, Dilley A. Evidence for Increased Magnetic Resonance Imaging Signal Intensity and Morphological Changes in the Brachial Plexus and Median Nerves of Patients With Chronic Arm and Neck Pain Following Whiplash Injury. J Orthop Sports Phys Ther. 2018;48(7):523-32.
6. Farrell SF, Sterling M, Irving-Rodgers H, Schmid AB. Small fibre pathology in chronic whiplash-associated disorder: A cross-sectional study. Eur J Pain. 2020;24(6):1045-57.
7. Winkelstein BA. How can animal models inform on the transition to chronic symptoms in whiplash? Spine (Phila Pa 1976). 2011;36(25 Suppl):S218-25.
8. Marsland AL, Walsh C, Lockwood K, John-Henderson NA. The effects of acute psychological stress on circulating and stimulated inflammatory markers: A systematic review and meta-analysis. Brain, Behavior, and Immunity. 2017;64:208-19.
9. Sterling M, Hendrikz J, Kenardy J. Similar factors predict disability and posttraumatic stress disorder trajectories after whiplash injury. Pain. 2011;152(6):1272-8.
10. Bernier Carney KM, Guite JW, Young EE, Starkweather AR. Investigating key predictors of persistent low back pain: A focus on psychological stress. Applied Nursing Research. 2021;58:151406.
11. Rolke R, Baron R, Maier C, Tölle TR, Treede DR, Beyer A, et al. Quantitative sensory testing in the German Research Network on Neuropathic Pain (DFNS): standardized protocol and reference values. Pain. 2006;123(3):231-43.
12. Lauria G, Hsieh ST, Johansson O, Kennedy WR, Leger JM, Mellgren SI, et al. European Federation of Neurological Societies/Peripheral Nerve Society Guideline on the use of skin biopsy in the diagnosis of small fiber neuropathy. Report of a joint task force of the European Federation of Neurological Societies and the Peripheral Nerve Society. Eur J Neurol. 2010;17(7):903-12, e44-9.
13. Zhu GC, Böttger K, Slater H, Cook C, Farrell SF, Hailey L, et al. Concurrent validity of a low-cost and time-efficient clinical sensory test battery to evaluate somatosensory dysfunction. Eur J Pain. 2019;23(10):1826-38.
14. Ridehalgh C, Sandy-Hindmarch OP, Schmid AB. Validity of Clinical Small-Fiber Sensory Testing to Detect Small-Nerve Fiber Degeneration. J Orthop Sports Phys Ther. 2018;48(10):767-74.
15. Schmid AB, Campbell J, Hurley SA, Jbabdi S, Andersson JL, Jenkinson M, et al. Feasibility of Diffusion Tensor and Morphologic Imaging of Peripheral Nerves at Ultra-High Field Strength. Invest Radiol. 2018;53(12):705-13.
16. Farrell SF, de Zoete RMJ, Cabot PJ, Sterling M. Systemic inflammatory markers in neck pain: A systematic review with meta-analysis. Eur J Pain. 2020;24(9):1666-86.
17. Farrell SF, Armfield NR, Elphinston R, Cabot PJ, Sterling M. C-reactive protein and chronic pain risk in the UK Biobank. Back & Neck Pain Forum Global Virtual Conference; Virtual2021.
18. Farrell S, Sterling M, Klyne D, Mustafa S, Campos A, Kho P-F, et al. Genetic impact of blood C-reactive protein levels on chronic spinal and widespread pain. 2023.

This workshop will commence. with Prof’s Reid and Rebbeck presenting a complex cervical spine case with focus on clinical reasoning on screening, differential diagnosis, assessment and management . Participants will engage interactively in the clinical reasoning process and practical skills as the case progresses. Prof Jull will demonstrate a range of clinical tests essential to assess and manage this case. The diverse competencies required to manage the cases will be discussed with the audience via interactive participation. How the evidence informs the clinical reasoning process will be highlighted in the case.
Structure:
1. Complex Case presentation with interactive clinical reasoning. Differentiating neck pain, dizziness, and post-concussion symptoms This will involve undertaking relevant screening processes to rule out red flags and understand the clinical reasoning processes to differentiate the dizziness and headache related symptoms in this case. This will be an interactive discussion and demonstration of differential tests for dizziness. (Prof Duncan Reid and Prof Rebbeck 35-mins).
2. Discussion on the need for accurate performance and interpretation of tests of cervical musculoskeletal function in differentiation diagnosis of headache. Prof Jull will provide a practical demonstration of relevant tests emphasising that interpretation cannot rely on a pain response only (15 mins)
3. Discussion and wrap up 10 mins

Learning Objectives
Participants will
1. Understand the screening, assessment and diagnostic reasoning in the management of complex cervical spine disorders.
2. Understand how to differentiate dizziness and vestibular ocular dysfunction from cervicogenic dysfunction in patients presenting with post-concussion type conditions with relevant clinical tests.
3. Understand how to apply clinical reasoning frameworks to differentially diagnose different headache presentations.
4. Understand that interpretation of tests of cervical physical function cannot rely solely on a pain response

Background: Low back pain (LBP) is a leading cause of disability worldwide. Early detection of prognostic factors using the Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPQ-21) or the Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) can predict improvement in pain and disability for patients with nonspecific LBP. However, an Italian version of these instruments is not available.
Purpose: To translate and cross-culturally adapt the ÖMPQ-21 and the OSPRO-YF with their short versions into Italian and to test their measurement properties in LBP patients.
Methods: ÖMPQ-21 and OSPRO-YF were translated into Italian following international guidelines and were administered to patients with LBP together with a Numerical Rating Pain Scale (NPRS), the Oswestry Disability Index (ODI), the Pain Self-Efficacy Questionnaire (PSEQ), and the Pain Catastrophizing Scale (PCS). The following measurement properties were evaluated: test-retest reliability (by means of Intraclass Correlation Coefficient [ICC]), measurement error (Standard Error of Measurement [SEM], Minimal Detectable Change [MDC]), and construct validity (hypotheses testing for correlations with other instruments) in line with COSMIN recommendation.
Results: Eighty-three patients (mean±SD age=47.0±15.2 years; 56.6% female) with nonspecific LBP were included. The translation process was performed without any issues for both questionnaires. The ÖMPQ-21 and the OSPRO-YF were completed in an average±SD time of 3.6±2.2 and 3.5±3.0 minutes, respectively. No floor or ceiling effects were reported with few missing items. Test-retest reliability of the ÖMPQ-21 and the OSPRO-YF and their short forms (studied in a subsample of 31 patients) were excellent and good, respectively (ICC=0.82; 95% CI=0.65-0.91 for ÖMPQ-21; ICC=0.80, 95% CI, 0.63-0.90 for ÖMPQ _short form; ICC=0.92; 95% CI=0.84-0.97 for OSPRO-YF; ICC=0.92, 95% CI=0.84-0.96 for OSPRO 10 item; ICC=0.92, 95% CI=0.92-0.98 for OSPRO 7 item). The measurement error analysis revealed a SEM of 2.3 points (2.8%) and a MDC of 6.4 points (7.8%) for the OSPRO-YF and a SEM of 6.7 points (3.2%) and a MDC of 18.6 points (8.9%). The construct validity of the ÖMPQ-21 and its 10-item short version and OSPRO-YF was satisfactory and moderate, as 100% (4 out 4) and 50% (2 out 2) of the a-priori hypotheses were met, respectively. Overall, the OSPRO-YF performed better than the OMPQ-21 on all three measurement properties.
Discussion: The Italian versions of the ÖMPQ-21 and OSPRO-YF were developed and their reliability and validity were confirmed. These instruments and their short versions are quick to administer, reliable and valid. These multidimensional psychological tools can assist physiotherapists in setting goals and providing psychosocial patient education. Moreover, future studies with a greater sample in different settings and musculoskeletal pathologies are needed to confirm the current study's findings.
Conclusion: ÖMPQ-21 and OSPRO-YF and their short versions are reliable and valid for identifying yellow flags in Italian LBP patients, with the latter generally performing better than the former. Further research is needed to confirm their ability to predict core outcomes in patients with LBP.
Implications: OSPRO-YF performed better than OMPQ-21 in all three assessed measurement properties: test-retest reliability, measurement error and construct validity and it could be clinically useful.

Background:
Delivering interventions to support self-management of persisting musculoskeletal health conditions can pose challenges for clinicians. However, there is limited knowledge regarding the actual implementation of these interventions in clinical practice. If the delivery falls short of the desired level this may severely impact on effect.
Fidelity evaluation offers a valuable perspective for scrutinizing the delivery of complex interventions, elucidating the key elements that influence the efficacy of an intervention by bridging research, clinical practice, and education.
To the best of our knowledge, there are currently no generic measurement tools designed to assess the fidelity of treatment delivery in the context of self-management supportive care for persisting musculoskeletal health conditions.

Purpose:
We aimed to develop a checklist for evaluating the delivery of structured patient education and exercise interventions by clinicians for persistent back pain in primary care. The specific objective was to create a checklist tailored to the GLA:D Back program. Ultimately, we wanted that checklist to be an adaptable tool for the broader evaluation of self-management interventions for musculoskeletal pain across various clinical settings.

Methods:
We systematically developed items for the treatment delivery fidelity checklist, integrating The Behaviour Change Technique Taxonomy and communication style theory. Our approach involved a structured three-step process: 1) creating a preliminary fidelity intervention framework, 2) validating checklist content, and 3) pilot testing with refinement.

