LEARNING OBJECTIVES
1. Understand the practicalities, strengths and limitations in the clinical interpretation of sub-grouping science.
2. Understand uses, limitations and implementation of first contact clinician sub-grouping and individualised-care for musculoskeletal pain disorders
3 Understanding these concepts from the viewpoint of clinicians, consumers/patients and health systems.

DESCRIPTION
Recommendations for the musculoskeletal pain management include calls for sub-grouping. Sub-grouping refers to the practice of placing individuals into categories based on similarities in their clinical profiles. Historically, this involved deriving sub-groups based on single factors, like length of time with a disorder or patterns of pain. Evolution of this concept has led to profiling based on multiple factors, sometimes across multiple health dimensions. These more complicated sub-grouping systems might include factors associated with current clinical status (factors driving pain and disability), or factors associated with prognosis (risk factors for poorer outcomes).

At the clinician level, the argument for sub-grouping is so that management can be targeted to the characteristics of that sub-group, and thus improve management outcomes for people with musculoskeletal pain. More broadly, sub-grouping may inform care pathways through health-care systems and assist with decision making of how to apportion (usually limited) health resources. Ultimately, sub-grouping may influence the behaviours of all those participating in these systems.

However, here is ongoing debate about the use and future of sub-grouping. Does sub-grouping improve treatment fidelity? How does sub-grouping intersect with person-centred care? Does sub-grouping assist in the pursuit of precision medicine? Here we have assembled a group of experts in sub-grouping pain disorders, who have spent significant portions of their careers grappling with the science and implementation of this approach. They will provide a state-of-the art perspective to help clinicians make sense of sub-grouping and individualised-care.

Martin Rabey has profiled 300 people with low back pain on over 100 clinically assessable factors. He has focused on ‘data-driven’ sub-grouping methodology as an attempt to address potential bias from more judgement-based approaches to sub-grouping. He will present the challenges faced in developing a true multidimensional sub-grouping system, the compromises required in this process, and a model for clinician understanding of the broad concept of multidimensionality.

Alice Kongsted will discuss the conceptual idea of individualised care and sub-grouping in care planning and clinical decision making. And importantly, how do we know if sub-grouping/individualised care is working? Based on her work with clinicians, she will talk about what skills and techniques may be useful for clinicians to be able to deliver targeted treatment to people with musculoskeletal pain conditions.

Jonathan Hill will focus on the learning from the original STarT Back trial and the more recent STarT MSK trial which has tested the use of a risk stratified approach designed for United Kingdom first contact clinicians for patients with common musculoskeletal disorders. He will present the findings from the Back-UP project (a large European Union funded project) which sought to implement evidence-based back and neck pain care online providing support for clinical decision making (including stratified care) across Europe, and describe the scalability and next steps for sub-grouping research.

Peter O’Sullivan has spent 25 years evolving his (and our) understanding of sub-grouping and individualised care for people seeking care for low back pain. This research/clinical journey has led to the development of a physiotherapy-led individualised approaches to managing disabling low back pain disorders. Underpinning this approach is a multidimensional clinical reasoning framework, that enables clinicians to identify and then target relevant modifiable biopsychosocial barriers to recovery for each individual. He will present the framework and application of Cognitive-Functional Therapy as an example of a patient centred, individualised behavioural approach for people with persistent and disabling low back pain disorders.

IMPLICATIONS/CONCLUSIONS
Efforts to reduce the global burden of musculoskeletal pain over a number of decades have been challenging. Evidence suggests the costs of managing this burden continue to rise without concomitant improvement in the level of burden for individuals or society. While far from perfected, evidence would suggest that sub-grouping and individualised care holds some promise, and further exploration of this is warranted. In this symposium, we provide guidance for clinicians to integrate the latest knowledge of sub-grouping into their clinical work, how this links to the provision of individualised-care and how this might fit at a health-care systems level.

The Beighton Score has long been the mainstay in detecting Generalised Joint Hypermobility (GJH). This easy-to-use screening tool offers clinicians a quick insight into a patient’s hypermobility who may warrant further management. Despite having age, sex and sport/cohort specific cut-offs established for better classification of GJH (Singh et al., 2017, Chan et al., 2018), more comprehensive assessments to improve clinical decision making are still needed. The Upper Limb Hypermobility Assessment Tool (Nicholson and Chan, 2018) and Lower Limb Assessment Score (Meyers et al., 2017) are tools that assess physiological and accessory mobility of all the major joints of the periphery and in all planes of movement. This allows for clearer directions when planning rehabilitation or injury reduction programs than the Beighton Score (Nicholson et al., 2022).

The most common diagnosis of a hypermobility-related disorder was previously called Joint Hypermobility Syndrome (JHS). Because of the significant and often clinically indistinguishable overlap between JHS and hypermobile Ehlers-Danlos Syndrome (hEDS)(Tinkle et al., 2009), the 2017 hEDS diagnostic criteria abandons use of the label JHS; instead considering it to be part of the clinical spectrum from asymptomatic JH to hEDS (Castori et al., 2017). The gap in diagnosis between people with symptomatic GJH who do not meet the criteria for hEDS is now filled by the descriptive diagnosis of Generalised Hypermobility Spectrum Disorder (G-HSD). The prevalence of hEDS and G-HSD using the new 2017 diagnostic criteria have not yet been established. The prevalence of JHS, likely a combination of those currently diagnosed with hEDS and G-HSD, is 1 in 500 to 600 in 2016/2017 (Demmler et al., 2019; Hakim et al., 2021). With a point prevalence of 30% attending a musculoskeletal triage clinic, and 39% in pain clinics in United Kingdom hospitals (Connelly et al., 2014; To et al., 2016), musculoskeletal physical therapists will come into contact with this patient population.

Despite the different diagnostic criteria, individuals with hEDS and G-HSD demonstrate similarities in their clinical profiles (Aubry-Rozier et al., 2021; Copetti et al., 2019). Both exhibit sustained reduced maximal muscle strength and endurance compared to controls. This reduction remains lower over an 8-year period, and is associated with high levels of physical impairment (Coussens et al., 2022; Coussens et al., 2020a). Both groups have smaller bone cortices, which may be related to prolonged decreased mechanical loading (Coussens et al., 2023). Indeed, physical activity levels in individuals with these disorders are also lower, with 75% not meeting the recommended 7500 daily steps due to kinesiophobia or pain-related factors.

Beyond finding greater odds of musculoskeletal diagnoses in the symptomatic hypermobile cohort compared to other chronic musculoskeletal pain cohorts, they experience higher diagnoses in other disease categories such as mental health, cardiovascular, nervous, and digestive systems (Demmler et al., 2019). Our Australian study similarly revealed some non-musculoskeletal problems that are common such as orthostatic intolerance (98%), easy bruising (97%) and urinary incontinence (84%) (Chan et al., 2019). These non-musculoskeletal manifestations significantly impact quality of life (De Wandele et al., 2014; Scheper et al., 2016). When seeking diagnosis and treatment, many patients report that these symptoms are neglected.

A comprehensive questionnaire tool, The Spider, has been developed to evaluate the impact of these important symptoms and guide care. Its eight domains assess neuromusculoskeletal, pain, fatigue, cardiac dysautonomia, urogenital, gastrointestinal, anxiety, and depression symptoms. The completed questionnaire produces a radar graph, shaped as a spider web allowing healthcare professionals to identify which symptoms should be prioritised, assessed and treated. Our research has demonstrated good convergent validity and known group validity in all domains in young adults (Ewer et al., 2022). Ongoing research is being undertaken to validate The Spider as a valid and reliable, free to access web-based outcome measure for use across the lifespan.

A multidisciplinary approach to the management of individuals with hEDS/G-HSD is recommended by experts in the field, with physical therapy playing a central role especially in pain management (Reychler et al., 2021). Pain is a major symptom in people with hEDS/G-HSD (Voermans et al., 2010), and they struggle to comprehend and effectively manage their complex pain presentations (Bennett et al. 2019). Our international Delphi survey on 396 participants with hEDS/G-HSD found that 81% felt an online pain management program specific to their condition was important or very important (Chew et al., 2023). Results of this survey were used for the development of the HOPE (Hypermobile Online Pain managEment) program. Its content covers the seven most highly rated categories from the Delphi study: pain neuroscience, the condition, accessing and navigating healthcare support, self-management, living with hEDS/G-HSD; medical management, and other associated topics (e.g. women’s health and neurodiversity).

Learning Objectives:
1. Recognise the spectrum of musculoskeletal and non-musculoskeletal manifestations, common comorbidities and natural history of hEDS/G-HSD.
2. Apply contemporary hypermobility assessment tools and advance clinical reasoning when assessing individuals with hEDS/G-HSD to develop a patient-centred approach to management
3. Evaluate the role of physical therapists in the overall management of individuals with hEDS/G-HSD particularly in pain management

Implication/Conclusions: Physical therapists working in primary and secondary care need to be able recognise hEDS/G-HSD and the common comorbidities in order to effectively manage these individuals.

Background
Fibromyalgia is a chronic primary pain syndrome, characterized by widespread pain, sleep disturbances, cognitive dysfunction, fatigue, and functional symptoms. It exerts a significant impact on health quality of life, resulting in a substantial number of medical visits, a higher average count of missed workdays and early retirements.
Guidelines recommend the combination of pharmacological and non-pharmacological approaches, emphasizing the relevance of self-management and exercise programmes. EHealth interventions hold the potential to facilitate the implementation of these programmes, ensuring their efficacy and safety, while enhancing the accessibility and sustainability of care. The successful development of an eHealth solution requires a deep understanding of patients` needs and perceptions, as well as the involvement of relevant stakeholders.
Purpose
This study is part of a community-based participatory research project aiming to develop an eHealth supported self-management programme for individuals diagnosed with fibromyalgia. Following a framework for mapping the full process of co-creation, this study was focused on the initial stage of contextual inquiry. It aimed to explore the perceived needs, facilitators, and barriers to engage in such a programme, from the perspective of patients, patient representatives and health professionals.
Methods
A qualitative study supported by two focus groups with different stakeholders was completed. The focus groups were based on a semi-structured interview schedule, were audio recorded and videotaped, transcribed verbatim and thematically analysed. Interview transcripts were coded independently by two researchers. Codes were compared and emerged themes were identified and refined by those two researchers. The preliminary analysis was shared with the research team and further refined with the collaboration of eight researchers from different backgrounds (health and computer sciences).
Results
Each focus group session lasted for ninety minutes. A total of fifteen participants were included: eight patients diagnosed with fibromyalgia; two patient representatives from national patient associations; two physiotherapists; two psychologists; one rheumatologist.
Three major themes were identified: 1) needs, 2) facilitators, and 3) barriers. Within the first theme, the need for individualized and personalized approaches was identified, with a strong preference for a flexible hybrid programme that combines traditional in-person care with digital options. In the second theme, the easy access, and the potential to integrate exercise, supervised by a physiotherapist, into their daily routines were considered important facilitators. In the third theme, several anticipated barriers were noted, including concerns about digital literacy, uncertainty about the efficacy and safety of digital health solutions, and fear about the ability to establish a therapeutic relationship.
Conclusion
This study focused on conducting a contextual inquiry, serving as the first stage of a research project that aims to create an eHealth supported self-management programme for individuals diagnosed with fibromyalgia. The insights gained here may provide valuable input for subsequent studies focused on the co-creation, usability testing and clinical effectiveness of the eHealth supported self-management programme.
Implications
Identifying the perceived needs, facilitators, and barriers to engage in an eHealth supported self-management programme, from the perspective of patients diagnosed with fibromyalgia, patient representatives and health professionals can contribute to developing a user-friendly, clinically relevant, and tailored solution.

Background
Neck pain is one of the most common musculoskeletal conditions globally. Disturbed cervical range of motion and reduced movement velocity are often seen in people with neck pain. Objective assessments of movement functions are important to identify dysfunctions, for tailored interventions and evaluation of treatment effect.

Purpose
The aim was to investigate the concurrent validity of a newly developed VR-technology for assessment of cervical range of motion and cervical movement velocity, by comparing VR-technology against a gold standard 3-dimensional optical motion capture system.

Methods
A quantitative cross-sectional study design was used. Twenty people with a natural variation of neck status participated, 10 women, 10 men, 18-65 years old. Participants performed VR-based tests, being cervical range of motion in right/left rotation, flexion, extension, right/left lateral flexion, and four diagonal directions. Velocity was assessed in fast cervical rotation to the right and left, respectively. Kinematics were obtained from VR-headset (Curest VR) and the gold standard Qualisys Motion Capture system simultaneously. The agreement between VR-technology and Motion capture system was analyzed using Bland-Altman plots with 95% Limits of agreement [LOA], as well as the Intraclass Correlation Coefficient [ICC].

Results
The correlation between Curest VR and Qualisys Motion Capture system for cervical range of motion and velocity was excellent, with ICC-values > 0,95. All ROM-variables except right rotation showed a mean bias < 1° (smallest LOA -1,65° to 1,23°, highest LOA -5,36° to 6,84°). Right rotation was the only ROM variable where VR was significantly different from Qualisys, with a mean bias 2,07° (LOA -0,88° to 5,03°). Max velocity variables showed a mean bias < 12 °/s (smallest LOA -40,93°/s to 25,54°/s, highest LOA -71,61°/s to 48,2°/s). Bland Altman plots for max velocity showed largest differences at values above 500 °/s. Mean velocity had mean biases < 3,1°/s (smallest LOA -14,59°/s to 13,03°/s, highest LOA -17,2°/s to 20,15°/s).

Conclusion(s)
Curest VR-headset is a useful assessment device for range of motion measurements in the traditional and diagonal movement directions, with clinically acceptable biases. Movement velocity measurements had clinically acceptable biases for mean velocity. Max velocity measurements had limits of agreement up to ±60°/s indicating larger spread of differences, where largest differences were seen in very fast movements with values above 500 °/s, where extra caution should be taken. Future studies should investigate the reliability and discriminant validity of the VR-based cervical range of motion and velocity tests.

Implications
The VR-device enables for accurate objective assessment of cervical range of motion and movement velocity, with instant test results. VR can be used in the clinical setting or at patients' homes, as a "mini-lab", as it can assess cervical range of motion with good precision and now also velocity which previously was mainly doable in the advanced laboratory setting. A great advantage of the VR is that it can be used in digital health rehabilitation, as test results can be monitored from a distance, making rehabilitation possible for people in remote areas or for people who cannot come to a physical clinic.

Purpose: Mentored clinical practice is central to enabling achievement of educational standards in advanced musculoskeletal physiotherapy, including IFOMPT Educational Standards. Whilst traditionally delivered face-to-face, telehealth e-mentoring is a novel alternative to offering this unique pedagogy, to facilitate mentee critical reflection, deeper learning and enhanced knowledge translation to optimise patient care. With Covid-19 resulting in widespread adoption of telehealth and access to mentors often limited by geography or cost, the potential value of telehealth e-mentoring needs investigating. The purpose of this study was to understand the experiences and outcomes of multiple stakeholders (student-mentees, mentors and patients) engaged in musculoskeletal physiotherapy telehealth e-mentoring. Methods: Using case study design, sequential mixed methods involving qualitative (interviews/focus group) and quantitative components explored stakeholder experience of a 20-week telehealth e-mentoring service in a UK University. Semi-structured interviews exploring experiences of telehealth e-mentoring, including influence on critical thinking, clinical reasoning, communication skills, confidence, motivation, career enhancement etc. with mentee participants and a focus group with mentor participants (topic guide informed by earlier analysis) were audio recorded and transcribed verbatim. Using validated outcome measures, patient participant experiences for care and empathy, patient empowerment and change in musculoskeletal health were collected at baseline and following discharge. Quantitative data was analysed using descriptive statistics (median and IQR) and qualitative data analysed following the Framework Method. Trustworthiness was assured through reflexivity and code/recode audits with experts. Results: Data from patients participants (n=90), mentee participants (n=10) and a mentor focus group (n=6,) contributed to the developed analytic framework. Patient participants had a median age 42 years (18-73 years) with a range of musculoskeletal complaints, with n=52 receiving follow up appointments. Of those returning participants improvements were seen with MSK-HQ increasing 11 points (MCID 6), Patient Specific Functional Scores improving by 4 points (MCID 2.7), and high scores for the Consultation and Relational Empathy and Patient Enablement Instrument. Mentor and mentee participants provided rich descriptions of their experiences. Mentor participants main themes (sub-themes) related a) preparedness (telehealth skills, relationship building, managing perceptions/expectations etc.), b) journey of development (formative feedback, peer discussions, mimicking behaviours etc.) and c) challenges (non-verbal communication, home environment, exercise prescription/goal-setting etc.) and specifically for mentee participants a) social learning (group mentorship, feedback, individualisation etc.), b) advanced professional practice (communication, clinical reasoning, reflective practice etc.), c) learner experience (expectation/acceptance, enjoyment/motivation etc.) and c) limitations of telehealth (caseloads, therapeutic relationship etc.). Conclusions: Data afforded understanding of the experiences of multiple stakeholders (patients, mentors and mentees) in telehealth e-mentoring. Findings illustrate that telehealth e-mentoring is an appropriate alternative to conventional approaches to mentored clinical practice to develop and fulfil the requirements of educational standards in advanced musculoskeletal physiotherapy (skills, knowledge and attributes). Planning for telehealth e-mentoring requires multi-stakeholder preparation, relating to setting expectations, creativity in practice and acquisition of technical skills and literacy. Impact: Adoption of telehealth e-mentoring may usefully enhance capacity to support profession specific skill development and service capability to meet planned growth in advanced musculoskeletal physiotherapists. In particularly, evidence based mentorship provision that considers the preparation, planning and setting expectations

Background: As demand exceeds capacity in primary care, internet interventions have the potential to provide rapid and scalable support for behavioral self-management of low back pain.

Purpose: To determine the clinical and cost-effectiveness of an internet intervention with and without physiotherapy support, on low back pain-related disability in UK primary care.

Methods: A three-arm, multicenter, pragmatic, randomized controlled trial, comparing: 1) usual primary care; 2) usual care + internet intervention; 3) usual care + internet intervention with additional telephone support (3 calls from a senior musculoskeletal physiotherapist, up to 30, 15 and 15 minutes each, designed to provide reassurance, address concerns, problem-solve, and encourage engagement with activity goals, using a standardized support manual).
SupportBack 2 is an evidence-based, self-tailored, 6-week internet intervention, designed to help patients self-manage their back pain, set weekly goals, receive feedback, and access different modules including mood, sleep, managing flare-ups, medication, daily living and work. The intervention, developed with 22 patient representatives, was underpinned by social cognitive, self-regulatory and self determination theories.
The primary outcome was LBP-related disability over 12 months using the Roland Morris Disability Questionnaire (RMDQ) measured at 6 weeks, 3, 6 and 12 months. Analysis was by intention-to-treat and used 97.5% confidence intervals (CIs).

Results: 825 patients were randomised (274 to usual care, 275 to usual care + internet intervention, 276 to the physiotherapist-supported arm). Their mean age was 54 years, 58% were female, 58% were in paid employment. Their average reported pain over the last two weeks was 4.8 (0=no pain, 10=maximum pain), and reported baseline disability (RMDQ) was 7 (0=no disability, 24=maximum disability).
Patients in the intervention + telephone support group accessed the website more often. With a follow-up rate of 79% at 12 months, the results showed a small reduction in RMDQ compared to usual care: internet intervention without support (-0.5, 97.5% CI -1.2 to 0.2, p=0.085); and the internet intervention with support (-0.6, 97.5% CI -1.2 to 0.1, p=0.048). These differences were not statistically significant at the 0.025 level. Both interventions however, led to the majority of participants reporting clinically important benefit (30% reduction in RMDQ) at 12 months compared with usual care (61% in both intervention arms versus 51% in usual care alone). Base case results indicated both intervention groups could be considered cost-effective compared to usual care, at £20,000 per QALY. Whilst the additional benefit of adding physiotherapy telephone support was limited, the effects were present sooner (by 3 months), however by 12 months, the effects were larger in the unsupported group. No harms were reported.

Conclusions: The internet intervention SupportBack 2, used with and without telephone support from a physiotherapist, had a small and clinically important impact on LBP-related disability in a heterogenous primary care population. It was safe and is highly scalable. The benefit of additional physiotherapy telephone support although limited, was present sooner.

Implications: High quality interventions that are evidence-based, goal-oriented and co-designed with service-users can be a cost-effective adjunct in primary care, empowering behavioural self-management, without requiring additional support from health professionals.

Background:
Improving access to evidence-based information for people living with musculoskeletal conditions is likely to enhance patients’ ability to discuss treatment options with health providers. Our earlier analysis of common websites relating to shoulder pain showed that these were limited to information about the pathoanatomy, without considering the psychosocial and neurophysiological influences.
Purpose
(1) To co-create a website to improve health literacy and self-management for people with shoulder pain in Aotearoa New Zealand.
(2) To explore the participants’ experiences of the research process.
Methods
We used participatory action research (PAR) with five cycles to design, develop and produce the website. Participants were recruited from the community, organisations and professional email distribution lists. Six physiotherapists and 7 people with shoulder pain participated as PAR members (2 Māori, 2 Pacifika, 5 New Zealand European, 2 Asian, 2 European). During the PAR meetings, break-out groups were formed for people with shoulder pain, physiotherapists and a mixed group for Māori and Pacifika. A process evaluation was held in the form of a final focus group. PAR meetings 2 to 4 and the focus group for process evaluation were recorded, transcribed and thematically analysed. PAR themes were used to plan and construct the website, and to summarise participants’ perspectives. The University’s Office of Māori Development provided Te Reo (sub)headings. We used the Flesch Kincaid Reading Ease Scale to ensure acceptable readability level. The research team worked with a local website provider to design the website and PAR members assessed two iterations of the drafts, accepting the final product. The final website was peer reviewed by two international physiotherapy experts.
Results
Main PAR themes were grouped as (1) Content (Understanding medical terminology for the shoulder girdle; Why do we feel pain?; Whole body health; Common conditions; and Treatment options), (2) Presentation (images reflecting Aotearoa people) and (3) Further Support (links to relevant health professional groups, Frequently Asked Questions). Culturally important concepts were interwoven with research-based evidence to enhance inclusivity.
The process evaluation had three main themes about the participants’ experiences of the research process: (1) Uncertainty to Empowerment (about shoulder pain, self-management, searching online information, final product), (2) Diversity (ethnicity, culture, professional versus consumer) and (3) Logistics (organisational, inclusivity, hybrid delivery within post-pandemic challenges).
Conclusion(s)
PAR was effective to identify content considered important by people with shoulder pain and physiotherapists, guiding construction of the website.
Implications:
Co-constructing patient resources with health providers and people living with musculoskeletal conditions is likely to enhance external validity and accessibility, encourage use and collaborative decision making. The website is being used as a patient support (education) tool in a randomised clinical trial. Continuous feedback and updates for the website will be needed to maintain relevance.

Final website: https://shoulderpain.org.nz/

Background: Exergames are interactive technology-based exercise programs. By combining physical and cognitive training components, they aim to preserve independence in older adults and reduce their risk of falling.
Purpose: This study explored whether primary end users (PEU, healthy older adults and patients with neurological and geriatric diagnoses) and secondary end users (SEU, health professionals) evaluated the ExerG functional model to be usable, providing a positive experience and therefore acceptable.
Methods: We conducted a mixed-methods study using several assessments to quantify usability and enjoyment outcomes, along with semi-structured interviews to gain an in-depth understanding of the users’ experiences. Descriptive statistics were used for quantitative outcome measures. For qualitative data, a thematic analysis (TA) using an inductive, data-driven approach was carried out to develop themes for each user group.
Results: We interviewed 20 PEUs (13 healthy older adults, 7 patients) and 22 SEUs at two rehabilitation centres in Austria and Switzerland. Users' scores of over 70 on the System Usability Scale denoted good usability. On the Physical Activity Enjoyment Scale-16, both PEU groups rated the ExerG highly. Our TA approach identified four themes per user group. Themes from both PEU groups confirmed their enjoyment of training with the ExerG, however more variety and greater challenges were requested. Whilst the patient group appreciated the security given by the harness system, the healthy older adults reported feeling restricted. SEU themes reflected their approval of this novel training device, although a desire for increased difficulty and more individualisation was expressed. Clear instructions and an easy-to-use harness system were acknowledged and useful feedback for the developers emerged.
Conclusions: The ExerG is usable, provides a positive experience and is thus considered an acceptable solution for the combined physical and cognitive training of the elderly. Our findings contribute to the ongoing development of the ExerG, which will be a welcome addition to current training options for the elderly.
Implications: Further research is needed to confirm its effectiveness in preserving or improving functional independence in daily life and reducing the risk of falling.

Abstract:
Background
Digital self-management platforms have been proposed as a solution to better support people manage their musculoskeletal (MSK) condition. However, there is a lack of evidence supporting its effectiveness and trials often explicitly exclude people who can’t access internet connected devices. An important consideration is that digital exclusion (for people without access to an internet connected device) from these new digital options will worsen already existing inequality in healthcare. The importance of this is highlighted by the fact that MSK pain and disability has a disproportionate impact in areas of economic deprivation and on minor ethnic groups

Aim
To evaluate the acceptability and potential causes of digital exclusion of the South West London (SWL) MSK self-management app.

Objectives
1 a) Explore why some patients are not using the app and any barriers they have.
b) Explore why some clinicians are not prescribing the app.
2 Make recommendations, based on these findings, to improve digital inclusion.


Methods

Design
An explanatory sequential mixed methods service evaluation consisting of initial questionnaires to identify suitable collaborators followed by structured interviews of patients and clinicians
Phase 1.
A questionnaire was developed to assess the ‘acceptability’ of the SWL MSK app for patients and clinicians. We used the London Office of Technlogy & Innovation data, map and personas to identify areas with SWL with high levels of potential digital exclusion, and matched people who found getUBetter less acceptable to these areas. Clinician Interviews were targeted by questionnaire returns and prescription rates.
Phase 2 .
Interviews were then carried out to gain a deeper understanding for potential reasons for digital exclusion.

Results
256 people responded to the initial questionnaire. Of these we took 11 patients and 11 clinicians to interview. Following a comprehensive data analysis, 10 sub-themes were grouped into 4 main themes:
1) Beliefs: Importance of understanding the role of digital; Face to face consultation is still valued and needed.
2) Barriers: Lack of digital literacy; Lack of physical examination/contact with a clinician.
3) Enablers: Immediate access to advice/information; Perceived better control over health; Ease of use; No appointment needed
4) Solutions: Support and training; Greater awareness

Conclusion(s)
The project will enable an existing digital technology to be adopted by more patients as the technology design and delivery can be adapted to address the causes of digital exclusion we have identified from the perspective of people using the technology and clinicians prescribing it. Although service providers and digital health technology companies have a duty to address health inequalities and digital inclusion, a broader response is needed at a societal level.