Results:
We developed the GLA:D BACK Self-management Adherence and Competence (SMAC) Checklist. The SMAC Checklist covers the dimensions adherence to structure of the program and clinicians’ competence in delivery of the central elements of the intervention. Preliminary pilot test results indicated a high level of observer agreement, suggesting its reliability.

Conclusion:
The SMAC Checklist serves as a fidelity measurement instrument for assessing the implementation of self-management interventions for persistent back pain. Its versatility enhances its value, making it adaptable for various self-management interventions addressing musculoskeletal pain.

Implications:
Existing knowledge underscores the challenges associated with delivering interventions aimed at supporting self-management. Notably, there is a lack of generic measurement tools specifically addressing treatment delivery in the context of self-management supportive care for patients with back pain care. Evaluating treatment delivery becomes imperative to identify challenging components for clinicians and comprehend the impact of delivery on patient outcomes.
This study contributes to the field by introducing the GLA:D BACK Self-management Adherence and Competence Checklist. This checklist is designed to assess the adherence and competence of clinicians in delivering a self-management supportive group-based intervention, which includes patient education and exercises. It addresses key behavior change elements and is adaptable to similar complex health interventions, providing a valuable tool for clinicians in enhancing the effectiveness of self-management support strategies in clinical practice.

Background:
Disturbed cervical proprioception has been reported in neck pain conditions. Proprioception can be defined as the conscious and unconscious awareness of joint position, movement, force, heaviness and effort. While cervical proprioception is commonly assessed with joint position sense or movement sense tests, research investigating cervical force sense is scarce. Force sense can be measured as force reproduction, i.e., the ability to reproduce a pre-determined force, or as force steadiness, i.e., the ability to maintain a steady sub-maximal contraction. There is a need for valid and reliable force sense tests for research and clinical use.

Purpose:
Examine the discriminative validity and test-retest reliability of cervical force sense tests using a Nintendo Wii Balance Board™ (WBB).

Methods:
Forty-two participants (44.6 ±12.7 years, 76% females) were recruited, 22 with persistent neck pain (NP) and 20 asymptomatic controls (CON). Assessments were performed at two physiotherapy clinics. Cervical extension force was measured with the participant in a supine crook lying position with the head positioned on the WBB. The participant received visual feedback from a small TV-screen. Maximum voluntary isometric contraction (MVIC) force was assessed, followed by the force reproduction and force steadiness tasks, both at 10% and 20% of MVIC. Outcome variables were constant error (CE), variable error (VE) and absolute error (AE) for the force reproduction tests, and coefficient of variation (CoV), standard deviation, and mean absolute error for the force steadiness tests. The tests were repeated after 5-7 days for test-retest reliability evaluation. Group differences were analyzed with independent t-test or Mann-Whitney U-test. Association between force sense and neck disability index (NDI) was analyzed with Pearson’s correlation. Intra class correlation (ICC) was used to analyze relative reliability, and standard error of measurement (SEM) was calculated for absolute reliability.

Results:
The MVIC test showed significantly reduced strength among NP (p=0.022, effect size 0.124). The force sense tests showed significant group differences in force steadiness CoV 10% (p=0.023, effect size 0.122) and CoV 20% (p=0.049, effect size 0.093), while no significant group difference was seen in force reproduction. Moderate positive correlations were seen between NDI and CoV 10% (p=0.043, r=0.456) and CoV 20% (p=0,043, r=0.455) in the NP group. Reliability was excellent for the MVIC test (ICC 0.98) with SEM value 1.78. Force steadiness CoV 10% and 20% were good (ICC 0.75-0.79) with SEM 2.4-11.89, and force reproduction variables were moderate to excellent (ICC 0.71-0.91) with SEM 5.01- 68.06.

Conclusion(s):
Neck pain patients had reduced muscle strength and deficits in force steadiness, although effect size of the difference was small in this group. Testing MVIC and force steadiness with WBB has acceptable reliability. Future studies should evaluate other psychometric properties, e.g., responsiveness; and include other NP groups, e.g., cervical dizziness or whiplash disorders. The tests could be modified to include other movement directions such as flexion or lateral flexion. Intervention studies could target force sense with specific exercises.

Implications:
WBB can be used in the clinic for objective assessment of MVIC and force steadiness to guide clinical intervention for people with neck pain.

Objective
To explore modifiable psychosocial factors, sleep-related variables, indices of central pain processing and patients’ characteristics as potential prognostic factors for shoulder function, pain and Quality of Life (QoL) one-year after RCR.
Design
This observational longitudinal study included 142 patients undergoing rotator cuff repair (RCR). All measures took place pre RCR (T1), and 12 weeks (T2) and 12 months (T3) post RCR.
Methods
Mixed-effects linear regression modelled relationships between the Western Ontario Rotator Cuff Index (model 1), the Subjective Shoulder Value (model 2) and Euroqol’s EQ-5D-5L for QoL (model 3) and potential prognostic factors (PF) over time. Factors included; psychosocial variables (pain catastrophizing, perceived stress, injury perceptions, patients’ expectations for RCR); sleep–related variables (sleep quality, sleep efficiency, sleep duration); factors related to central pain processing (central sensitisation, temporal summation, cold hyperalgesia, pressure pain threshold and douleur neuropathique 4 (DN4) for neuropathic pain component). Patients’ age, sex, and body mass index complemented the analyses.
Results
At follow-up (T3) 124 participants provided analysable datasets. Expectation for symptom reduction (p < 0.0001), DN4 score (p=0.0481), injury perception subscale consequence (p = 0.0035), sleep quality (p = 0.0011) and sleep efficiency (p = 0.0002) were identified prognostic factors for the outcomes over time (models 1,2,3).
Conclusion
Cognitions, pain mechanisms and sleep behaviour ought to be addressed prior to RCR in order to identify potential mal-responders to surgery. Only then we are able to master the patients’ course of care towards beneficial outcomes.

Background: The combination of Action Observation (AO) and Motor Imagery (MI) added to physical practice might be beneficial therapy option.
Purpose: We evaluated the effect of the combined intervention of AOMI on motor learning in healthy individuals and patients.
Methods: We systematically searched Cochrane Library, Embase, Medline Ovid, Physiotherapy Evidence database, PsycINFO, Scopus, SPORTDiscus, Web of Science and clinicaltrials.gov. Screening processes and data extraction were performed by two independent authors. Study methodologies were independently assessed with the Risk of Bias and the GRADE tools.
Results: The interventions of the selected 22 randomized controlled trials out of 5440 references (total 869 participants: healthy individuals, Parkinson's disease, patients after stroke, patients after total hip arthroplasty, children and students with neurological impairments) differed greatly. Four studies were included in three meta-analyses. AOMI simultaneously and alternately compared to conventional therapy regarding dart throwing performance were both effective with SMD=0.38 (95%CI=- 0.24-1.01). AOMI training compared to conventional therapy alone were effective for ball rotation performance regarding completion time (SMD=-0.32 (95%CI=-0.91-0.28)) and error-rate (SMD=-0.21 (95%CI=-0.65-0.23)). Mainly, the first-person perspective was used for AO and MI and the kinesthetic mode for MI. The AOMI intervention lasted from 1 day to 8 weeks including 1 to 126 AOMI sessions with 3 to 630 AOMI trials.
Conclusion: Our results showed a positive effect of AO combined with MI on motor learning. So far, no final conclusion can be drawn on essential parameters (mode, perspective) of an AOMI intervention due to the high heterogeneity of the studies. PROSPERO register number: CRD42021242812.
Implications: Further research should be conducted including different age and patient populations. Furthermore, we recommend some aspects to be considered: (1) use of a consistent terminology (Action Observation and Motor Imagery) for AOMI; (2) evaluation of participants' MI ability before and after the intervention with standardized assessments; (3) introductory sessions for AOMI before the actual AOMI training to ensure the same knowledge regarding AOMI for all participants; (4) include control processes for the AOMI training (e.g., diary); and (5) include follow-up assessment to explore the long-term effect of the AOMI training.

BACKGROUND
Lumbar spinal stenosis is a disabling condition affecting older people and there is a need to provide effective rehabilitation. The BOOST programme is a group physical and psychological intervention for patients with spinal stenosis that we evaluated in the BOOST randomised controlled trial (RCT). The BOOST programme significantly improved walking at 6 and 12 months, reduced risk of falling and was cost-effective compared to best practice advice. Pain related disability improved at 6 months. This study aimed to evaluate implementation of the BOOST programme into routine practice and provided the opportunity to optimise the programme.

METHODS
The integrated Promoting Action on Research Implementation in Health Services framework informed this study. In stage 1, we worked with patients and physiotherapists to optimise the programme for implementation. We used a synthetic control method to test the optimised programme in an identical way to the BOOST RCT and compare outcomes. Physiotherapists attended face-to-face training before delivering the optimised programme. We undertook a prospective cohort study at four sites aiming to recruit 24 participants. Participants completed the Oswestry Disability Index (ODI) and underwent the 6-minute walk test at baseline and 6 months. We interviewed physiotherapists. In stage 2, integrating stage 1 feedback, we developed and evaluated a Massive Online Open Course (MOOC) to provide physiotherapist training. We conducted another cohort study to evaluate clinical outcomes when delivering the BOOST programme in routine practice by a subset of MOOC learners (recruitment target of 60 participants). We compared outcomes from this implementation study to the BOOST RCT control arm using propensity score methods.