Implications
We were able to propose several areas for development to improve digital inclusion. The recommendations are as follows:
1. Signposting to local support services available to improve general digital skills.
2. Increase awareness of the app in the community such as GP surgeries, pharmacies, library and community centres.
3. More training around the app and its capability as well as a demonstration of the app (for both practice staff and patients).
4. Better communication that the app is a supportive tool and not intended to replace seeking clinical advice when indicated.
5. If possible, clinicians should give a more in-depth discussion about the app before prescribing it.
6. Access to video demonstration of the app in various languages.
7. Better accessibility options with clearer larger fonts.
8. A dedicated helpline for queries was recommended by patients to help with engagement, motivation and reassurance when using the app.

Aim: To evaluate patient experience and identify if there are barriers to using a mobile health (mHealth) exercise application (app) in musculoskeletal (MSK) Physiotherapy

Methods: An online patient experience survey was sent to 10,287 MSK Physiotherapy patients who had appointments between January 17th and April 9th, 2022. The survey was open for 25 days, with a reminder sent after 14 days.

Results: The survey received 1,447 responses (response rate: 14.07%), with 954 (65.93%) respondents previously provided the mHealth exercise app (PhysiApp). Most participants used PhysiApp (83.06%), found PhysiApp easy to use (82.20%) and had positive perceptions on how PhysiApp added value to their Physiotherapy treatment through its functionality (increased motivation, supported exercise adherence, helped achievement of treatment goals and reduced hospital visits). However, qualitative feedback revealed negative impacts on patient-centred care and practical demonstration of exercises. Key barriers to PhysiApp use included suboptimal explanation, digital exclusion, registration/ login issues and opinion that PhysiApp was superfluous to Physiotherapy treatment. These differed to the main barriers of why participants stopped using/ used PhysiApp less; if they were confident exercising without it, their condition improved/ resolved, loss of motivation, their exercise programme ended or if they found their exercise programme was unsuitable.

Conclusion: Despite multiple interdependent factors influencing patient experience and barriers of using PhysiApp, the survey results revealed the significant influence that is exerted by MSK Physiotherapists. The patient-physiotherapist interaction can positively or negatively impact upon many barriers of use and the subsequent potential added value of PhysiApp to MSK Physiotherapy treatment. Future qualitative research on patient experience and barriers to using mHealth exercise apps in MSK Physiotherapy, with a possible focus on those who are at greatest risk of digital exclusion and health inequalities, is recommended.

Objective:
Upon completion of this session, attendees will have contemporary knowledge and skills regarding identifying and management of a possible vasculogenic cause of the complaints, in patients with headache or neck pain.

Description
Neck pain is a highly prevalent condition that can lead to consider-
able pain, disability and economic costs. Cervical spine manipulation and mobilization are frequently used in the management of neck pain and headache. Although rare, serious adverse events following cervical spine manipulation and mobilization have been described in literature (Kranenburg et al., 2017). The current opinion with regard to vascular events is that patients presenting with neck pain and headache who develop a serious adverse vascular event (in particular, arterial dissection) during or after treatment may have an underlying pathology or flow limitation that was not recognized and was subsequently aggravated by treatment (Rushton et al., 2022; Rushton et al., 2020; Hutting et al., 2022). Additionally, some interventions or practices may impose greater stress on the cervical arteries and should be recognized.

Although events and presentations of vascular pathologies of the neck are rare, they are an important consideration as part of an Orthopedic Manual Physical Therapy (OMPT) assessment (Rushton et al., 2020). Vascular pathologies may be recognizable if the appropriate questions are asked during the patient history, if the interpretation of elicited data enables the recognition of this potential, and if the physical examination can be adapted to explore any potential vasculogenic hypothesis further (Rushton et al., 2021).

To assess and recognize a potential vasculogenic contribution, up-to-date knowledge and skills are important (Hutting et al., 2022). However, evidence suggests that physical therapists, including OMPTs, do not always have sufficient knowledge to conduct an evidence-based clinical reasoning process (including patient history and physical examination) regarding the identification of vascular pathologies or blood flow limitations. For example, although the current explanation is that people who develop a serious adverse vascular event after OMPT have an underlying pathology or flow limitation, about 47% of the physical therapists (n=776) believe that there is an increased risk of arterial dissection after cervical spine manipulation (Thomas et al., 2011; Thomas et al., 2015; Mourad et al., in preparation). Therapists mainly focus on manipulation as a cause of serious adverse events (Mourad et al., in preparation; Mourad et al., 2021), while the evidence to support this is lacking.

Knowledge about risk factors is also lacking. For example, over 50% of the physical therapists believe that cardiovascular risk factors are associated with a high risk of carotid or vertebral artery dissection, while literature suggests that this is not true (Mourad et al., in preparation). In addition, therapists often lack the knowledge and skills to conduct a contemporary pre-treatment examination. Anecdotal evidence (based on polling among about 200 physical therapists) suggest that OMPTs mainly rely on the results of positional testing (VBI tests) (about 70% of the therapists are still using these tests to the determine the risks associated with treatment), while the use of these tests is generally not recommended for this purpose (Hutting et al., 2020; Rushton et al., 2022). A recent survey found that positional testing is currently used in 30% of the patients with neck pain of headache (Mourad et al., in preparation). However, although positional testing and craniovertebral ligament testing are excluded from the IFOMPT Cervical Framework (Rushton et al., 2020; Rushton et al., 2022), most educational programs will keep these tests in their curriculum (Hutting et al., 2022). Moreover, although not recommended, a considerable number of educational programs still teach end range manipulations in the middle and lower cervical spine (33.3%) and upper cervical spine (25.5%) (Hutting et al., 2022).

Conclusion
As contemporary musculoskeletal physical therapy clinicians are evolving into more rounded, expert health care professionals in more diverse settings, they should be aware of a potential vasculogenic contribution to the patient’s complaints, and assess and refer the patient accordingly. To assess a potential vasculogenic contribution, up-to-date knowledge and skills are important. However, we can conclude that there is sufficient evidence indicating that physical therapists, including OMPTs, do not always have sufficient knowledge and skills to conduct an evidence-based clinical reasoning process regarding the identification of vascular pathologies or blood flow limitations. Therefore, this workshop will focus on contemporary practical knowledge and skills regarding clinical reasoning (including the subjective and objective examination) aimed at identifying a possible vasculogenic cause of the complaints, in patients with headache or neck pain.

Background: Neck pain is among the most common musculoskeletal disorders worldwide. It poses a major burden on office workers, resulting in discomfort and decreased work productivity. Despite the expected growth of the service sector, the current literature does not offer a convincing approach to address this issue. Thus, the need to develop an effective intervention to reduce neck pain in the context of office work became evident. Given the substantial socio-economic consequences of neck pain (i.e., costs resulting from neck pain-related presenteeism), this emerged as the primary interest of our study.
Purpose: This study aimed to investigate the effect of a 12-week multi-component intervention, combining current best-evidence interventions, on neck pain-related work productivity loss in Swiss office workers.
Methods: Between January 2020 and April 2021, we conducted a stepped-wedge cluster randomized controlled trial titled “Neck Exercises for Productivity” (NEXpro). Office workers aged 18 to 65 years, and without severe neck problems were recruited from two Swiss organizations. The 12-week multi-component intervention included neck exercises, health-promotion information workshops, and workplace ergonomics. The primary outcome of neck pain-related work productivity loss (absenteeism, presenteeism) was measured using the Work Productivity and Activity Impairment Questionnaire and expressed as percentages of working time. Additionally, we reported the weekly monetary value of neck pain-related work productivity loss. Data were collected through an online questionnaire. A generalized linear mixed-effects model was fitted to the data to estimate the change in neck pain-related productivity loss.
Results: This analysis included data from 120 participants with a total of 517 observations (average of 4.3 observations per participant, attrition rate of 22%). At baseline measurement in January 2020, the mean age of participants was 43.7 years (SD 9.8 years), 71.7% of the participants were female (N=86), about 80% (N=95) reported mild to moderate neck pain, and neck pain-related work productivity loss was 12% of working time (absenteeism: 1.2%, presenteeism: 10.8%). We found an effect of our multi-component intervention on neck pain-related work productivity loss, with a marginal predicted mean reduction of 2.8 percentage points (-0.27; 95% CI from -0.54 to -0.001, p=0.049). Weekly saved costs were CHF 27.40 per participant. One adverse event occurred.
Conclusion: This study provides evidence of the effectiveness of a 12-week multi-component intervention in reducing neck pain-related work productivity loss among office workers. Not only employers and the socio-economic system benefit through decreased neck pain-associated costs (i.e., productivity), but also office workers by reduced pain and disability. Further research is necessary to investigate long-term effects.
Implications: In the context of office work, we strongly recommend the implementation of our multi-component intervention to reduce the burden of neck pain. Within Switzerland, the multi-component intervention has already been promoted through various media appearances, including television and radio, and a video is planned for sharing on social media in order to reach patients and healthcare providers (i.e., physical therapists).

Background:
Office workers are specifically vulnerable to headache conditions. Neck pain is reported by almost 80% of patients with headaches. Associations between currently recommended tests to examine cervical musculoskeletal impairments, pressure pain sensitivity and self-reported variables in headache, are unknown.
The aim of this study is to evaluate whether cervical musculoskeletal impairments and pressure pain sensitivity are associated with self-reported headache variables in office workers.
Methods:
This study reports a cross-sectional analysis using baseline data of a randomized controlled trial. Office
workers with headache were included in this analysis. Multivariate associations, controlled for age, sex and neck pain, between cervical musculoskeletal variables (strength, endurance, range of motion, movement control) and pressure pain threshold (PPT) over the neck and self-reported headache variables, such as frequency, intensity, and the Headache-Impact-Test-6, were examined.
Results:
Eighty-eight office workers with a 4-week headache frequency of 4.8 (±5.1) days, a moderate average
headache intensity (4.5 ± 2.1 on the NRS), and “some impact” (mean score: 53.7 ± 7.9) on the headache-impacttest-6, were included. Range of motion and PPT tested over the upper cervical spine were found to be most consistently associated with any headache variable. An adjusted R2 of 0.26 was found to explain headache intensity and the score on the Headache-Impact-Test-6 by several cervical musculoskeletal and PPT variables.
Discussion:
Cervical musculoskeletal impairments can explain, irrespective of coexisting neck pain, only little
variability of the presence of headache in office workers. Neck pain is likely a symptom of the headache condition, and not a separate entity.

Abstract

Background

Head-load bearing is a common phenomenon across sub-Saharan Africa. The Gambia shows an above average rate of female head-load carrying water collectors compared to other sub-Saharan African countries. From a health perspective, questions arise of how long-term head-load bearing affects the carrier’s health.

Objectives

To explore whether reported pain and functional limitations are related to range of motion (ROM) and proprioception of the cervical spine in rural female Gambian head-load bearers.

Methods

Cross sectional study. Women aged 18 to 45 years with a minimum of one year of head-load bearing experience were examined. The relationship between independent variables such as cervical ROM and proprioception, and head-load bearing characteristics towards the outcome variables pain and functional limitation have been examined by backwards linear regression models. Frequencies between functional limitation and regions of pain complaints have been determined.

Results

Thirty-five of 39 eligible women complained about neck pain. The amount of weight carried; together with reduced extension mobility in the upper cervical spine has been found the strongest explanatory variables for pain and functional limitation. Those women suffering from moderate to severe pain and functional limitation carried on average 3.05 and 2.70kg less weight. Functional limitation was associated with lower back pain but not with neck pain.

Conclusions

Although frequently reported in head-load bearing women, neck pain has not been found functionally limiting. Nonetheless, women suffering from at least moderate pain and functional limitation carry less weight compared to women reporting no limitation and no or only mild pain.

Background:
Tinnitus, or ‘ringing in the ears’, is the perception of sound in the absence of acoustic stimulation. It appears in 10-15% of adults and is typically caused by hearing loss or noise trauma. In about 25% of patients with tinnitus, however, tinnitus gets worse when cervical spine or temporomandibular dysfunctions are present, then called somatic tinnitus (ST). Previous studies have proven that musculoskeletal treatment of the cervical spine and temporomandibular area can decrease tinnitus severity and loudness. To maximize this treatment effect, it is essential that only patients with a large somatic influence on their tinnitus are referred for musculoskeletal physiotherapy. Diagnosing these patients correctly, though, remains a challenge.
In 2018, a set of 16 diagnostic criteria for ST was determined based on an international Delphi study with a consensus meeting. The next step in the development of easily applicable diagnostic criteria is now to provide an uncomplicated model based on the existing criteria, which can easily be used in clinical practice.

Objectives:
This study aimed to construct an accurate decision tree, combining several diagnostic criteria, to optimize both sensitivity and specificity of ST diagnosis.

Design:
An online survey was launched on the online forum Tinnitus Talk, managed by Tinnitus Hub in a convenience sample of participants with tinnitus. The survey included 42 questions, both on the presence of diagnostic criteria for ST and on other potentially influencing factors. A decision tree was constructed to classify participants with and without ST using the rpart package in R. Tree depth was optimized during a five-fold cross-validation. Finally, model performance was evaluated on a subset containing 20% of the original dataset.