RESULTS
BOOST Optimisation:
Key changes were providing more information about medication, earlier promotion of long-term exercise and two new exercises focusing on standing. Thirty-one participants were enrolled in the programme with 26/31 (84%) providing follow up data.

MOOC evaluation:
Thirty-one learners enrolled in the MOOC and 24/31 (77%) completed the course evaluation. They were satisfied with the training and felt confident to deliver the programme with 21/24 (87.5%) intending to implement it. At 6 months, 18/31 (58%) learners provided feedback, 12/18 (66%) reported delivering the programme and 4/18 (22%) reported using programme elements. Physiotherapists from nine sites implemented the programme and collected clinical outcomes (74 participants with 57/74 (77%) providing follow up data).

Clinical outcomes:
In stage 1, implementation study participants had larger reductions in the ODI compared to the BOOST RCT control arm (-5.7 points (95%CI -1.7 to -9.6). In stage 2, the difference was -3.6 (95%CI -6.9 to -0.3). Findings were similar to the RCT. In stage 1, implementation study participants were able to walk 75.24m (95%CI 49.97 to 100.51) more than the BOOST RCT control arm. In stage 2, the difference was 63.78m (95%CI 38.84 to 88.72). Improvements were more than twice those observed in the RCT.

CONCLUSIONS
We have demonstrated successful implementation of the BOOST programme into routine practice and that we could train physiotherapists using a MOOC to deliver the programme effectively. Improvements in walking compared to the BOOST RCT suggest optimisation was worthwhile.

Background:
Low back pain is recognised globally as a prevalent, costly and disabling condition. Recurrences are common, with approximately 7 in every 10 individuals experiencing a recurrence of low back pain within 12 months following recovery from an episode. While exercise and education are recommended to prevent recurrence, the effectiveness and cost-effectiveness of an accessible and low-cost intervention, such as walking, is yet to be established.

Purpose:
This randomised controlled trial aimed to establish the effectiveness and cost-effectiveness of an individualised, progressive walking and education intervention for the prevention of low back pain recurrences.

Methods:
The WalkBack trial was a pragmatic, two-armed, randomised controlled trial, recruiting adults (aged 18 years or older) across Australia who had recently recovered from an episode of non-specific low back pain. Participants were randomly assigned to an individualised, progressive walking and education intervention or to a no-treatment control group. Those allocated to the intervention group received 6 sessions with a physiotherapist upskilled in health-coaching, to facilitate a progressive walking program and education over a 6 month period. The primary outcome was days to the first recurrence of an activity-limiting episode of low back pain, collected monthly via self-report. Secondary outcomes included days to the first recurrence of any episode of low back pain, and days to the first episode of low back pain leading to care seeking, and adverse events. Cost-effectiveness was evaluated from the societal perspective. Participants were followed monthly for a minimum of 12 and a maximum of 36 months, depending on the date of enrolment.

Results:
Seven hundred and one participants (n=351 intervention, n=350 control) were randomised between September, 2019, and June, 2022. The intervention was effective in preventing an episode of activity-limiting low back pain (hazard ratio (HR) 0.72, 95% CI 0.60-0.85, p=0.0002). The intervention also reduced the risk of any recurrences of low back pain and care-seeking recurrences of low back pain compared to the control group (HR 0.80, 95% CI 0.68 to 0.94, p=0.0066 and HR 0.57, 95% CI 0.44 to 0.74, p < 0.0001, respectively). A similar number of participants experienced at least one adverse event across the intervention and control groups over 12 months (183/351 and 190/350, respectively, p=0.80). The intervention also had a high probability of being cost-effective (94% at a willingness-to-pay of AU$28,000/QALY).

Conclusion:
An individualised, progressive walking and education intervention significantly reduced low back pain recurrence and was highly likely to be cost-effective.

Implications:
This accessible, scalable, and safe intervention could profoundly impact how low back pain is managed within the physiotherapy profession. These results emphasise the importance of preventive management for low back pain.

A subgroup of patients with low back pain (LBP) present with movement control impairment (MCI). From a biomechanical standpoint, effective spine movement control encompasses dynamic and static activities, requiring precise trunk muscle activation for posture maintenance. These actions are orchestrated by the central nervous system, which integrates peripheral sensorimotor inputs and cortical information to plan and execute coordinated motor responses to environmental changes. Despite extensive research in this area, knowledge of the temporal aspect of MCI in acute LBP is lacking. Using functional MRI, we have demonstrated that lumbar spine stimulation activates brain regions, serving as a proxy for anticipatory trunk control.
This explorative fMRI study applied pain-free mechanosensory stimulation to the lumbar spine's functional spinal units. We examined functional connectivity based on this stimulation and its correlation with the clinically assessed MCI. In this study, to assess MCI, we applied a battery of six reliable, rapid, and easy-to-use tests to address extension, flexion, and lateral flexion. The test score was based on the number of positive (i.e., inaccurately performed) tests and served as the outcome measurement. The study included 19 participants experiencing acute LBP (within 4 weeks of onset), with a mean moderate pain intensity of 4.5/10 and mild associated disability.
The results showed that within the salience network, there was a positive correlation between the connectivity of the parietal operculum and various cerebellum areas with the MCI score. Additionally, a strong positive correlation was observed between the MCI and the connectivity of the cerebellum with the hippocampus in the limbic and parahippocampal network. In the sensorimotor network, the MCI was moderately correlated with the association between the postcentral gyrus and the cerebellum.
Functional adaptations of the sensorimotor networks within four weeks of an acute LBP episode have been confirmed. The present results further elucidate these findings by linking MCI with adaptations in functional brain networks. Specifically, MCI was associated with regions involved in sensory integration, accurate planning, and correction of trunk movements based on sensory feedback. Complex movement sequences, such as trunk movement control, typically involve premotor areas for planning. However, disruption or pain necessitates cerebellar coordination, supported by robust connectivity with various cerebellum areas. Additionally, the correlation of MCI with brain regions within the limbic and hippocampal network suggests potential involvement in disturbances of integration of internal states, emotional regulation, and memory-related aspects of motor control. Our findings align with behavioral studies indicating various effects on cognitive processes and motor responses attributed to LBP. Understanding factors influencing movement control in patients with LBP remains a significant challenge for clinicians. The results suggest that stratified care of patients with MCI in primary care could be beneficial in preventing persistent symptoms.

Learning Objectives:
On session completion, participants will:
1. Be aware of biopsychosocial factors involved in the presentation of GTPS, implications for management and the current evidence for various management approaches
2. Understand the rationale and current evidence for exercise and load management approaches for GTPS and identify current gaps and future research directions.
3. Be aware of the recommended core outcomes to be used in research and clinical practice of GTPS
Description: Greater trochanteric pain syndrome (GTPS) is a common condition characterised by pain and tenderness over the greater trochanter, which adversely affects function and quality of life. It encompasses tendinopathy of the gluteus medius and minimus tendons (gluteal tendinopathy) with or without distention of the trochanteric bursae. Traditionally, corticosteroid injection (CSI) has been a first-line intervention despite concerns regarding long-term impacts on local soft tissues. In recent years, studies elucidating alterations in musculotendinous morphology and function, kinetics and kinematics, in this patient population (Allison et al, 2015; Allison et al., 2016) provided the basis for innovation of management techniques through integration of this evidence-base. Emerging evidence shows that pain may not just be nociceptive in nature, and psychological factors may contribute to the complexity and severity of the clinical presentation and require consideration in management (Plinsinga et al., 2018; French et al., 2019).
As tendinopathy is recognised as the most common pathology, focussing on exercise and load management is justified. Randomised controlled trials investigating exercise for gluteal tendinopathy/GTPS have been undertaken (Mellor et al., 2018; Clifford et al., 2019; Ganderton et al., 2018; Cowan et al., 2022)), with varying results. This symposium will explore the pathological basis and principles underpinning exercise and load management, current evidence, and gaps remaining in relation to the role of exercise for gluteal tendinopathy. Exploratory analysis of results from the landmark LEAP trial, which compared exercise and education to CSI or wait-and-see, identified underlying causal mechanisms and patient features that may influence the observed treatment effects of exercise and education. These findings will be discussed in the symposium (Mellor et al., 2022).
While education and exercise provide the framework for management of GTPS, other interventions used in clinical practice such as shockwave therapy and platelet rich plasma (PRP) injection have also been investigated. The current evidence for these interventions will also be presented, as well as adjunctive therapies such as dynamic tape (Robinson et al., 2019) and orthotics (Hunter et al., 2023), that have been used with the aim of reducing the increased hip adductor moment seen in this population (Allison et al., 2016).
To continue to build the evidence on the optimal management approaches for gluteal tendinopathy, it is important that standardised use of outcome measures to determine treatment effectiveness are applied in clinical practice and research (Nasser et al, 2022). A core set of outcome domains have been devised for use in gluteal tendinopathy trials, and the results of this 6-stage process to develop this core set will be presented during this symposium.
Implications/Conclusion: Until recently, gluteal tendinopathy/GTPS was a poorly understood condition, with the literature suggesting that physiotherapy treatments had little to offer those with GTPS. Over the last few years, a substantial body of evidence has evolved regarding physical and psychological impairments associated with GTPS and the success of targeted load management and exercise, laying a solid foundation for a more efficacious management approach. Current gaps in our knowledge and evidence, with recommendations for future research and implementation into practice will be presented during the symposium.

Implications/Conclusion: Gluteal tendinopathy/GTPS is one of the most common painful tendon conditions assessed by medical practitioners and physiotherapists, causing disability equal to that of severe hip osteoarthritis, imposing a substantial health and economic burden. Current evidence indicates this is a complex condition with physical and psychosocial features. This symposium will focus on the increasing body of, and often conflicting, evidence for different management approaches, as well as highlighting the importance of using consistent core outcomes in research and practice to determine treatment effectiveness.

The rapid emergence of generative AI presents novel opportunities and challenges for the physiotherapy profession, and meaningful engagement with this technology requires inclusive discussion and debate within our community. Traditional conference formats, where invited experts present their perspectives, often fail to facilitate this kind of inclusive engagement.
This conference event series aims to promote inclusive discussion on generative AI through participatory activities spanning the timeframe before, during and after the conference. Input will be gathered from a diversity of conference participants, avoiding over-reliance on invited expert opinion.
In the weeks prior to the conference, an initial survey with open-ended questions will be distributed to a small group of thought leaders in physiotherapy practice and education. The goal is to identify a limited set of themes and questions to help focus the upcoming discussions. Given the infancy of generative AI, no one can claim expertise, so gathering preliminary perspectives from a sample of engaged practitioners and educators will provide helpful direction.
The identified themes and questions will next be shared through the conference organisers' social networks and professional communities. This larger-scale survey will collect current thoughts and concerns about generative AI in a broader cross-section of the physiotherapy community, to be used as a foundation for the following events in the series.
These survey results will then inform a pre-conference workshop. Through small group dialogue, debate, and creative activities, participants will expand on the previously identified themes and questions. The workshop will culminate with each group proposing strategies to maximise opportunities and minimise risks from generative AI in physiotherapy practice and education.
Key insights from the pre-conference surveys and workshop will be presented at the focused symposium during the conference itself. This symposium will summarise survey results and workshop outputs, connecting them to produce a synthesis of community perspectives on generative AI. The symposium will also include panel discussions to further explore tensions, trade-offs and open questions.
Post-conference, the organisers will distribute a discussion framework that captures community input from the surveys, workshop and symposium. All conference participants will be invited to provide feedback on this framework through an online discussion platform with the goal of giving attendees a continued voice in the conversation after the conference concludes
This event series design intentionally avoids treating conference speakers as definitive experts on generative AI. Instead, attendees are positioned as co-creators whose experiences and insights can guide the profession's response to this potentially disruptive technology. The series weaves together activities before, during and after the conference to support sustained participation.
In focusing more on inclusive discussion than top-down expertise, this event series aims to empower practitioners to collaboratively steer their profession amidst the uncertainties of technological change. While specific strategies will evolve, physiotherapy's underlying ethic of human-centred, participatory practice can anchor the community through times of transformation.
Chair: Prof. Michael Rowe, Associate Professor for Digital Innovation, School of Health and Social Care, University of Lincoln.
Announcement of further collaborators to follow.

Preparation supported by Prof. Dr. Veronika Schoeb, from the Scientific Committee and Anita Hartmeier from the Programme Committe
References:
Masters, Ken. ‘Ethical Use of Artificial Intelligence in Health Professions Education: AMEE Guide No.158’. Medical Teacher, 13 March 2023, 1–11. https://doi.org/10.1080/0142159X.2023.2186203.
Lomis, Kimberly, Pamela Jeffries, Anthony Palatta, Melanie Sage, Javaid Sheikh, Carl Sheperis, and Alison Whelan. ‘Artificial Intelligence for Health Professions Educators’. NAM Perspectives 2021 (n.d.): 10.31478/202109a. https://doi.org/10.31478/202109a

Background
People with musculoskeletal conditions often seek treatment from allied health and medical practitioners in primary care. Clinical practice guidelines recommend that those people at risk of poor outcomes may benefit from interprofessional collaboration and multidisciplinary care including early referral to specialist musculoskeletal physiotherapists. Despite this recommendation, recent studies suggest that early referral and interprofessional collaboration between allied health and medical practitioners may not be occurring in practice. Inefficiencies in the delivery of health services to manage musculoskeletal disorders, including inappropriate referrals for imaging and/or surgery are the single highest contributor to total health expenditure in Australia. Therefore, greater clarity is needed regarding when, why, and to whom people with musculoskeletal conditions are, or should be referred in primary care as well as the barriers and facilitators of early referral to specialist physiotherapists.
Aim: (i) explore factors influencing referral practices of Australian allied health and medical practitioners managing people with musculoskeletal conditions in primary care and (ii) investigate practitioners’ perceptions of the barriers and facilitators of early referral to specialist musculoskeletal physiotherapists within a proposed clinical pathway of care (PACE MSK).
Methods
Semi-structured interviews were conducted with 58 Australian health professionals currently managing people with musculoskeletal pain in primary care: 38 allied health practitioners (physiotherapists, psychologists, exercise physiologists), and 20 medical practitioners (general practitioners, pain physicians, rheumatologists, rehabilitation physicians, sports and exercise physicians, orthopaedic surgeons, neurosurgeons). Perspectives on participants’ current referral practices (to whom, when, and why they referred) were sought. Participants were also presented with a proposed clinical pathway of care (PACE MSK) and asked their thoughts on the barriers and facilitators of referral to specialist musculoskeletal physiotherapists for people at risk of poor outcome. Interviews were recorded and transcribed verbatim prior to a qualitative analysis. Data collection and thematic analysis were conducted iteratively.
Results
Key themes were grouped under (i) patient-related factors (specific pathoanatomical or clinical presentations, psychosocial factors, lack of improvement, patient preferences) (ii) practitioner-related factors (trusted professional networks, expertise hierarchy, access to services), and (iii) external/system-related factors (financial impact, referring rights). Trust in professional networks, location of services and financial impact on patients and practitioners were key factors influencing referral practices for all participants. Trust was underpinned by three factors: good communication, mutual respect for professional roles, and positive patient feedback. AHPs and MPs but not surgeons expressed preferences for multidisciplinary, co-located care.
Early referral of people at high risk of poor outcomes was acceptable to all participants. Barriers to implementation included lack of awareness of specialist roles and financial disincentives. Establishing interprofessional trust and clear referral guidelines were identified as facilitators of optimal care pathways.
Conclusions
Referral decisions of allied health and medical practitioners are not only influenced by patients' clinical presentation, but also by trusted professional networks established amongst practitioners. Discordant perceptions of roles, funding disincentives and lack of communication amongst and between professional groups may be a barrier to implementing optimal care pathways for people presenting with musculoskeletal conditions in primary care in Australia.

Background

Delay to diagnosis and treatment of Degenerative Cervical Myelopathy (DCM) is a well-documented phenomenon, with surgical timing an important consideration, as individuals with DCM typically deteriorate if left untreated. However, no clinical guidelines currently exist to differentiate when emergency or elective surgery is indicated. Historically, those with DCM were evaluated prior to surgical listing by Spinal Surgeons. However, with lengthy waits for Spinal Surgeon review, at our tertiary centre, patients with DCM are assessed by Advanced Practice Physiotherapists (APPs) within two weeks from referral, before multi-disciplinary team discussion for listing. Those agreed for surgery are either admitted directly to our spinal ward for emergency intervention ‘Priority 1 (P1)’ or listed for urgent elective surgery ‘Priority 2 (P2)’.

Purpose

To evaluate current surgical listing practices following APP assessment for those with DCM at our tertiary spinal centre. To establish whether any statistically significant factors differentiated emergency from electively listed patients. This project aims to provide evidence for establishing a standardised listing pathway for DCM patients assessed by APPs at our centre.

Methods

This retrospective analysis collated patients with DCM listed for either P1 or P2 surgery over a 24 month period (September 2021-2023) through the APP pathway. Extracted data from medical records included: demographic variables, patient history factors such as symptom onset and deterioration, Modified Japanese Orthopaedic Association (MJOA) score, Neurological examination findings and radiological variables such as cord signal change, type of anatomical pathology and number of spinal segments with cord compression. This data was then analysed using multi-variate regression analysis.

Results

Overall, 184 patients were listed for surgery. Sixty-four as P1, including 11 that converted from P2 due to acute deterioration. There was a statistically significant difference in MJOA score between groups using binary logistic regression model with P1 having a lower MJOA (mean=10.42) compared with P2 (mean=12.55) (95% CI [0.43, 0.85]). Patients with severe MJOA scores were more likely to be listed for emergency intervention compared to those with moderate or mild scores. P1 patients were statistically more likely to have had recent deterioration in symptoms within the last month (95% CI [0.18, 0.48]). Patients below the age of 60 were also more likely to be P1 listed (95% CI [0.05, 0.87]). There were no other statistically significant factors between groups when accounting for control variables.

Conclusions

These data suggest a clinically important difference between P1 and P2 cases using multi-variate regression analysis. This will inform the implementation of a standardised surgical listing pathway for DCM patients at our tertiary hospital.
The number of patients listed for surgery following APP assessment over this period could indicate that APPs with sufficient knowledge and training can appropriately triage those with DCM.