Results:
Data of 7981 participants were used to construct a decision tree for ST diagnosis. Four criteria were included in the final decision tree: ‘Tinnitus and neck/jaw pain increase/decrease simultaneously’, ‘Tension in suboccipital muscles’, ‘Somatic modulation’, and ‘Bruxism’. The presented model has an accuracy of 82.2%, a sensitivity of 82.5%, and a specificity of 79%. Receiver operator characteristic curves demonstrated an area under the curve of 0.88.

Conclusions:
Based on a 42-item survey, a decision tree was created that was able to detect ST patients with high accuracy (82.2%) using only 4 questions. The RaSST is therefore expected to be easily implementable in clinical practice.

Background: Migraine patients may present with both cervical and balance dysfunctions. The neck plays an important role in balance by providing substantial proprioceptive input, which is integrated in the central nervous system and influences the balance control systems. Whether balance and neck dysfunctions are associated in patients with migraine is still to be explored. Objectives: This study aimed to assess the association between the sensory organization test of balance with neck pain features, cervical strength, endurance, and range of motion in patients with migraine. Methods: Sixty-five patients with migraine underwent the sensory organization test assessed with the Equitest- Neurocom® device. Maximum voluntary isometric contraction, cervical flexion and extension range of motion, and cervical flexor and extensor endurance were assessed. In addition, the features of migraine and neck pain were collected. Patients were dichotomized according to cut-off scores of balance performance and the association between outcomes were explored. Results: Patients with reduced balance performance presented a higher frequency of migraine (p = 0.035), a higher frequency of aura (p = 0.002), greater neck pain intensity (p = 0.013), and decreased endurance of cervical flexors (p = 0.010) and extensors (p < 0.0001). The total balance score was correlated with age (r = - 0.33; p = 0.007), migraine frequency (r = - 0.29; p = 0.021), neck pain intensity (r = - 0.26; p = 0.038), and endurance of the cervical flexors (r = 0.39; p = 0.001) and extensors (r = 0.36; p = 0.001). Migraine frequency, neck pain intensity, and endurance of the cervical flexors can predict 21% of the sensory organization test variability. Conclusion: Neck pain features and endurance of the cervical muscles are related to reduced balance performance in patients with migraine. These results shed light to a better understanding of balance alterations in migraine patients.

Background:
The close relationship between head, neck and facial dysfunction and pain and the effects of treatment during manual therapy are often explained by a neurophysiological model in which the trigeminocervical nucleus (TCN) plays a predominant role. Existing evidence has established a link between the orofacial, cranial and cervical regions mediated by the TCN. However, the prevailing direction of this connection, whether from the cervical region to the orofacial/cranial region or vice versa, remains uncertain.

Objective:
The purpose of this study is to determine the dominant direction of connectivity within the TCN when investigating the relationship between the neck and oro-craniofacial regions.

Methods;
A scoping review was conducted in accordance with the PRISMA-Scoping Review (ScR) guidelines. Six electronic databases were systematically queried, employing a search strategy that combined subject headings and keyword terms for three concepts: TCN, cervical region, and face/jaw/head region. No date, language, study design, or publication type limits were used. No restrictions were imposed on publication date, language, study design, or publication type. The screening and data extraction processes were carried out independently by two reviewers. The investigation included a comprehensive assessment of anatomical, histological, biochemical, electrophysiological, neurophysiological, radiological, and clinical parameters in both humans and mammals. In addition, the study determined the extent of interconnectivity between different regions (i.e., cervical region, head, and face) through the TCN.

Results:
Following the evaluation of 2,284 papers based on title, abstract, and full text, a total of 83 studies were included in the analysis. The predominant direction of connection between the orofacial and cervical regions via the TCN was reported to be from the orofacial region to the cervical region (58 of 83), with the majority of studies (82 of 83) conducted in mammals. About the TCN area investigated, 62.8% (n = 49) of the studies looked at the transition zone interpolaris/caudalis (Vi/Vc), 19.2% (n = 15) looked at the upper cervical spinal cord (C1/C2), followed by the transition zone oralis/interpolaris (Vo/Vi) in 11.5% (n = 9) of them. Twenty-three studies (29.5%) investigated other TCN areas, and four (4.8%) studies did not report the specific area investigated.


Conclusion:
Although the orofacial to cervical direction was dominant in the included studies, it remains uncertain whether this observation reflects researchers' interest or represents the true prevailing direction. Caution should be exercised when extrapolating findings from animal studies to humans.

Implications:
Simultaneously, this discovery aligns with clinical observations and studies on clinical outcomes, indicating that manual therapies and/or neck exercises may have the potential to influence orofacial symptoms, and vice versa. Further investigations are required, encompassing both animal and human clinical studies involving varying kind of stimuli with different intensities applied to the cervical region, head, and face and determine possible interconnections of these areas through the TCN. These studies can offer deeper insights into the assessment and treatment options within the orofacial-cervical complex in the future.

Background:
Guidelines for the assessment of people with whiplash have yet to be systematically produced. To date, individual recommendations exist for constructs to assess people with whiplash (e.g., cervical range of motion (ROM), neurological assessment, muscle performance, and sensorimotor control). However, these are difficult to interpret because they have yet to systematically be appraised to determine the strength of evidence that underpins the recommendation.
The objective was to develop clinical guidelines for the assessment of people with whiplash using a modified GRADE approach to develop recommendations for clinical constructs to be assessed in acute and chronic whiplash conditions.

Methods:
We conducted a systematic review of cross-sectional studies. Studies were eligible if participants were of driving age ≥16 years, had a WAD grade I-III resulting from a motor vehicle accident, and compared an acute or chronic WAD group to other populations (e.g., idiopathic neck pain). Further considerations were if the purpose of the study was to determine differences between people with WAD and comparison groups, to quantify impairment, or results inform treatment.
Assessment constructs were divided into the following categories: physical/musculoskeletal impairment, sensorimotor, pain sensitivity, psychological factors, symptom factors, advanced medical testing, and imaging. The certainty of the evidence was determined using a modified GRADE approach.
A multidisciplinary panel was convened, comprising clinicians, research experts, insurers, legal and government regulators, and consumer representatives. Eighteen panel members voted to provide consensus recommendations. The evidence-to-decision framework was adapted to assist in recommending what factor or assessment methods or tests/techniques clinicians should assess in people with WAD. Clinical feasibility of assessing or performing the test, the strength of association (number of studies finding differences between groups) and undesirable effects (benefits/adverse effects of performing the test) were considered by the panel when developing consensus recommendations.

Results:
From 4287 titles screened, 29 acute and 135 chronic WAD studies were included. For acute WAD, guideline panel consensus recommendations FOR measuring the factors to establish diagnosis (WAD grade) were following Canadian C-spine rule, conducting a neurological assessment and measuring Cervical ROM. Other constructs reaching consensus FOR to assess in acute WAD were pain sensitivity (i.e., thermal hyperalgesia) and additional symptoms (i.e., sleep quality). NEUTRAL recommendations were to assess neck muscle function and performance, sensorimotor assessment (i.e., joint position error), and psychological factors (i.e., fear avoidance). Recommendations were made AGAINST imaging or advanced testing (e.g., inflammatory biomarkers, fat infiltration).
In chronic WAD, more categories achieved a consensus FOR measuring the factor based on stronger evidence. These included ROM, pain sensitivity (i.e., thermal hyperalgesia) and additional symptoms (i.e., sleep quality), psychological factors (e.g., depression), neck muscle function and sensorimotor assessment (i.e., balance).

Conclusion(s):
Clinicians are recommended to undertake assessments to establish the WAD grade, such as the Canadian C-spine rule, neurological assessment and cervical ROM. Other factors can be assessed depending on the individual clinical presentation, risk stratification status and stage of disorder (acute vs chronic). Advanced imaging techniques are not recommended as they are not feasible to implement in clinical settings and do not assist in treatment direction.

Background: Current evidence suggests that specific exercise (SNE) for the deep craniocervical flexors is effective in reducing pain and disability in different cervical disorders including cervicogenic headache. Jull et al. 2008 described a testing and training protocol for the deep craniocervical flexor muscles in which a pressure biofeedback unit is used to guide the instruction for exercise performance and progression. Recent recommendations suggest that while the pressure biofeedback is essential for clinical assessment, it not be used as a training device. Rather it is recommended that emphasis be placed on teaching and practicing correct performance of the craniocervical flexion movement and facilitating the deep cervical flexors with strategies such as eye movement, i.e. looking down during the exercise. To enhance training and its progression further, a device was developed (the Spinertial) which facilitates and guides the performance of the exercise with the facility to add resistance. However, its efficacy to reduce symptoms and improve performance in the craniocervical flexion test (CCFT) is yet to be tested.
Purpose: To compare a guided and progressive resistance exercise performed with the Spinertial to free exercise in a cohort with CH.
Methods: Twenty-four participant with CH were randomly allocated to either the Spinertial group (SG) or to the free-exercise group (EG). Both groups performed twelve sessions of SNE for cervical flexor and extensor muscles over six-weeks. The SG performed the SNE flexor-extensor (SNE-fe) with the Spinertial device and a patient-tailored progression was performed by adding elastic bands. The EG performed the SNE-fe as free exercise without the device with a similar patient-tailored progression but without resistance. The primary outcome was the headache impact test (HIT-6). The secondary outcomes were performance in the CCFT, total upper cervical spine (UCS) range of movement (ROM), flexion rotation test (FRT) analysed as more restricted side (MRS) and less restricted side (LRS), mid-lower cervical spine ROM, self-reported global rating of change (GROC-scale) and satisfaction with the exercise program (PACES). All outcomes were measured at baseline, post-intervention (T1) and after 1-month (T2).
Results: Statistically significant between-groups differences were found favouring the SG for HIT-6 at T1 and T2 (p < 0.001), CCFT, UCS ROM, FRT MRS, FRT LRS, PACES and GROC-scale at T1 and T2 (p < 0.01). No between-groups differences were found for mid-lower cervical ROM in any plane.
Conclusion: Training with the Spinertial device was more effective than free exercise for improving the impact of headache, the endurance of deep neck flexor and UCS ROM in participants with CH. The results warrant further research into physiological effects of training with the Spinertial device.
Implications: The Spinertial device guides and facilitates correct craniocervical flexion and extension movement, and resistance can be added to progress training. Exercising with the Spinertial device improved headache impact, upper cervical range of motion and cervical muscles endurance to a greater extent than did free exercise.

Background: Several studies have shown that patients with non-traumatic or traumatic neck pain without vestibular pathology and visual disorder have impaired postural control compared to asymptomatic individuals. Furthermore, when disturbing the function of the cervical spine, e.g., changing the head's position seems to weaken postural control even more. Therefore, balance measurements have been considered an alternative for testing cervical sensorimotor control.

Postural stability has often been assessed with force-plate posturography. Although posturography has been reported as a reliable tool for assessing static postural control and balance performance, most studies have evaluated posturography tests' reliability with healthy subjects. According to our knowledge, the reliability of the computerised static posturographic (CSP) balance tests with or without perturbation tests, such as the balance test in the neck rotation position, has yet to be studied in patients with neck pain.

Purpose: Our study aimed to examine the inter- and intra-tester repeatability of postural stability tests in patients with whiplash-associated disorder (WAD).

Methods: Fourteen adults with chronic WAD performed in randomised order seven different balance tests with eyes open using CSP: neutral head, gaze rotated 20° (left and right), head rotated 20° (left and right), and body turned 20° (left and right). Two testers independently and blinded to all subject information performed all tests, and one of the testers on two occasions two to four weeks apart. The reliability of the balance outcomes from the sway velocity (mm/s) and velocity moment (mm2/s) was evaluated using intra- and interclass correlation and a group of means of two measurements (T-test or Wilcoxon).

Results: Six out of seven tests showed at least a strong (≥0.70) interclass correlation between the two measurements. The correlation of the body rotation to the left test was moderate (≥0.40). Furthermore, the average results of each test did not differ significantly between the testers. The intraclass correlation between the first and second test sessions was at least strong in all tests. However, the average results of the two test sessions differed significantly in the gaze rotation test.

Conclusions: Preliminary results suggest that the reproducibility of balance tests with different test variants is at least moderate in patients with WAD. However, a systematic error in the intraclass correlation may occur in the gaze rotation test.

Implications: Clinicians can reliably use these tests to assess the effects of symptoms and neck position on postural control in patients with WAD.

Background: In view of the scientific evidence that demonstrates the benefits of telerehabilitation for musculoskeletal conditions and the social impact that traumatic fractures of the lower limbs can cause, there is still no consensus on the use of telerehabilitation for this health condition.
Purpose: To sistematically review the literature regarding the effects of telerehabilitation on the physical and functional capacity of individuals with traumatic fractures of the lower limbs.
Methods: The following electronic databases were searched from the beginning of creation until July 31, 2023: MEDLINE/PubMed; EMBASE; PEDro; Cochrane; LILACS and Science Direct. Only randomized clinical trials with at least one intervention group and one comparator group were included. The intervention group should have undergone some form of telerehabilitation and the control group should have undergone conventional physical therapy or the health education strategy. Two reviewers evaluated the titles and abstracts of the initial research in isolation and independently, as well as extracted and synthesized the data.
Results: 5 randomized controlled trials were included in this systematic review. Telerehabilitation did not have favorable effects on functional capacity, with low certainty of evidence, both when measured through the Functional Independence Measure (FIM) (MD=7.35; CI95% [5.48 – 9.22]), when according to the Harris Hip Score -HHS (MD=4.98; CI95% [2.54 – 7.42]). In terms of physical capacity, telerehabilitation presents favorable results and a low level of certainty of the evidence in relation to the Time Up and Go (TUG) test (MD= -7.40; 95%CI [-9.64, – 5.16]), but not favorable and with moderate certainty of the evidence in relation to the Short Physical Performance Battery – SPPB (MD=1.17; 95%CI [0.90 – 1.43]).
Conclusions: Telerehabilitation did not have favorable effects on the physical and functional capacity of individuals with lower limb fractures, but with a low certainty of evidence in the outcomes, which shows the need for more quality clinical trials.
Implications:
In view of the results of this research, physical therapists need to be cautious in the use of telerehabilitation for this health condition, since the evidence that this technique has positive effects on the physical and functional capacity of these patients is still limited.

Background:
The use of measurement instruments (MI) is important for the practice of evidence-based physiotherapy. This is not only from the perspective of therapists and patients, but also from the perspective of other health professionals and health insurances. Standardized MI are used for diagnosis, evaluation, prognosis, and documentation. Currently, there are no data available on the use of MI by physiotherapists in Switzerland.

Objective:
The aim of this study was to evaluate the use of MI among practicing physiotherapists in Switzerland, to identify subjectively perceived facilitators and barriers and to identify predictors of MI use.

Method:
A cross-sectional study was conducted among physiotherapists in Switzerland. An online survey was used to collect data. MI use, facilitators and barriers were assessed descriptively. Relationships between possible factors of influence on the frequency of MI use were evaluated with regression analyses.

Results:
477 physiotherapists participated in the survey. Of these, 90% used MI with their patients. The three most reported MIs were the visual analogue scale or numeric rating scale (60.8%), the goniometer (36.3%) and the 6-minute walk test (19.1%). The majority of respondents (59.3%) used a maximum of five different MI. Workplace, age and education of the physiotherapists had a significant influence on the use of MI.
Positive attitudes towards MI, support in the clinical reasoning process and stronger arguments for communication with insurances were found to be the greatest facilitators. Conversely, lack of time to use and document MI and the need of many therapists to learn more about the use of MI were seen as barriers.

Conclusion:
The aim should be to increase the use of MI by physiotherapists in Switzerland, especially in private practices. The identified time factor and the need for further knowledge about MI have to be taken into account. The results of this study provide a basis for future research questions in the field of the application of MI in daily physiotherapy practice to ensure evidence-based physiotherapy.

Background: Cervical radiculopathy is characterized by pain, sensory and motor disturbance in structures innervated by the affected nerve root, and approximately 50 % of patients have headache. Between 10-25 % of all individuals with cervical radiculopathy undergo surgery to relieve the compressed nerve root, and two common techniques are anterior cervical decompression surgery (ACDF) and posterior cervical foraminotomy (PCF). However, there is a lack of knowledge about which surgical methods have the best effect on neck-related disability, headache, and neck- and arm pain, in the sub-group of individuals with cervical radiculopathy who also express headache.

Purpose: To evaluate the effect of ACDF and PCF on neck-related disability, headache, and neck- and arm pain in individuals with cervical radiculopathy combined with headache.

Methods: This is a prospective observational register-based cohort study with 2 years follow-up with data from the national Swedish Spine Register (Swespine). All individuals (n = 3106) underwent either ACDF (n = 2590) or PCF (n = 516) and were operated between 2014-2021. Patient-reported data was collected preoperatively (baseline), and at 1- and 2-year follow-ups and surgeon-reported data regarding the operation were collected after the operation. Primary outcome was self-reported neck-related disability measured with Neck Disability Index and secondary outcomes were headache, measured with an item about headache of Neck Disability Index, and neck- and arm pain, measured with a 0 to 10-point numeric rating scale.

Results: There were no between group differences at baseline in neck-related disability, headache, and neck- and pain. For primary outcome neck-related disability and secondary outcome neck pain, no significant between-group differences were found between ACDF and PCF (p > 0.05) at 12- and 24 months. Secondary outcome headache decreased more with PCF then ACDF from baseline to 2-years follow-up (p = 0.033) and arm pain decreased more with ACDF from baseline to 1-year follow-up (p = 0.048). No other between-group differences were found for headache and arm pain (p > 0.05). In all variables there were a significant within-group improvements from baseline to all follow-ups in both ACDF and PCF (p < 0.001).

Conclusion: ACDF and PCF show similar improvement in neck-related disability and neck pain in individuals with cervical radiculopathy combined with headache. Both interventions decrease headache and arm pain, but ACDF seems to decrease arm pain more the first year postoperatively and PCF seems to decrease headache more over time.

Implications: In preoperative information to individuals with headache who are undergoing ACDF and PCF due to cervical radiculopathy, clinicians can inform them that neck-related disability, headache, and neck- and arm pain may decrease after surgery although arm pain seems to decrease more the first year with ACDF and headache seems to decrease more over time with PCF.

Background: The most common type of whiplash injury is Whiplash-Associated Disorder grade 2 (WAD2), which includes pain and musculoskeletal signs without frank nerve injury. Approximately 50% of people with WAD2 develop persistent pain. However, we have limited knowledge of prognostic factors that provide pathological insights.
Purpose: To assess the temporal profile of nerve pathology using clinical, serologic, and skin testing. A secondary objective was to assess if nerve pathology can predict recovery at six-months.
Methods: Participants aged 18-85 with acute WAD2 were recruited within 4 weeks of injury and re-evaluated six-months later. Exclusion criteria included: pregnancy; previous cervical/arm pain lasting >3 months; pre-existing peripheral neuropathy. We also included 55 healthy controls without a history of whiplash or treatment for neck, spine or upper limb pain in the past 3 months.
Upper extremity neurological assessment included light touch, pin prick, thermal sensation, myotomal strength and deep-tendon reflexes (nerve roots C5-T1).
Quantitative sensory testing (QST) included sensory detection and pain thresholds over the index finger.

Serum neurofilament light chain (NfL) concentrations were measured using Simoa assay.

Intraepidermal nerve fibre density (IENFD) was evaluated from skin samples taken from the index finger.

Analysis: Neurologic examination is presented as percentages of patients with normal, loss, or gain of function. Changes in NfL and QST between acute, follow-up, and controls were assessed using ANOVA or Kruskal-Wallis with post hoc testing. Prognostic ability of NfL was assessed using linear regression controlling for age, sex, and initial Neck Disability index (NDI).
Results:
Our current cohort consists of 130 people with acute WAD2 (median age: 36 years, 58% female), 50 WAD2 follow-ups, and 55 healthy controls (median age: 31, 56% female).
Neurological assessment: Neurologic dysfunction was identified in 63% acutely and 37% at follow-up WAD2.
QST: There was a significant decrease in detection thresholds for cold (p < 0.001), warm (p < 0.001), mechanical (p < 0.001), and vibration detection (p < 0.001) in people with acute WAD2 compared to controls. At follow-up, sensory detection remained impaired for cold (p < 0.01), warm (p < 0.05), mechanical detection (p < 0.001) as well as mechanical (p < 0.01) and pressure pain thresholds (p < 0.001) compared to controls. There were no differences in any QST measures between acute and follow-up timepoints, besides reduced pressure pain at follow-up (p < 0.001).
NfL: There was significantly increased serum NfL concentrations in people with acute WAD2 (P < 0.05) but no difference at six-months compared to acute WAD2 or controls.
IENFD: There was no significant difference in nerve fibre density at the index finger in acute WAD2 compared to controls.
Prognosis: Acute serum NfL was not prognostic for neck-related disability at 6-months (adjusted r2= 0.248; coefficient estimate: 0.325, standard error: 2.96).
Conclusions: Our findings suggest clinical signs of acute nerve pathology in a subgroup of people, with the NfL resolving while functional deficits largely remain. Acute NfL did not appear prognostic for WAD2.

Implications: A comprehensive clinical neurological examination is critical for assessing signs of nerve pathology in WAD2.

Background: There is international agreement that physical functioning is the most important outcome domain to measure effectiveness of interventions for low back pain. Patient reported outcome measures (PROMs) are the norm in lumbar spinal surgery populations, but physical functioning is multidimensional and necessitates evaluation with physical measures. Physical measures are an important component of a physiotherapy assessment and inform clinical reasoning to formulate a diagnosis, prognosis and intervention plan.

Purpose: To identify outcome measures (PROMs and physical) used to evaluate physical functioning in the lumbar spinal surgery population. To assess the measurement properties of physical measures of physical functioning in this population.

Methods: Using a two-staged approach, this systematic review was conducted according to a registered and published protocol. MEDLINE, EMBASE, Health and Psychosocial Instruments, CINAHL, Web of Science, PEDro (stage one only) and ProQuest Dissertations and Theses were searched. Stage one (inception to 15 December 2021) included studies evaluating physical functioning (PROMs, physical measures) in lumbar spinal surgery populations. Stage two (inception to 10 July 2023) included studies evaluating measurement properties of stage one physical measures. Two independent reviewers determined study eligibility, extracted data and assessed risk of bias (RoB) according to COSMIN guidelines. Measurement properties were rated according to COSMIN criteria. High heterogeneity and RoB directed a narrative synthesis. Level of evidence was determined using a modified GRADE approach.

Results: Stage one included 1,101 reports using PROMs (n=70 established in literature, n=67 developed by study authors) and physical measures (n=134). The most frequently used PROM to evaluate physical functioning was the Short Form Health Survey (e.g., SF-36, SF-12) physical component score and physical functioning domain. The most frequently used physical outcome measure was range of movement for impairment-based measures, walking tests for performance-based measures and physical activity parameters for activity in a natural environment. Stage two included 43 articles evaluating measurement properties of 34 physical measures. The strongest evidence supports performance-based physical measures, with moderate-level evidence for sufficient responsiveness of 1-minute stair climb and 50-foot walk tests, insufficient responsiveness of the 5-minute walk test and sufficient reliability of distance walked during the 6-minute walk test. Very low/low-level evidence limits further understanding of measurement properties for a wide range of physical measures.

Conclusion(s): Many physical measures of physical functioning are used in lumbar spinal surgery populations. Few have investigations of measurement properties. Strongest evidence supports responsiveness of 1-minute stair climb and 50-foot walk tests and reliability of distance walked during the 6-minute walk. Further recommendations cannot be made because of very low/low-level evidence. However, results highlight promise for a range of measures.

Implications: There is promise for physical measures of physical functioning to demonstrate sufficient measurement properties, but few clear recommendations can be made. Knowledge of measurement properties is essential in establishing consensus on appropriate physical measures of physical functioning to evaluate effectiveness of interventions for lumbar spinal surgery populations and inform physiotherapy practice. Prospective low RoB studies are required owing to emerging evidence demonstrating the value of physical measures.

This symposium aims to provide a deeper understanding of:  the mechanisms of migraine associated neck pain  the clinical criteria to differentially diagnose migraine related neck pain  indications for local neck treatment for migraine associated neck pain and outcome expectations Migraine is a severe and disabling brain disorder1 causing significant societal and personal burdens.2 Up to 70-80% of persons report significant neck pain with their migraine.3 Many persons seek local treatments for their neck thinking it might be the cause, or at the least, to assist both the neck pain and migraine. Nevertheless, recent trials and systematic reviews reveal only weak evidence for neck treatments as effective adjunct treatments for migraine.4-7 This realises the need for better understanding about (i) the origins of neck pain in migraine, (ii) the nature and frequency of presentation of cervical musculoskeletal dysfunction (iii) examination for differential diagnosis and (iv) and future approaches to management. Neck pain associated with migraine has two predominant mechanisms. Neck pain may reflect pain hypersensitivity and be part of the migraine symptom complex without any neck dysfunction).8-11 Conversely, local nociception from cervical musculoskeletal dysfunction may be causing or contributing to the neck pain.10,12,13 These mechanisms are driven by the trigeminocervical nucleus which receives afferent input from both the trigeminal and upper cervical nerves, which creates this potential for head pain to be referred to the neck and neck pain to be referred to the head.14 In recent years, there has been a body of research by physiotherapists investigating cervical musculoskeletal dysfunction and other physical impairments in migraine.10,15-18 Two systematic reviews appraising the evidence for cervical musculoskeletal dysfunction in migraine compared to healthy controls19,20 concluded that overall, differences in cervical impairments were minor which does not support a strong case for a frequent cervical musculoskeletal cause of neck pain in migraine. Cross-sectional studies may suffer wash-out effects if the neck pain of some migraineurs has a neurobiological origin. A subsequent study used a cluster analysis to classify patients based on outcomes of a combination of neck function tests and determined that about 40% of the migraine cohort had neck dysfunction which aligned with participants with non-specific neck pain while the neck function of the remainder aligned with the healthy controls.10 This evidence indicates the strength of identifying a combination of cervical musculoskeletal dysfunction to identify a local cause or contributor to neck pain, noting the evidence of the importance of the presence of upper cervical joint signs.10,21 The clinical examination of the patient with migraine and associated neck pain aims to determine the indications for neck related treatment. Care must be taken in the clinical reasoning process. Clinicians often seek a confirming relationship between the neck pain and headache, but the evidence indicates that this relationship is not helpful in determining if the migraineur’s neck pain is related to local dysfunction.22 Additionally, migraineurs often have pain hypersensitivity23 24 whether or not they have local neck dysfunction.8,10,24,25 It has been shown that as a consequence, musculoskeletal tests might elicit pain even when musculoskeletal dysfunction is absent.10 Hence provocation of symptoms alone cannot reliably be interpreted as musculoskeletal dysfunction. Knowledge of the true value of interventions to the neck as an adjunct treatment for migraine requires further research. For both the clinical setting and when designing future clinical trials, current research informs on the need for; selection of appropriate patients,10 a clear knowledge of treatment aims e.g. acute/abortive or preventative treatment, consideration of patient preferences26 and an evidence informed management program. The evidence indicates that the program must recognise neurobiological as well as musculoskeletal aspects of migraine. Multimodal treatment is indicated, including pain education, manual therapy, specific therapeutic exercise and self-management programs.27,28 It is vital that research continues so that the indications and outcomes of local interventions to the neck for persons with migraine and neck pain are known and supported by high quality evidence.