Introduction
Advanced practice physiotherapists (APPs) manage the national low back and radicular pain pathway across the UK. In Nottingham, a novel APP-led spinal same-day emergency care (SDEC) pathway, accepts referrals from community services and the emergency department (ED). Low back pain is generally considered to be predominantly non-specific, with < 1% of all presentations in primary care due to serious pathology. Patients may attend ED with spinal pain in the belief their pain is due to a serious underlying cause. An Australian study quantified the prevalence of serious spinal pathology in patients admitted from the emergency department with non-specific low back pain (NSLBP) and found a significantly higher proportion of serious pathology than is reported in primary care data. Little data exists on prevalence of serious pathologies in a spinal pain cohort within a secondary care setting in the UK. This paper aims to review the number of serious pathologies identified by APP’s on a same-day emergency care pathway.
Methods
Retrospective data from 2 years (2021-2022) of routinely collected information was extracted and analysed by two APPs. Counts were reported as a percentage of total patients seen on the SDEC unit and compared to nationally reported figures. A total of 4244 patients referred with spinal +/- radicular pain, were assessed over the two year period. 416 (9.8%) had serious spinal or serious pathology beyond the spine identified.
Patients were classified into type of serious pathology (n, % of serious pathology): fractures (121, 29.1%), cauda equina compression (77, 18.5%), infection (54, 12.9%)[ including discitis, sepsis and wound infections], cancers (58, 13.9%)[including metastases, metastatic spinal cord compression, nerve sheath tumours and intradural tumours], acute or deteriorating myelopathy (54, 13.0%), neurological conditions (21, 5.0%)[including transverse myelitis, multiple sclerosis, guillan barre syndrome, demyelinating or inflammatory neuropathy and strokes] and other (31, 7.5%) serious pathology [including for example venous thrombosis, renal colic, intramedullary tumours, syrinx, arteriovenous malformations, acute foot drop].
Conclusion
Prevalence of serious spinal pathologies appears higher on an ED pathway compared to the reported prevalence in primary care settings. Most patients visiting ED or SDEC areas with spinal pain will have a benign self-limiting cause. However, from our data, around 10% of patients will have a serious pathology that, if not rapidly diagnosed and treated, could result in poor outcome and permeant neurologic impairment. The most common include fractures, cord or cauda equina compression, infection and cancers. The role of the APP working on an emergency pathway is to identify this subset in a timely fashion. Knowledge and training to identify serious pathology, robust escalation pathways and close multidisciplinary team working are essential in support of APP roles. Clear escalation pathways alongside training to identify common masquerade pathologies are necessary to support APPs working in secondary or emergency care settings.

Background: Diagnosis is a fundamental concept in clinical reasoning. Compared to physical examination alone, a more conclusive pathoanatomical diagnosis of a patient's presentation can be made with ultrasound imaging (USI). USI is expanding in point-of-care applications to augment the physical examination in physical therapy (PT) practice. Early PT adopters provide unique perspectives on PT-specific applications and decision-making.

Purpose: To highlight an innovative model of integrating USI into the physical therapist clinical examination and assess the clinical decision-making process.

Methods: Summary of two studies. The first study was a mixed methods longitudinal, observational design that evaluated the clinical application of USI of sixteen PT’s certified as registered musculoskeletal sonographers (RMSK) in practice across the United States. Demographic data and weekly reflective journals were collected over three months using REDcap™. Journal data included patient cases significant to clinician learning. Demographic data were summarized using descriptive statistics. Significant case data were analyzed thematically. The second study reviewed published case reports of USI in PT practice. Papers were categorized based on indications for imaging.

Results: In study one, PTs reported that 93% of the weekly musculoskeletal USI exams were performed for diagnostic purposes, the remaining 7% were for intervention, biofeedback and/or research. Of these diagnostic exams, participants reported USI contributed significant information very often (75%) and often (25%) to the PT evaluation. Seventy-three significant cases were reported, USI indications were qualitatively analyzed resulting in three themes. Theme 1: USI augments the clinical evaluation, subthemes included comparing patient symptoms and functional limitations with tissue changes, confirming an inconclusive clinical exam, and narrowing potential differential diagnoses. Theme 2: Support clinical decision-making, subthemes included changes in diagnosis, treatment or supporting a referral. Theme 3: Metacognition/ reflection on diagnostic strategies, subthemes included avoiding confirmation bias and considering too few hypotheses. In the second study, 44 published case studies were identified. Cases often included more than one indication for USI. The two most common reasons were to aid in differential diagnosis and identify serious pathologies. Thirty-three cases (77%) resulted in confirmation of a diagnosis. Twenty-five cases (63%) resulted in referrals. The third indication was to support the evaluation outcome; 29 cases (67%) documented significant changes in PT intervention strategies due to USI findings.

Conclusions: The qualitative study of RMSK-credentialed PTs demonstrated consistency with the clinical impact illustrated by published case reports. Integrating USI into the evaluation process directly influenced clinical reasoning by informing the diagnostic process, treatment plan, and ensuring appropriate and timely care. USI clarified potential red flags, tissue healing status, and ambiguous clinical findings, in addition to providing the clinician an opportunity for reflection. Further investigation is needed to "cross the bridge" and define when and how PTs use USI and the impact on patient outcomes.

Implications: USI offers a visual perspective of anatomy and pathology that increases confidence related to diagnosis, treatment choice, progressions, patient education, and referral. Recent advancements in technology and more affordable devices make this the ideal time to explore the value of USI to supplement a PTs physical examination for future practice.

RESEARCH QUESTION: What is the diagnostic accuracy of the IFOMPT framework to assess the risk of vascular complications in patients with neck pain and/or headache?
DESIGN: Cross-sectional diagnostic accuracy study. Participants: One hundred and fifty patients seeking physiotherapy for neck pain and/or headache in primary care.
METHODS: The index test was performed according to the IFOMPT framework by nineteen physiotherapists. Patients were classified as having a high, intermediate, or low risk for vascular complications, following manual therapy and/or exercise, derived from the estimated risk for the presence of vascular pathology. The reference test was a consensus medical decision reached by a vascular neurologist and an interventional neurologist, with input from a neuro-radiologist. The neurologists had access to clinical data, magnetic resonance imaging of the cervical spine, including an angiogram of the cervical arteries. Outcome measures: Diagnostic accuracy measures were calculated for ‘no contra-indication’ (ie, the low-risk category) and ‘contra-indication’ (ie, the high and intermediate-risk categories) for manual therapy and/or exercise. Sensitivity, specificity, predictive values, likelihood ratios, and the area under the curve were calculated.
RESULTS: Manual therapy and/or exercise were contra-indicated in 54.7% of the patients. The sensitivity of the IFOMPT framework was low (0.50, 95% CI 0.39 to 0.61) and its specificity was moderate (0.63, 95% CI 0.51 to 0.75). The positive and negative likelihood ratios were weak at 1.36 (95% CI 0.93 to 1.99) and 0.79 (95% CI 0.60 to 1.05), respectively. The area under the curve was poor (0.57, 95% CI 0.49 to 0.65).
CONCLUSION: The IFOMPT framework has poor diagnostic accuracy when compared to a reference standard consisting of a consensus medical decision.
 

Background
Emergency Department (ED) crowding is a significant issue in many countries. Hospital EDs are under considerable work pressures that were further exacerbated by the COVID-19 pandemic response. The pandemic has also impacted primary care delivery and costs to patients. Thus, we are facing yearly increases in presentations to Emergency Departments.

A significant proportion of patients who attend ED, including patients with some MSK pain conditions, could be treated in non-emergency settings. Providing care to this cohort of patients in ED is expensive and novel models of care, that engage a non-medical workforce, have potential to provide cost effective alternative access to care.

Purpose:
To establish a physiotherapy-led clinic to divert suitable patients with MSK conditions away from ED and to examine the feasibility, patient and health service outcomes of this new service compared to usual ED care

Methods:
This was a prospective non-randomised cohort study comparing the ASP outpatient diversion clinic with usual care in the ED and describing characteristics of patients considered suitable and not suitable for diversion.

Patients with MSK conditions were triaged by an advanced scope physiotherapist (ASP) in the ED waiting room and diverted directly from the ED to a physiotherapy diversion clinic. The clinic was staffed ASPs, supported by senior physiotherapists with outpatient and ED experience. Physiotherapy care was provided for people with musculoskeletal conditions, including plastering and thermoplastic splinting for fractures.

Patients aged 8-65 were diverted from May 2022 to December 2022 at a secondary hospital ED in Perth, Australia. A REDCap database captured clinical encounter data, tracked ED metrics and surveyed patients for clinical outcomes and satisfaction. The clinic was piloted by experienced ED ASPs, but after recruitment and training, transitioned to running with clinicians primarily recruited from existing hospital senior staff.

Results:
Data from the pilot project covers 1099 patients diverted from ED. Most diverted patients were low acuity (Australasian triage category 4) (74%) and 97% were satisfied with the care they received. Median ED LOS was 64 mins for diverted patients, 110 minutes (95% CI 99-120 mins) less than similar patients receiving care in the ED. The clinic connected 71% of patients to ongoing care in orthopaedics, hand surgery or physiotherapy outpatients. 3.2% of patients re-presented to the ED with the same condition within 28 days (compared to 3.7% of patients seen in the ED). The main reasons that patients were deemed not suitable for diversion to outpatients were that they had a differential diagnosis that encompassed non-MSK diagnoses, met exclusion criteria (e.g. open fracture) or required multi-disciplinary care.