All references numbered in the text can be provided

Learning objectives
The participants have basic:
1) knowledge about implementation strategies
2) knowledge about strength and weaknesses in three different cases of implementation
3) knowledge to consider and discuss bridging of research evidence into practice through implementation strategy.

Description

Introduction, Per Kjaer:
Substantial research about management of people with back pain has been published in clinical guidelines [1] and in the most prestigious international journals [2, 3]. Still, the bridging of the research findings to musculoskeletal physiotherapists for the benefit of their patients seems incomplete and patients are not necessarily offered recommended treatments for their back pain [4].
Reasons for this include lack of knowledge about effective implementation [5]; conflicting beliefs within clinicians [4]; lack of contextual understanding [6]; and not considering patients’ needs and beliefs in clinical decision making [7].
The aim of this symposium is to discuss different implementation frameworks for improved management of people with back pain.
The workshop includes a lecture on implementation followed by three cases of implementation strategies as well as their underlying theories. This leads to the final debate involving lecturers and participants on crossing bridges from research evidence to physiotherapists and patients by effective implementation strategies.

Implementation, Per Nielsen:
Developers of clinical guidelines tend to focus on summarising the evidence and to a much smaller degree, on how to make it work in clinical practice [8]. The lack of success in implementing research evidence about effective treatment may be partly explained by poor understanding of implementation strategies, lack of a theoretical and practical knowledge about frameworks for implementation [5], and poor understanding of the context in which implementation should take place [6].
This lecture will outline an overall categorisation of theories, models and frameworks that can be used in implementation science [5, 9] including process models, determinant frameworks, classic theories, implementation theories, and evaluation frameworks. The aims of the different theories, models and frameworks will be presented as well as their strengths and limitations. To conclude, 10 recommendations for implementation frameworks in practice will be presented [10].

RapidAccess Utah, Jake Magel
University of Utah Health (UUH) adopted an LBP clinical pathway intended to better align LBP care with established evidence-based standards. One area of care in UUH identified as frequently inconsistent with the recommended pathway was the relationship between physiatry and physical therapy. Patients with LBP were often referred to physiatry following a primary care visit for LBP, or directly entered care with a physiatrist [11]. Many of these patients were then referred to physical therapy, representing an inefficient pathway associated with increased use of low-value care including advanced imaging and injections and longer episodes of care due to appointment waiting times [11]. We implemented a guideline concordant alternative care pathway (RapidAccess)[12] that emphasized early physical therapy for patients with LBP prior to a consultation with a physiatrist. The RE-AIM (reach, effectiveness, adoption, implementation, and maintenance)[13] framework was used to evaluate the implementation of RapidAccess. Patients’ perceptions of the RapidAccess programme were assessed [14].

GLA:D® Back, Inge Ris:
GLA:D® Back is a patient education and exercise programme [15], implemented by over 80 clinics in Denmark, involving more than 5000 patients.
The implementation strategy was based on face-to-face clinician courses; approximately 10% of private practice physiotherapists and chiropractors in Denmark have attended the course [16]. Most of the promotion activities occurred before the first course, and the essential source for the spread of the courses was word of mouth [17]. Adoption of the GLA:D® Back programme was successful in half of the clinics attending the courses [18]. Facilitators and barriers for implementation showed that both implementers and non-implementers identified personal gain, practicalities and their attitudes towards the programme as relevant for implementation, perceiving them as either positive or negative [19]. High levels of knowledge and skills were not guiding implementation. Adherence of patients showed that most participants of this 10-week low back pain programme attended almost all sessions [20].

My Back, Jeppe Knudsen:
“My Back” was a co-designed research project including citizens, a university, a university college, and a municipality. It is a mixed-method research study focusing on user-involvement and co-design [21]. Initially, we studied municipal rehabilitation including citizens’ and employees' experience, organisation, and current best practice. The co-designed workshops pointed towards three development areas: 1) knowledge and skills, 2) management of rehabilitation, and 3) organizational processes.
We developed prototype actions to test for further implementation potential. Focus was on micro-changes of interpersonal relations and digital platforms and knowledge-sharing between the employees to optimize rehabilitation-practice to support citizens in managing their back problems. Employees and managers initiated a total of eight prototyping actions.
Citizens, employees, managers, and researchers indicated that the co-design process was meaningful for creating new, relevant, and locally sustainable solutions. The actions are currently being upscaled and implemented.

Debate, Per Kjaer:
The participants will be involved in small group discussions based on the four talks before discussing with the panel of lecturers.

Implications:
We will facilitate an informed discussion about possibilities for making changes to clinical management of people with back pain in the future. This includes preparing participants to balance research evidence, patient preferences and contextual factors.

References
1. Corp N, Mansell G, Stynes S, Wynne-Jones G, Morsø L, Hill JC, van der Windt DA: Evidence-based treatment recommendations for neck and low back pain across Europe: A systematic review of guidelines. Eur J Pain 2021, 25(2):275-295.
2. Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, Hoy D, Karppinen J, Pransky G, Sieper J et al: What low back pain is and why we need to pay attention. Lancet 2018, 391(10137):2356-2367.
3. Buchbinder R, Underwood M, Hartvigsen J, Maher CG: The Lancet Series call to action to reduce low value care for low back pain: an update. Pain 2020, 161(Supplement 1):S57-S64.
4. Slade SC, Kent P, Patel S, Bucknall T, Buchbinder R: Barriers to Primary Care Clinician Adherence to Clinical Guidelines for the Management of Low Back Pain: A Systematic Review and Metasynthesis of Qualitative Studies. Clin J Pain 2016, 32(9):800-816.
5. Nilsen P: Making sense of implementation theories, models and frameworks. Implement Sci 2015, 10:53.
6. Nilsen P, Bernhardsson S: Context matters in implementation science: a scoping review of determinant frameworks that describe contextual determinants for implementation outcomes. BMC Health Serv Res 2019, 19(1):189.
7. Hoffmann T, Bakhit M, Michaleff Z: Shared decision making and physical therapy: What, when, how, and why? Brazilian Journal of Physical Therapy 2022, 26(1):100382.
8. Stochkendahl MJ, Kjaer P, Hartvigsen J, Kongsted A, Aaboe J, Andersen M, Andersen MO, Fournier G, Hojgaard B, Jensen MB et al: National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J 2018, 27(1):60-75.
9. Nilsen P: Theories, models, and frameworks in implementation science: a taxonamy. In: Implementation science : the key concepts. Volume Sidorna 34-37, edn. Edited by Frances Rapport RWJB. London: Routledge; 2022: 34-37.
10. Moullin JC, Dickson KS, Stadnick NA, Albers B, Nilsen P, Broder-Fingert S, Mukasa B, Aarons GA: Ten recommendations for using implementation frameworks in research and practice. Implement Sci Commun 2020, 1:42.
11. Fritz JM, Kim J, Dorius J: Importance of the type of provider seen to begin health care for a new episode low back pain: associations with future utilization and costs. J Eval Clin Pract 2016, 22(2):247-252.
12. Magel J, Hansen P, Meier W, Cohee K, Thackeray A, Hiush M, Fritz JM: Implementation of an Alternative Pathway for Patients Seeking Care for Low Back Pain: A Prospective Observational Cohort Study. Phys Ther 2018, 98(12):1000-1009.
13. Glasgow RE, McKay HG, Piette JD, Reynolds KD: The RE-AIM framework for evaluating interventions: what can it tell us about approaches to chronic illness management? Patient Educ Couns 2001, 44(2):119-127.
14. Sharpe JA, Thackeray A, Fritz JM, Martin BI, Magel J, Vanneman ME: Patients' use of physical therapy for lower back pain: A qualitative study. Musculoskelet Sci Pract 2021, 56:102468.
15. Kjaer P, Kongsted A, Ris I, Abbott A, Rasmussen CDN, Roos EM, Skou ST, Andersen TE, Hartvigsen J: GLA:D® Back group-based patient education integrated with exercises to support self-management of back pain - development, theories and scientific evidence. BMC Musculoskelet Disord 2018, 19(1):418.
16. Kongsted A, Ris I, Kjaer P, Vach W, Morso L, Hartvigsen J: GLA:D® Back: Implementation of group-based patient education integrated with exercises to support self-management of back pain. Protocol for a hybrid effectiveness-implementation study. Submitted 2018.
17. Morso L, Bogh SB, Ris I, Kongsted A: Mind the gap - Evaluation of the promotion initiatives for implementation of the GLA:D® back clinician courses. Musculoskelet Sci Pract 2021, 53:102373.
18. Kongsted A, Ris I, Boyle E, Kjaer P, Hartvigsen J: Adoption, sustainability, and reach of GLA:D® Back - a structured patient education and exercise program for people with back pain. An observational implementation study. In. https://portal.findresearcher.sdu.dk/da/publications/adoption-sustainability-and-reach-of-gla-d-back-a-structured-pati: SDU; 2022.
19. Ris I, Boyle E, Myburgh C, Hartvigsen J, Thomassen L, Kongsted A: Factors influencing implementation of the GLA:D® Back, an educational/exercise intervention for low back pain: a mixed-methods study. JBI Evid Implement 2021, 19(4):394-408.
20. Ris I, Broholm D, Hartvigsen J, Andersen TE, Kongsted A: Adherence and characteristics of participants enrolled in a standardised programme of patient education and exercises for low back pain, GLA:D® Back - a prospective observational study. BMC Musculoskelet Disord 2021, 22(1):473.
21. Donetto S PP, Tsianakas V, Robert G.: Experience-based co-design and healthcare improvement: Realizing participatory design in the public sector. The Design Journal 2015, 18(2).

Human activities have created unprecedented degradations of our natural environment, accelerating social, ecological and health crises, including pandemic and syndemics. The occidental societies’ relationship with nature, considering the latter as ressources to consume, has equally accelerating the process, leading with greater human physical and psychological health issues. As an example, climate change have been claimed worldwide to present the biggest threat for health at a global scale for the 21st century. The typical occidental model of health system, based on hospital care, technology, (over)medication, and surgeries, is participating actively to the degradation of our natural environment via the large amount of resources needed, resulting in a massive pollution and high carbon footprint (over 4% of the total footprint worldwide).
How does this “new” reality apply within the musculoskeletal (MSK) physiotherapy field? What can MSK physiotherapists do to positively contribute to face the future challenges and pursue the mission to take care of the whole population?
In the light of a clinical case study, the aim of this symposium is to give insights to the participants on some of the future challenges that MSK physiotherapy will face regarding environmental, social and economical issues. It will then discuss and explore alternative ways of framing MSK health challenges and treatment options, both shaping a vision of a common future for our profession, as well as elaborating concrete applicable solutions for the everyday practice. The potential solutions to transform this threat into an opportunity to innovate and transform our practice for a more sustainable model necessitates considerations and actions towards one health, one welfare and one justice for all things living.

Propose and background:
The objective of this study is to explore the Mézières Method (MM) as a comprehensive approach to cultivating body awareness among individuals suffering from low back pain. MM is recognized for fostering bodily self-awareness and is considered an embodiment practice.

Methods:
For this qualitative phenomenological study, we purposefully selected twenty participants who had sought treatment for low back pain and underwent ten sessions of MM intervention. We conducted semi-structured interviews to delve into their experiences with low back pain and MM treatment. Open-ended questions were designed to encourage participants to share their self-experience, particularly during sessions four, eight, and ten.
Data analysis encompassed several stages: 1. manual transcription, 2. meaning formulation, 3. theme categorization and clustering, 4. exhaustive description of the phenomenon, 5. identification of fundamental structures, and 6. validation of the exhaustive description and its fundamental structure through participant feedback. Atlas.t software was employed for data analysis.

Results:
The results of our analysis revealed two primary categories:

Teaching and Learning Process: This category encompassed subcategories such as embodied learning, the use of physiotherapist tools, and the role of the physiotherapist as a facilitator of body control.

Embodied Awareness: Within this category, subcategories emerged, including integral body awareness, voluntary control, balance, economy, comfort, and pain relief.

Participants perceived MM treatment as an educational process that unfolds in a unique setting. Here, the individual with low back pain engages in embodied learning that integrates the entire body. The physiotherapist is viewed as a mediator of this learning process, utilizing various instruments for teaching and paying close attention to the patient's body control. Pedagogical tools employed by physiotherapists in MM include hand contact, breathing awareness, and exercise. Hand contact is particularly valuable for assessing myofascial tension, as the therapist continually identifies unnecessary tension in different muscle groups.

The core aspect of the MM learning experience is embodied awareness. This concept is expressed through voluntary body control and self-use, involving a comprehensive self-perception that connects all bodily components. The goal is to attain balance, reduce energy consumption, experience comfort, and achieve relief from pain.

The synthesis of these two categories underscores 'embodied learning' as a central element of this study. Embodied learning centers on the bodily interactions between the therapist and the LBP patient, constituting a teaching-learning process. The therapist employs pedagogical tools to facilitate the client's self-discovery, primarily by opening the sensory body to diminish sensory-motor amnesia, achieve body control, and employ the body in more balanced and efficient ways. The ultimate aim is to self-manage pain, either through its prevention or control.

Conclusion: the Mézières Method serves as a strategy that fosters body awareness in individuals with low back pain, enabling them to better utilize their self-knowledge for improved well-being.

Background: Musculoskeletal disorders (MSKDs) demonstrate a high global prevalence and an enormous social and financial burden on healthcare systems worldwide. Exercise therapy has become an established therapeutic approach in the treatment of MSKDs, as it has been shown to improve pain in patients with musculoskeletal complaints. However, the physiological mechanisms underlying these effects of exercise (central and peripheral pain modulation mechanisms) have not yet been conclusively investigated. Purpose: to review the literature regarding the effects of exercise in patients with musculoskeletal pain on modifying: (1) pain-related endogenous substances concentrations (2) changes in cerebral activity of areas linked with pain processing and modulation, and (3) changes in cerebral plasticity of areas linked with pain processing and modulation. Methods: Systematic searches were conducted in five bibliographic databases: Medline, Embase, CINAHL, Cochrane Trials database, and SCOPUS. Randomized control trials ( parallel and crossover), controlled trials, and before-after studies were included if they investigated pain-associated changes at the cerebral level or endogenous substances in adults with MSKDs. Two independent investigators screened, extracted the data, assessed the risk of bias of the included studies, and evaluated the certainty of the evidence of the included studies. The quality of the studies was assessed using risk of bias tools. The overall certainty of the evidence was determined using the GRADE approach. Results: Nineteen studies (in twenty manuscripts) were included. Fourteen studies presenting a high risk of bias, and only four a moderate risk of bias. The studies comprised a total of eight different musculoskeletal pain conditions, various exercise modalities from different categories (e.g., aerobic exercise, body-mind exercise, resistance exercise) and several neurophysiological outcomes (e.g., corticomotor/corticospinal excitability, inhibition and facilitation; fMRI changes in grey matter volume). Changes in brain plasticity were considered in six studies mostly comprising pain-related brain areas in the prefrontal cortex, descending analgesic system, motor cortex pathways, cingulate cortex, and further parts of the limbic system. Changes in the concentration of pain-related endogenous substances was examined in eleven studies. A total of fifteen different substances was investigated, for which in comparison before and after treatment but also compared with to other interventions, placebo or no therapy. Exercise was shown to induce changes on brain activity and several of the pain-related endogenous substances which could correlate with pain relief in various musculoskeletal conditions. Conclusions: These findings provide evidence that exercise induces changes in pain-related brain plasticity, activity, and endogenous substances that may act to relieve pain in individuals with musculoskeletal pain. In search for new, more effective therapeutic methods to treat MSKDs, exercise therapy, which is often still used primarily under conservative structural paradigms, is showing potential to be better utilized and developed under a new neurophysiological approach for pain management. Implications: This systematic review shows a wide range of available evidence on very different effects of exercise on the brain and endogenous substances in terms of pain. Nevertheless, further studies of higher quality are needed to consolidate these results and to advance the transfer of findings into the practical treatment of patients with MSK

Background: Impaired sleep due to low back pain (LBP) might be influenced by multidimensional domains related to the painful experience, although this has been little explored.
Purpose: This study investigated the association between pain-related characteristics with impaired sleep due to LBP in patients with chronic LBP.
Methods: A cross-sectional study from a primary-care based project database from a low-income setting. Data from adults with chronic LBP with information from the 18th item of the Roland and Morris Disability Questionnaire (RMDQ) was included to detect reports of impaired sleep due to LBP. Multidimensional factors related to the pain experience (pain intensity, pain duration, fear of movement and self-efficacy for pain) were evaluated to explore their association with impaired sleep due to LBP.
Results: The final analyses included 301 participants who met the eligibility criteria. In total, 57.1% of patients reported impaired sleep due to LBP. Multivariate logistic regression analyses revealed that higher pain intensity and higher fear of movement were associated with impairment in sleep due to LBP in this population after adjusting for age, self-report of depression, gender and body max index. Impaired sleep due to LBP was not associated with self-efficacy for pain management or pain duration.
Conclusions: Impaired sleep due to LBP was related to more than one pain-related domain in patients with chronic LBP. Thus not only pain intensity but fear of movement should be addressed as an important component of the assessment and management of those with chronic LBP and impaired sleep due to LBP at Primary Care.
Implications: Patients with impaired sleep due to low back pain are those who have higher pain intensity and higher fear of movement. These findings suggest that the multidimensionality of the experience of low back pain needs attention in the assessment and treatment of sleep impairment.

CKGROUND:
Manual pressure techniques on the suboccipital muscles are commonly used physical therapy modalities for people with tension-type headaches, migraine and cervicogenic headaches. Despite its effectiveness, the working mechanisms remain unclear. As the applied pressure is slightly painful, a central ‘pain-inhibits-pain’ mechanism termed Conditioned Pain Modulation (CPM) could be involved. Since CPM is a central mechanism, manual pressure techniques should reduce pain sensitivity on both local and remote test sites. Consequently, we hypothesized that the CPM effect induced by manual pressure techniques is not significantly different from the CPM effect induced by the Cold Pressor test and that both stimuli induce a larger CPM effect than sham techniques.
PURPOSE:
This study aimed to test the role of conditioned pain modulation as central inhibiting pain mechanism underlying manual pressure techniques in the cervical spine.
METHODS:
The effects of three conditioning stimuli on pain sensitivity were measured using pressure pain thresholds (PPT) in three muscles (locally: suboccipital muscles, regionally: trapezius muscle and remotely on the tibialis anterior muscle). The manual pressure techniques (suboccipital), CPT (with the contralateral hand submerged in ice water), and sham techniques (suboccipital) were used as conditioning stimuli. All participants underwent all three conditioning stimuli in random order. The PPT assessors were blinded. Statistical analysis were performed using Linear Mixed Models.
RESULTS:
We included 63 healthy participants. No significant absolute differences were found between manual pressure techniques and CPT on PPT at all test sites (suboccipital muscles, 11 kPa [95%CI:-3 to 25], trapezius muscle, 15 kPa [95%CI: -10 to 39], tibialis anterior muscle, -24 kPa [95%CI:-55 to 7]). Furthermore, manual pressure techniques demonstrated significant differences compared to sham techniques in suboccipital (20 kPa [95%CI:6 to 34]) and trapezius (38 kPa [95%CI:14 to 63]), but not at the tibialis anterior muscle (18 kPa [95%CI:-14 to 49]).
CONCLUSION:
Manual pressure techniques reduce pain sensitivity in the same order as the CPT does, locally, regionally and remotely, suggesting that CPM as a central working mechanism is involved.
IMPLICATIONS:
Mechanism based classification require a deeper understanding of the mechanism of both the pain and the intervention used. This study revealed an underlying central mechanism of conditioned pain modulation, supporting manual therapists in clinical reasoning. In patients with inhibitory CPM, this technique will theoretically likely benefit the patient.

Background: Chronic pain involves several brain regions associated with sensory and affective pain processing. Whereas chronic nonspecific neck pain is one of the most prevalent musculoskeletal disorders, the precise morphological changes of the brain of patients with chronic nonspecific neck pain are still not fully understood.
Purposes: To investigate morphological changes of the brain (cortical thickness and volume) in patients with chronic nonspecific neck pain and to determine the relationships between such morphological changes and clinical features of neck pain and pressure pain sensitivity.
Methods: A cross-sectional study. Thirty participants with nonspecific neck pain (> 3 months) and 30 healthy controls were recruited into the study. Clinical features included pain intensity, disability and symptoms of anxiety and depression (Hospital Anxiety and Depression Scale, HADS). Pressure pain thresholds (PPTs) were measured at C2-3 and C5-6. Cortical thickness and volume of whole-brain and regions of interest (ROIs) were derived from high resolution T1-weighted images. The ROIs included primary somatosensory cortex (S1), prefrontal cortex (PFC), anterior cingulate cortex (ACC), precuneus and insula. Cluster-wise correction for multiple comparisons was performed using FreeSurfer with false discovery rate (FDR) to estimate group analysis of cortical volume and thickness (cluster-weighted p-value; CWP < 0.05). An independent t-test was used to determine between-group differences in extracted cortical thickness and volume for the ROIs (the adjusted p-value ≤ 0.01). Pearson correlation was used to analyze the relationships between brain morphology and clinical features and PPTs.
Results: There were no differences in demographic characteristics between groups (p > 0.05). Cluster-wise analysis revealed increased cortical thickness in the precuneus, paracentral, postcentral, supramarginal, parietal and occipital regions in patients with neck pain compared to controls. The neck pain group exhibited an increase in cortical volume in the parietal region and a decrease in the PFC, precentral, precuneus, supramarginal, parietal, lingual and temporal regions (CWP<0.05). ROIs analysis revealed that patients with neck pain exhibited increased cortical thickness in the S1, ACC and precuneus and decreased cortical volume in the PFC, S1, ACC and insula compared to controls (ES = 0.66 to 0.72, p≤0.01). A decrease in insula volume was correlated with higher neck disability (r = -0.39, p<0.05). PPTs were negatively correlated with cortical thickness in the S1, ACC, PFC and insula (r = -0.26 to -0.33, p<0.05) and positively correlated with cortical volume in the S1, PFC and insula (r = 0.27 to 0.40, p<0.05).
Conclusion: The study provides evidence for alterations of brain morphology (i.e., thickness and volume) in various regions related to pain processing, emotion and cognition in patients with chronic nonspecific neck pain. Some alterations are associated with neck disability and pressure pain sensitivity. The results suggest cortical reorganization, which may play a significant role in modulating and controlling chronic neck pain.
Implications: Alterations of pain-related regions in patients with chronic nonspecific neck pain can not only enhance our understanding of its underlying mechanism, but also facilitate the diagnosis and effective management of chronic nonspecific neck pain.
Keywords: Neck pain, Neuroimaging, Structural brain
Funding acknowledgement: This research project was supported by Fundamental Fund 2022 and 2023, Chiang Mai University (grant number FRB650031/0162 and FRB660046/0162).
Ethics approval: Ethical approval of this study has been granted by the Faculty of Associated Medical Science, Chiang Mai University (No. AMSEC-63EX-101).

Background
Pregnancy related Pelvic Girdle Pain (PPGP) during pregnancy is common, but little is known about the cause1. Perceived cause is an important aspect of illness perception and drives self-management and health care utilisation2. It is unknown what women who are pregnant of their first child (primiparae) perceive as the cause of PPGP. Illness perceptions come into being largely based upon information that people gather. Hence, healthcare providers’ information on PPGP has an important influence in this process, but the exact mechanism is unclear

Purpose
1) To explore and describe the illness perceptions that primiparae hold towards PPGP and its cause in particular. 2) To describe the influence of the health- and illnessbeliefs of the physio- or manual therapist (PT) and the information that primiparae are provided with by PT’s during a first consultation, on health- and illnessbeliefs of primiparae towards PPGP.
Materials and Methods
Both studies used a mixed-methods design, as follows: 1) Semi-structured interviews were performed in primiparae with and without self-reported PPGP. Thematic analysis was used to identify themes to describe health- and illness perceptions on PPGP. Scores on questionnaires (pain, disability and fear on childbirth) were integrated in the analysis to provide a deeper understanding of the themes. 2) Semi-structured interviews on health- and illnessbeliefs towards PPGP were performed in primiparae before and after they consulted a PT, and audio recordings of these consultations were analyzed. Additionally, semi-structured interviews were performed with the PT’s on their health- and illness beliefs on PPGP. Thematic analysis was used across the datasets to describe the illness perceptions of primiparae and how they were influenced by their physical therapist and the information shared during the first consultation for PPGP.

Results
1) Primiparae perceive PPGP primarily as a biomechanical condition during pregnancy, due to hormonal laxity and softening of the pelvic structures. Primiparae experience similar symptoms, but do not always attribute them to PPGP. The attribution of physical symptoms to PPGP plays an important role in health-care seeking behavior. 2) PT’s confirm pre-existing biomechanical beliefs on hormonal laxity and PPGP and treat primiparae with PPGP accordingly, although many of them advocate a biopsychosocial approach. Primiparae perceive the information and treatment of their pain as comprehensible and reassuring.

Conclusion(s)
The perceived cause of PPGP of both patients and PTs largely centers on biomechanical factors. PTs reinforce these biomechanical beliefs in primiparae with self-perceived PPGP.

Further research is needed to understand why physical and manual therapists stick to conventional biomechanical approaches despite growing evidence for biopsychosocial approaches. It is essential to investigate factors that may drive changes in clinical practice in this context. Additionally, it is essential to investigate if altering the narrative on PPGP can positively impact the perception of patients.

Implications
It is important that physical and manual therapists not only become aware of the perceptions patients hold towards PGPP, but also competent and confident in eliciting and addressing them. Moreover, awareness is needed on the role healthcare providers may play in perpetuating the prevailing biomechanical and hormonal approach of PGPP.