Conclusion(s):
Based on the pilot project, this diversion clinic model of care appears promising as a safe and efficient way to increase ED capacity using a non-medical workforce.

Implications:
The South Metropolitan Health Service ED musculoskeletal diversion clinic has been permanently funded at Rockingham Hospital. This pilot project adds to a body of evidence supporting physiotherapy-led care for patients attending EDs. Models of care such as this should be explored internationally to reduce the burden on EDs.

Background: To face the rising number of patients presenting themselves to the emergency department a new scheme was established at a Swiss university hospital. “Physiotherapy in the emergency department” involves a physiotherapist (PT) treating patients with musculoskeletal disorders from the beginning of their journey.

Purpose: This study presented here was part of the scientific monitoring of the new scheme and was intended to fill knowledge gaps in the area of red flag screening by PTs. Furthermore, it explored the skills required by a PT to work in such an advanced practice role and the level of academic education and/or further training in which a physiotherapist can acquire these skills.

Methods: This study was designed as a retrospective observational study. The clinical records of patients treated in the emergency department under the new scheme were analysed to describe the number and kind of red flags screened by PTs and medical doctors (MDs). All patients treated by a PT within a period of 5 months were included.
To evaluate the aspect of physiotherapeutic education, a questionnaire on training of red flag screening was sent to 24 providers of educational programmes at different levels.

Results: The cohort consisted of 146 patients. Mean age of the population was 44 years (SD ±17.6), the lumbar spine (61%) was the most common area of complaint. PTs did additional screening in 78% of cases, mainly neurological tests (38%) followed by manual provocation testing (31%), pressure dolence (17%) and safety questions (15%). Their screening tools were largely consistent with those used by the MDs who had seen the patients before.
16 of 24 educational institutions answered the questionnaire. Screening tools similar to those used by the PTs are taught in basic training, in advanced courses/programmes mainly with a focus on manual/musculoskeletal therapy and in a specific postgraduate screening course.

Conclusion(s): The red flag screening of PTs in patients presenting to the emergency department for musculoskeletal disorders may be sufficiently comprehensive and comparable to that of MDs. On an educational level, first hints of a possible correlation between content of educational and training programmes and screened red flags in practice were found.

Implications: As advanced practice roles in physiotherapy are still in the early stages in Switzerland, studies on this topic are not only of (inter-)professional, but also of political relevance. Monitoring and evaluating the implementation of the new physiotherapeutic scheme in the emergency department is needed to ensure high quality of health care. Furthermore, it might stimulate similar approaches in other hospitals or other clinical settings.

Background: Unhelpful back beliefs (UBBs) are very frequent and play a critical role in the management of low back pain (LBP). Media campaigns promoting scientifically backed content could mitigate the level of UBBs. However, the impact of short educational videos on changing specific beliefs remains to be elucidated to design efficient educational strategies for the public.
Purpose: To evaluate the effect of a short educational video on back beliefs. The primary objective was to assess the effect of the video on the vulnerability theme of the 10-item Back Pain Attitude Questionnaire (Back-PAQ10). The secondary objective was to assess the effect on the total score of the Back-PAQ10.
Methods: The design of the study was a two-group randomized controlled trial with one intervention (n=113) and one control (n=109) group. The general adult population of German-speaking Switzerland, with or without back pain, was included in the study. The intervention consisted of a 3-minute video, targeting misconceptions about back vulnerability and needs for its protection. The control group was provided with an anatomical video about the back. Back beliefs were quantified pre and post intervention, using the Back-PAQ10 which included questions related to back vulnerability, injury, activity, and recovery. The scores of the Back-PAQ10 ranged between -2 and 2 where negative and positive values indicated the absence and presence of UBBs, respectively.
Results: The survey was completed by 222 participants (mean age: 46.14±17.17, male/female: 74/148). Prior to the intervention, the mean score for back vulnerability was 0.88±1.05 for the intervention and 1.1±0.85 for the control group (p=0.27), whereas the mean Back-PAQ10 total score was -0.42±0.56 and -0.29±0.53 for the intervention and control group, respectively (p=0.08). After the intervention, the back vulnerability mean score was -0.5±1.28 and 0.58±1.18 for the intervention and control group, respectively, showing a significant between group difference (p < 0.0001). Concurrently, the mean Back-PAQ10 total score was -1.1±0.64 and -0.4±0.65 for the intervention and control group, respectively (p < 0.0001).
Conclusions: Educational videos based on current scientific findings are an effective method to reduce UBBs. The German speaking general population of Switzerland has high levels of UBBs regarding the vulnerability of the back, which could be targeted with media campaigns. Future research should evaluate the long-term effects of similar educational content and the combination of educational videos with physiotherapy interventions.
Implications: Our data suggest that video education with proper evidence-based content could be used in mass-media campaigns to improve the frequent unhelpful beliefs about the back, found in this population.

Background:
The National Musculoskeletal (MSK) Triage Initiative was introduced in Ireland in 2011 to improve patient care and reduce waiting times for secondary care orthopaedics and rheumatology. However, patients often face lengthy waiting times and difficulties accessing quality MSK care pre and post MSK triage attendance. To address this, outreach clinics located at the interface between primary and secondary care are being rolled out nationally to improve MSK pathways. The perspectives of clinical specialist physiotherapists working in MSK-triage are critical to understand the acceptability of the current model of care and its expansion into interface clinics in community settings.

Purpose:
To explore MSK-triage CSPs' perspectives on the patient journey from primary to secondary care orthopaedics/rheumatology and following MSK-triage attendance. A secondary aim was to examine MSK-triage CSPs’ perspectives on the acceptability of implementing MSK triage in interface clinics in the Republic of Ireland.

Methods: Focus groups were conducted with 13 MSK triage clinical specialist physiotherapists (CSPs) from 8 urban and regional hospitals. A two-stage analysis framework was utilised. Data were analysed thematically by two independent reviewers, and resultant findings were explored using Normalisation Process Theory (NPT).

Results:
Four themes emerged: development of MSK pathways; clinical governance; implementation of interface clinics; physiotherapy role and identity. The current patient journey through musculoskeletal services in Ireland lacks structure and a stepped care approach, partly influenced by delays accessing allied therapy services in primary care, thus impacting GP referral behaviour. Whilst the implementation of interface clinics is viewed positively, with patients receiving specialist MSK care in primary care settings, delays for investigations and access to allied therapy services following MSK triage at interface was considered a limitation of the service by CSPs. Interface clinics achieved some degree of ‘coherence’ for CSPs with the expectation of patients receiving expert MSK care earlier in their journey. However, this was less ‘beneficial’ to some CSPs if clinics were held in community hospitals located close to the secondary care hospital versus primary care centres closer to patients’ homes, which would enable relationship building with primary care colleagues. CSPs conveyed strong recommendations on ‘collective action’ with IT infrastructure (establishment of a national Electronic Patient Record and modernisation of appointment booking systems) ability to order investigations (e.g., MRI, x-ray) and enhancing relationships with GP and primary care allied therapy colleagues essential for successful implementation of interface clinics in primary care.

Conclusions:
These findings contribute new knowledge about MSK triage CSPs’ perspectives on the patient journey through musculoskeletal pathways in Ireland and provide insights to inform the future implementation of MSK triage interface clinics in primary care.

Implications:
This research highlights the challenges MSK triage CSPs encounter in the patient journey through musculoskeletal services in the Republic of Ireland and the need for collective action in the implementation process of interface MSK triage clinics.

Background
Chronic pain contribute significantly to the years lived with disability globally. There is a growing body of evidence about interventions and approaches to address chronic pain and its concurrent burden. The implementation of evidence-based interventions for chronic pain can positively impact patient and healthcare system outcomes. However, there is a gap between the availability of evidence and its uptake in clinical practice, implying that there may be complex barriers to evidence uptake. There is a need to develop and evaluate implementation strategies for chronic pain management in primary health care (PHC) to optimize care.
Purpose:
The purpose of the scoping review was to systematically identify published literature on implementation of multi/interdisciplinary models for care for the PHC of chronic pain; and to synthesize information on the content, format, outcomes and factors affecting the implementation of the models of care.
Methods:
The review was conducted according to the guidelines of the Joanna Briggs Institute methodology of scoping reviews. Any qualitative, quantitative or mixed methods studies reporting on implementation of multi/interdisciplinary models for chronic pain management in adults in PHC settings, published since 1990 were eligible for inclusion. A systematic search was conducted using eight electronic databases and a set of keywords. Eligible studies were screened for inclusion. Data extracted comprised: bibliographic and characteristics of studies, characteristics of the implementation intervention, factors influencing implementation and outcomes of the implementation. Data was mapped and summarised.

Results:
The search strategy yielded 1061 citations. After screening 1047 titles and 53 abstracts, 15 manuscripts were included in the analysis. Most included studies were conducted in North America, and none were conducted in low-and-middle income countries. Nine studies were qualitative and two were mixed methods. There was a lack of use of implementation frameworks to guide implementation. All studies were interdisciplinary or multidisciplinary, however there was a low representation of rehabilitation in the models of care. The included studies reported variably on factors that influence implementation. There was little attention on reporting on patient factors that influence implementation. Studies reported on patient outcomes, health care system outcomes, cost effectiveness, process related outcomes and changes in practice patterns.

Conclusion(s):
The findings of the review indicate a need for more compressive reporting of implementation strategies and processes to facilitate the uptake of evidence-based models for PHC of adults with chronic pain. The lack of representation of rehabilitation professionals (including physiotherapists), may indicate that rehabilitation options for chronic pain management are not sufficiently incorporated in chronic pain management, despite evidence for its effectiveness. Further studies can focus on a qualitative evidence synthesis for context factors affecting implementation.

Implications:
Contextually relevant models of care may play an important role in healthcare reform and the operationalization of evidence-informed practice. Physiotherapists are an important part of the interdisciplinary team to empower patients regarding chronic pain management.

Background: Musculoskeletal (MSK) conditions represent the leading cause of disability globally, with those living with these conditions requiring the greatest need for rehabilitation services. These disorders often reflect a complex interplay of risk factors, such as low physical activity, overweight, obesity, and older age, together with related co-morbidities, such as cardiovascular disease, diabetes, hypertension, and depression. However, to date, the responses of MSK services to strengthen systems to meet this challenge appear lacking. With this increasing burden, there is a need to deliver more effective, person-centred MSK health care. Purpose: The primary purpose of this community-based service development was to trial a new way to support the local population with MSK conditions in what matters most to them and to help them take an active role in their care; and secondly, to provide staff the opportunity to work together outside of their normal setting and join with other community service providers to help patients beyond their presenting MSK condition. Methods: Following discussions with key stakeholders to ensure a co-creative solution, two Community Appointment Days were planned. Patients on a routine waiting list for MSK rehabilitation services were invited to have their appointment in a local community centre. On arrival, patients had a ‘What Matters To You?’ conversation to determine what they felt they needed in their care and to discuss their care pathway options. In partnership with a staff member, patients could determine their plan to support them with options that patients could access including one or more of the following: a one-to-one assessment, advice and guidance, exercise rehabilitation, and a community hub of local services, including weight management, talking therapies, and wellbeing services, amongst others. Feedback was collected from patients using CollaboRATE, a three item questionnaire (scored between 0 – 15) with higher scores indicating greater patient satisfaction and feelings of shared decision-making. Patients and staff were also asked to reflect on their experience of the day. Results: Over the two separate days, 550 patients accepted and attended their appointment (272 and 278 at each location, respectively). CollaboRATE scores were 11.1 +/- 1.8 (range 3 – 15) indicating increased satisfaction with their experience. Common themes patients reported were that they valued having everything they needed in the same place and having different people and options together with staff that listened to what they needed. Approximately half of the patients over the two days (49.6 % and 51.8%, respectively) were discharged with the option of a follow-up within a year. Staff reported that they enjoyed working with others as a team to support patients and stepping out of their normal work setting. Conclusions: This innovative MSK service development allowed patients to have access to multiple services and help them determine their own care pathway. Having everything in one place rather than separate appointments allowed for 50% of those patients to be discharged on the day. Implications: Future MSK services should look beyond the one-to-one setting and the individual’s MSK condition to result in better person-centred care and patient satisfaction.

Background: Healthcare systems are struggling to deliver high-quality care for low back pain (LBP), which remains a substantial global health challenge and the primary cause of years lived with disability. In 2012 specialist physiotherapist-led musculoskeletal (MSK) triage services were introduced in Irish hospitals to expedite patient care and alleviate pressure on elective orthopaedic and rheumatology consultant clinics and are in the process of expanding to include community locations. Specialist physiotherapists have expertise to inform the planning, delivery and implementation of health service reform in line with best practice guidelines, but clinicians are often not sufficiently consulted to meaningfully influence healthcare development in Ireland and internationally.

Purpose: To explore specialist physiotherapists’ perspectives on LBP care in Ireland, the barriers and facilitators to quality LBP care and the development of MSK interface services in primary care settings.

Methods: This study employed a cross-sectional observational study design using an anonymous electronic survey of 34 clinical specialist physiotherapists working in Irish MSK triage services. Qualitative analysis of response data from open-ended questions was underpinned by thematic framework analysis.

Results: Thematic analysis resulted in six overarching themes, grouped into two categories. Category A, LBP healthcare in Ireland, included the following three themes: 1) Inadequate health services for patients with LBP; 2) Need for defined LBP clinical pathways; 3) Need for a multisectoral approach to spine health. Category B, Development of community-based MSK interface services, with the following themes: 4) Concern regarding isolation from secondary care services; 5) Unrealistic expectations of MSK triage; 6) Improved communication and collaboration with primary care services.

Conclusion: Clinical specialist physiotherapists identified the persistence of a biomedical model of LBP healthcare in Ireland that is over-reliant on secondary care services. They advocated for investment in comprehensive multidisciplinary primary care teams to enable best practice, enhanced integration across primary and secondary care services, the development of a national clinical pathway to foster equitable evidence-informed care, and a multisectoral approach to address the complexity of LBP-associated disability. Clinical specialist physiotherapists recognised that community-based MSK triage clinics should augment primary and secondary care collaboration, but identified concerns that hinder successful implementation and efficient patient care, including infrastructure challenges, alienation from hospital consultant teams and access to clinical imaging.

Implications: This study captures, for the first time, the perspectives of specialist physiotherapists on LBP healthcare delivery enabling a better understanding of the ‘on-the-ground’ issues in delivering quality LBP healthcare. Opportunities for LBP healthcare service improvement are identified at micro, meso and macro health system levels. The findings can be used to inform the development and implementation of a new national LBP clinical pathway and community-based MSK triage clinics. Specialist physiotherapists have valuable insights into the design, development and implementation of MSK health service quality improvement, which through meaningful clinical engagement may be used to effect positive change at clinician, organisation and systems levels to ensure best care for patients.

Background
The majority of musculoskeletal conditions that present to physiotherapy in New Zealand are treated in the private practice setting and are funded by a single government accident insurer, the Accident Compensation Corporation (ACC). In 2019 ACC initiated a series of pilot programmes named Escalated Care Pathways (ECP) to improve the pathway of people with knee, shoulder and spinal injuries. These body sites incur the greatest cost to ACC in terms of surgery, workers compensation and rehabilitation. The pilots were aimed to improve four key areas: Faster return to work, improved utilisation of services, more timely access to surgery and rehabilitation and improved equity and access for Māori and Pacific peoples. Careway, based in Auckland, was one of the five successful pilot groups and was an inclusive model to join physiotherapists and specialists.
Purpose:
The purpose of this project was to improve the systems of delivery to a high value health care system. The introduction of clear evidence based clinical pathways, patients reported outcome measures, functional measures, inter disciplinary team, improved access to care at less cost and improved support for return to work were tested in this pilot. To date the Careway education packages have engaged over 84 orthopaedic surgeons and sports medicine specialists, over 30 vocational therapists and over 700 physiotherapists across Auckland and Northland
Methods:
A quantitative methodology was used. Data were analysed using descriptive statistics Frequencies and percentages are presented.
Results:.
From March 2020 to June 2023, 8,400 patients have entered the Careway programme and 2,700 have successfully met the exit criteria with 5,600 still in active care. 89 % of patients are European and 11 % are Māori. Large datasets are showing good results for patient outcomes, engagement with ACC and other stakeholders.
The majority of surgeries are Knee (ACL) (65%), Shoulder (rotator cuff repair)(25%) and Spine (discectomy)(10%).
Quicker recovery rates following injury, return to work and lower surgical failure rates are currently tracking 77% ahead of target costs, with post-surgery reinjury rates for knee ACL injuries alone 283% ahead of target, indicating successful exits from rehabilitation pathways.
Conclusion(s):
This has been the most significant system change implemented in the private musculoskeletal rehabilitation setting NZ since ACC inception in 1974. The results of the pilot show improved rehabilitation goals, improved return to work rates, reduced reinjury rates especially in the knee. The visibility of the effects of physiotherapy rehabilitation have been enhanced by clear use of outcome measures (PROMS and function) and the use of evidence-based pathways and improved provider collaboration. The roll out for these new systems to become a nationwide programme has now been approved by ACC for 2024.
Implications:
Health care system changes that deliver high value, evidence based, patient focussed outcomes have demonstrated a significant improvement in surgery and rehabilitation for more patients presenting with key MSK conditions. These system changes could be useful to consider in other settings and countries.

Background: People with chronic pain who engage in regular physical activity have better outcomes than those who live a sedentary lifestyle; however, physical inactivity is common in people with chronic pain. Providing general advice to keep active is insufficient to motivate people with chronic pain to engage in physical activity. Health coaching is a behaviour change intervention that has been shown to increase physical activity in several populations.

Purpose: Despite increasing research investigating the effects of health coaching on physical activity in people with chronic pain, current evidence is still conflicting. Our purpose was to summarise the current evidence about health coaching for chronic pain.

Methods: We conducted a systematic review and meta-analysis of randomised controlled trials to investigate the effect of health coaching on physical activity, disability, pain and quality of life in adults with chronic pain. Six research databases were searched from inception to November 2023. We included randomised controlled trials of health coaching interventions designed to increase physical activity in adults with chronic pain (e.g. chronic back pain, knee osteoarthritis) compared to a control group. Physical activity was the primary outcome. Secondary outcomes included disability, pain and quality of life. Evidence was synthesised as standardised mean differences (SMDs) with 95% confidence intervals using random-effect modelling. Risk of bias was assessed using the revised Cochrane risk of bias tool. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to determine evidence certainty.

Results: Twenty-six randomised trials (n = 4,403) were included. Trials had moderate to high risk of bias. Health coaching had a trivial to small effect on improving physical activity compared with control (15 trials; SMD 0.21, 95% CI 0.07 to 0.35; low certainty evidence). Health coaching had a small effect on improving disability (19 trials; SMD 0.25, 95% CI 0.17 to 0.32; moderate certainty evidence) and pain (19 trials; SMD 0.31, 95% CI 0.18 to 0.43; very low certainty evidence) compared with control. The effect of health coaching on quality of life was unclear due to significant imprecision in the effect estimate (five trials; SMD 0.19, 95% CI –0.14 to 0.53; moderate certainty evidence).

Conclusions: Health coaching promotes a trivial to small improvement in physical activity and small improvements in disability and pain in adults with chronic non-cancer pain. The effect of health coaching on quality of life remains unclear.

Implications: Although this review identified only low certainty evidence of a trivial to small effect of health coaching on physical activity, this finding should be considered in light of the practicality, safety and cost of the intervention. Health coaching is a strategy that clinicians and people living with chronic pain can easily add to their management toolkits. There is a growing number of government-funded health coaching services that clinicians can refer their patients to or make their patients aware of. Alternatively, primary healthcare providers themselves are often well-placed to learn the skills of and implement evidence-based health coaching.

Background
Standards for the delivery of high quality musculoskeletal services were set by the Chartered Society of Physiotherapy (CSP) in 2021. The standards outline eight quality standards that support the development and delivery of musculoskeletal physiotherapy, allowing services to demonstrate the value of MSK physiotherapy and drive continuous quality improvement.
This service is set in a National Health Service district general hospital in southeast England. Significant service changes occurred from 2019- 2023 due to the pandemic, the introduction of digital innovation and changing characteristics of our patient group. We undertook an audit of the musculoskeletal service using the CSP service standards from March to July 2023.
Purpose:
This project aimed to benchmark our current quality of service and identify actionable improvement initiatives.

Methods:
This service audit used the CSP musculoskeletal service standards, split into ‘Process’ and ‘Structure’ measures. The Process measures are based on auditing patient notes. The Structure measures are based on a survey of the service management. The outputs are scored using a Red-Amber-Green (RAG) rating; Red indicates a standard is met less than 20% of the time, Green indicates greater than 80% of the time.
Results:
A random sample of two hundred sets of notes were reviewed. Under Process measures, the service scored Green for 2 of the standards; documented self-management plan and staff received communication training. The service scored Red for 2 standards; advice about health behaviour and collecting patient reported outcome and experience measures. All other standards were rated Amber. Patient reported outcomes and experience measures are collected for the service, but at NHS trust level, with limited access to the outputs by staff conducting the audit.
In Structure measures, the service scored 5/8. The Structure measures that require improvement are; using a shared decision-making approach, using a making every contact count approach and arrangements for co-creating self-management plans.
Conclusion(s):
Documentation of patient plans and communication with patients is of high quality. Priorities for service development are: recording a shared decision-making approach with patients, accessing patient reported measures and making every contact count.
A cohort of staff have started a shared decision-making training course, and will conduct a quality improvement initiative, developing a shared decision-making across the service. The department has implemented a digital patient reported outcome and experience measure because of this audit. The physiotherapy team plan to use the implementation guidelines for making every contact count, including changing our clinical notes paperwork to facilitate and support staff in taking a wider health-based approach. The team will undertake a re-audit in one year to assess the outcomes of these initiatives against the CSP musculoskeletal service standards.
Implications:
This audit has highlighted areas where the musculoskeletal service is delivering high quality physiotherapy to patients, and areas which are currently underserved both on a structural level and operational level. With the implementation of our shared decision-making and making every contact count initiatives, patients can expect to receive a higher standard of care, be included in their healthcare decisions and receive information about their wider health needs.

Background
We developed a computerised decision support system (CDSS) based on methods from artificial intelligence to support physiotherapists and their patients in the process of managing musculoskeletal pain. This is the first study to investigate the effectiveness of an AI-based CDSS in primary care physiotherapy.
Methods
In a cluster-randomised multicentre controlled trial, we randomised 44 physiotherapists from primary care in Norway in a 1:1 ratio to expose their patients to the CDSS in addition to usual care versus usual care only. The CDSS gives personalised treatment recommendations for a new patient based on knowledge of the most similar successful patients from the past. We enrolled patients with pain in the neck, shoulder, back, hip, knee or with complex pain from February to November 2021. Primary outcomes were assessed at 12 weeks by Global perceived effect (GPE) and clinically important improvement in function by the Patient Specific Functional Scale (PSFS). The outcomes were analysed by intention to treat using three-level mixed logistic regression models. Trial registration: ISRCTN1797832.
Results
A total of 724 patients were included. The mean age (SD) was 48.4 years (SD 15.1), and the majority were women (64.1%). At 12 weeks, 176/321 (55%) patients in the control group and 165/298 (55%) in the intervention group reported success in GPE (OR 1.18, CI 0.50 to 2.78) for improvement in the intervention group compared with the control group. For PSFS, 218/310 (70%) in control and 173/290 (60%) in intervention reported clinically important improvement in function (OR 0.41, CI 0.20 to 0.85), favouring the control group.
Conclusions
We did not find differences between groups for GPE. For PSFS, there was a difference between groups favouring the control group. However, the difference was less than the prespecified between-group difference of 15% we aimed for. The clinical importance of this finding is therefore uncertain. Further research to explore use of AI in musculoskeletal pain is however encouraged.

LEARNING OBJECTIVES
1. Gain understanding of the practicalities and limitations in the science of pain sensitivity as it applies to clinical practice.
2. Provide practical strategies for the patient interview and physical assessment of pain sensitivity, clinical-reasoning related to interpretation of these findings, and the latest thoughts on management for clients where pain sensitivity is a significant factor.
3. Have an evidence informed framework, aligned with the International Association for the Study of Pain curricula, allowing clinicians to understand where pain sensitivity fits within a person-centred approach.
DESCRIPTION
This session will include learning related to state-of-the-art concepts for integrating pain sensitivity into clinical practice. As a clinical term, pain sensitivity refers to a state where responses to somatosensory stimuli suggest altered nociceptive processing. Profiling people with musculoskeletal pain based on their responses to somatosensory stimuli, known as quantitative sensory testing, has escalated in pain research. Implementation of this knowledge into clinical practice for musculoskeletal therapists is emerging. Indeed, recent adoption of the term ‘Nociplastic Pain’ by the International Association for the Study of Pain means assessment for altered nociceptive processing should become more routine. Interestingly, there is not a clear link between pain sensitivity with pain and disability in all musculoskeletal disorders. Heightened pain sensitivity may be more important due to its links with prognosis, and potential for it to effect/modify an individual’s response to everyday treatments for musculoskeletal pain. Here we offer a framework from which clinicians can integrate the concept of pain sensitivity into clinical practice.
A case study of a person with significant pain sensitivity in their presentation will provide the basis for expert discussion.
Patient Interview:
This section applies scrutiny to the patient interview to discern the relative importance of pain sensitivity in the person’s presentation. Research has determined subjective pain descriptors more frequently associated with altered pain sensitivity. Specific questions related to sensitivity may supplement the traditional subjective question battery. The concept of ‘disproportionate’ reactions will be examined. Participant will be provided with a framework to interpret the interview findings for when to prioritise pain sensitivity testing in the physical assessment.

Physical Examination
Quantitative sensory testing used to determine pain sensitivity in the laboratory setting may require expensive equipment and considerable time not affordable to the average clinician. Here participants will be provided with instruction in a paradigm for assessing pain sensitivity in the clinic, with opportunity to practice one element of this assessment.

Diagnosis
This section will cover combining the information gathered from the patient interview and physical assessment, to understand the presence and relevance of pain sensitivity in an individual’s presentation. A model for prioritising pain sensitivity in management will be provided. This section will focus on the explanation of pain sensitivity to the patient within the context of their diagnosis, with opportunity for participants to practice this in a role-playing exercise.

Management
How does the presence of pain sensitivity inform clinical practice? Guideline based interventions for common conditions like spinal pain and knee osteoarthritis are important, but consideration is needed for patients with pain sensitivity who are less likely to respond well. A reasoning paradigm will be explored, with participant engaged in reflective exercise to build understanding of strategies to manage pain sensitivity as part of a person-centred care approach.
The Broader Whole-Person Approach
While pain sensitivity is an important consideration in musculoskeletal disorders, especially for identifying altered nociceptive processing/nociplastic pain, it is no more important than having a whole-person perspective and approach. The Musculoskeletal Clinical Translation Framework provides an integrated, evidence informed guide for clinicians to fit together the biopsychosocial elements on an individual’s presentation. Through the lens of this framework, participants will understand how to integrate the concept of pain sensitivity and nociplastic pain into a whole-person approach.
IMPLICATIONS/CONCLUSIONS
Managing pain sensitivity can be challenging. This session will improve clinician understanding of pain sensitivity from a whole-person approach, providing multiple tools to assist them to incorporate the concept of pain sensitivity into the assessment and management of clients with musculoskeletal conditions. They will have strategies to increase client understanding and make the concept of pain sensitivity meaningful to these clients.