Background
Pregnancy related pelvic girdle pain (PGP) is common during and after pregnancy, it affects almost half of all pregnant women. The risk of recurrent PGP in subsequent pregnancies is high, 85% - 88,5%. The majority of women recover spontaneously within three months after delivery. However, a substantial number of women (30%) still report PGP after this period. The pain is intermittent in nature and is provoked and relieved by specific postures and activities related to vertical or directional loading in weight bearing positions. The pain hinders daily life, influencing daily activities like sitting, standing, walking and lifting. It disrupts sleep and often leads to high levels of sick leave. It is therefore important to know which intervention reduces these complaints and improves quality of life.

Purpose:
The aim of the study is to perform a systematic review and perform a meta-analysis on the effect of exercise and additional manual therapy compared to any form of intervention on pain, disability, pelvic floor- function (PFF) and Transverse Abdominal muscle function (mTAF) in women with peripartum pregnancy-related PGP.
Methods
An extensive literature search was conducted using the following electronic databases: MEDLINE, Pubmed, Embase, Emcare, PeDRO, Web of Science, Cochrane, CENTRAL and PsycINFO, from commencement until April 2023. Protocol registry (https://www.clinicaltrials.gov) was screened for upcoming trials. The following PICO (Population, Intervention, Comparison and Outcome) strategy was used; P = Women with pelvic girdle pain peripartum, I = manual therapy, exercise, C other treatment, O = pain, disability, PFF and mTAF. Eligible for inclusion were RCT’s about exercise or manual therapy in women with peripartum PGP written in English.

Results
Only pain and disability could be pooled in six meta-analysis; manual therapy in combination with ‘stabilizing’ exercise compared to other treatment prepartum, ‘stabilizing’ exercise compare to other treatment postpartum and general exercise compared to other treatment prepartum. Preliminary results demonstrated four significant meta- analyses with a low to high heterogeneity (I2 range 0%-88%), due to heterogeneity in definition of PGP, questionnaires and outcome. Prepartum, positive effects of manual therapy combined with ‘stabilizing’ exercise (e.g. mTAF, m. multifidi) were demonstrated on both pain intensity and disability. No effect was found for general exercise (e.g stretching, aerobics, strength training core muscles) interventions compared to other treatment. Postpartum, meta-analyses revealed evidence for positive effects of ‘stabilizing’ exercise on pain intensity and disability when compared to other treatment. It was not possible to pool data for the outcomes PFF, mTAF and quality of life.

Conclusion
Manual therapy in addition to stabilizing exercise as well as stabilizing exercise alone are effective for reducing pain and disability in woman with PGP peripartum. This contradicts the outcomes of other reviews. Due to the heterogeneity among the studies, it’s possible that there is an overestimation in effects.

Implications
To reduce heterogeneity among studies, an international uniform definition of PGP and a uniform core set for physical tests, questionnaires and outcomes is recommended.

Background
Increased diaphragm fatiguability, more pronounced thoracic breathing, and decreased ventilation are often reported in individuals with spinal pain. Given these alterations in respiratory function, beneficial effects of breathing interventions on spinal pain may be presumed. However, their clinical effectiveness remains to be determined.

Purpose
The aim of this systematic review was to provide a comprehensive overview of the literature regarding the effect of breathing interventions on pain and disability in individuals with spinal pain.

Methods
Following the study registration (CRD42020199471), multiple databases were searched until August 2023. Studies investigating the effect of breathing interventions, whether or not compared with a control group, on pain or disability in individuals with spinal pain were eligible for inclusion. Breathing interventions comprised interventions using active instructions to modulate breathing components (e.g. pace, volume) or to increase breathing awareness. The Downs and Black checklist was used to assess risk of bias. Both within- and between-group differences were extracted and synthesized narratively, due to high heterogeneity of both breathing and control interventions.

Results
Fourteen studies related to low back pain (LBP), and six related to neck pain (NP) were included. Seventeen of them received a fair to good quality score (50-85%). Slow deep breathing, respiratory resistance training, and breathing awareness exercises were, amongst others, included as breathing interventions. In the LBP population, breathing interventions significantly decreased pain and disability in respectively 13/13 and 8/10 studies. When compared with an intervention group, pain and disability significantly decreased in respectively 5/12 and 4/11 studies. In the NP population, breathing interventions significantly decreased pain and disability in respectively 6/6 and 3/4 studies. When compared with an intervention group, pain and disability significantly decreased in respectively 4/4 and 1/2 studies.

Conclusion
Although breathing interventions appear to decrease pain and disability in individuals with LBP and NP, it remains unclear whether breathing interventions are more effective than routine physiotherapy or other control treatments for LBP. For NP, preliminary evidence suggests that breathing interventions may be more effective than routine treatment.

Implications
By July 2024, we aim to elucidate which components of the breathing interventions (e.g., breathing rate, volume, resistance) determine their clinical effectiveness in individuals with spinal pain.

The world of healthcare is rapidly evolving, and musculoskeletal physiotherapy is no exception. As patient expectations and the understanding of patient-centered care have evolved, there is an increasing recognition that the practice of physiotherapy must adapt in line with this (1,2). This symposium aims to address the crucial shift towards patient-centered care and the transformation of curriculum in the field of musculoskeletal physiotherapy (3,4). 1.Understanding Patient-Centered Care. Patient-centered care is not just a buzzword; it is a fundamental shift in healthcare that acknowledges the unique needs and preferences of each patient (5). In musculoskeletal physiotherapy, where precision and empathy converge, the realization that patient-centered care is imperative rather than a preference has become increasingly apparent (1,3). Through lectures, panel discussions and interactive participation tools, attendees will gain insights into the core principles of patient-centered care and its significance in improving patient outcomes. 2.Strategies for Effective Curriculum Implementation. This symposium also focuses on equipping educators of future physiotherapists to teach the skillset and mindset to understand and help manage the unique needs of their patients effectively. This paradigm shift necessitates a transformation in the way physiotherapy is taught and practiced. Attendees will explore innovative pedagogical approaches that foster empathy and active listening among students. They will gain knowledge on how to integrate patient narratives and experiences into the learning process, enabling students to gain a deeper understanding of the patient's perspective and needs. 3.Innovative Integration of Patient-Centered Principles:The third learning outcome of this symposium addresses this challenge head-on by exploring innovative strategies for seamlessly integrating patient-centered principles into an OMT curriculum (6). Participants will have the opportunity to delve into practical examples from two different curricula, interview with students, and discussions that showcase practical approaches to achieving this balance.They will gain actionable insights into how to adapt OMT techniques to align with patient-centered care principles, ultimately enhancing the quality of care provided to individuals with musculoskeletal conditions. As the healthcare landscape continues to evolve, embracing patient-centered care and adapting curriculum accordingly, is essential to ensure that patients receive the highest quality of care and support in their journey to musculoskeletal health. By addressing these three key learning outcomes, this symposium hope to empower physiotherapists and educators to not only recognize the imperative nature of patient-centered care but also take concrete steps towards transforming the way musculoskeletal physiotherapy is taught and practiced.

References: (1) Lin et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med. 2020 Jan;54(2):79-86. (2) IASP. Physical therapy pain curriculum. https://www.iasppain.org/education/curricula/iasp-curriculum-outline-on-pain-for-physical-therapy. 3) Killingback C et al (2022) Teaching person-centred practice in physiotherapy curricula: a literature review, Physical Therapy Reviews, 27:1, 40-50. (4) Wallengren C et al. Person-centered care content in medicine, occupational therapy, nursing, and physiotherapy education programs. BMC Med Educ. 2022 Jun 24;22(1):492. 5) Hutting N et al. Person-centered care for musculoskeletal pain: Putting principles into practice. Musculoskelet Sci Pract. 2022 Dec; 62. (6) Keter D et al. Modernizing patient-centered manual therapy: Findings from a Delphi study on orthopaedic manual therapy application. Musculoskelet Sci Pract. 2023 Jun; 65:102777

Swimmers are frequently burdened with gradual onset shoulder pain during training and competition.(1) While the demands on the shoulder in swimmers are high and specifically related to swimming volume/mileage,(2) injury risk profiling is in its infancy and consequently specific evidence on prevention strategies seems absent.(3-5)
To support physiotherapeutic clinical reasoning and decision-making in musculoskeletal shoulder physiotherapy, the goals of the focused symposium are various. In the exemplar athletic discipline of swimming, where progressive training volume needs technical optimisation and vice versa, it is important to emphasise on the biopsychosocial profile of a young female swimmer and how this profile meets the demands of the sport with all its stakeholders.(3, 6-8) During subsequent lectures we will dive deep into the biopsychosocial model, (shoulder) pain mechanisms, load management strategies and key learnings from a shoulder injury. We will focus the female adolescent patient with shoulder pain and highlight specific tools for the rehabilitation process to build a resilient person after an episode of pain. The presentations will highlight key principles that can be transferred to any other active young patient with gradual onset shoulder pain that we meet in daily physiotherapy.

Globally, physiotherapists are at different phases of professional development requiring different types of leadership:

Phase 1: Professional development and recognition phase. Physiotherapists are establishing their profession and working towards professional autonomy, independence and possible demarcation from other health professionals. This phase also encompasses physiotherapists who are establishing new areas of practice or building evidence to support expanded practice. In this phase, leadership requires a capacity to develop and bring together the evidence base underpinning practice, and advocate for the profession within a health system.

Challenges: In this phase, physiotherapists may encounter resistance from health practitioners who perceive the change as professional competition or conflict from those who disagree with the area of physiotherapy development.

Strategies: Leaders need ways of identifying and responding to different stages of readiness and strategies to acknowledge conflict, and being able to specify and justify the evidence base for and the value of ‘new physiotherapy skills’ or ‘expanded recognition or practices”. It may also require capacities to bring together relevant research to compare/contrast physiotherapy skills and contributions compared to other health professions.

Phase 2: Building patient centred practice phase encompasses situations where questions arise about how physiotherapy can best meet the needs of the patients they currently and might potentially serve. Leadership in this phase requires a capacity to reach different patient groups and to develop and justify models of care designed to meet diverse populations.

Challenges include changing expectations and needs of patients or health consumers and the increase in professionals offering services which overlap with physiotherapy.

Strategies: Leaders will need skills to gather data about patients’ or population’s needs. They will need to be able to communicate confidence and certainty about the value of physiotherapy including presenting evidence and demonstrating how physiotherapists can expand and respond to changing needs. Physiotherapy leaders may also need to advocate for and demarcate the unique skills that therapists can offer.

Phase 3: Professional advocacy phase refers to situations where physiotherapists are needing to build a case or synthesise data about why and how health funding should prioritise the work of physiotherapists or utilise their services more efficiently and how physiotherapy might contribute to the delivery of health care.

Challenges: include the problem of diminishing or finite resources in health service delivery and models of care which may not be fit for purpose.

Strategies: include knowing when and how to speak up as advocates for patients or for the physiotherapy profession. An understanding of building collaborations and being able to effectively position physiotherapy within health systems.

Physiotherapy clinicians working directly with patients, leading departments, managing health centres and teams or educating students may all find themselves requiring leadership skills any of these 3 phases of practice.

Learning objectives: Participants will
1. Identify leadership theories which are relevant to physiotherapy practice;
2. Recognise challenges to effective leadership across different physiotherapy practice situations;
3. Practice leadership skills relevant to challenges arising from organisational, professional behaviour and professional development situations.

In relation to each phase of physiotherapy practice, the symposium will draw on participants’ own experiences of leadership and combine that expertise with established key concepts from leadership theory to apply them to different phases. Participants will have opportunities to discuss cases from education, practice and policy and find practical responses to day-to-day challenges that physiotherapy leaders encounter.

Background:
Exercise is recommended as first line management for chronic non-specific low back pain (CLBP), the main cause for years lived with disability. The long-term benefits of exercise are evident, but short-term benefits are less explored. The phenomenon of exercise-induced hypoalgesia (EIH) describes a temporary decrease in pain sensitivity following exercise. Whilst several systematic reviews have confirmed that EIH occurs in asymptomatic people, there is a lack of research investigating people with spinal pain and the stability of the effects of EIH over repeated sessions.
Our recent rigorous systematic review (CRD42019145586) of 22 observational studies (n=807 participants) investigated whether EIH occurs for people with spinal. Specifically for people with CLBP, eight studies (n=352 participants) assessed eleven tasks with low-quality evidence for conflicting results (absent/altered EIH). These findings supported the need for low risk of bias studies assessing EIH in people with/without CLBP following local lumbar and remote tasks and thus informed this exploratory research.

Purpose:
To explore the occurrence and stability of EIH following different tasks and across repeated sessions in people with/without CLBP.

Methods:
A pragmatic observational study was conducted within a university setting according to the STROBE statement. Based on the sample size calculation, 30 participants with CLBP and 30 asymptomatic participants were allocated to six sessions of an individually tailored standardised task (n=15 each group): A) local dynamic lumbar resistance task (~12 minutes), B) remote brisk walking task (~15 minutes). Another ten asymptomatic participants did not exercise and rested instead (Task C). Changes in pain sensitivity indicative of EIH were assessed via an extensive quantitative sensory test battery immediately before and after each session. Lumbar pressure pain thresholds (PPT) were the primary outcome measure. A repeated-measures ANOVA was applied to determine the presence of EIH, and stability was assessed using the ICC (3,1).

Results:
Participants (n=70, 53% women, mean age 25±5 years, CLBP groups: minimal disability level) demonstrated EIH regardless of the task or the group (p≤ .035). Lumbar PPT changed following the local task A in participants with CLBP [mean PPT +42.30kPa, 95%CI 7.20;77.40] and asymptomatic participants [+63.44kPa, 28.33;98.54] and following the remote task B for CLBP [+35.39kPa, 5.58;65.21] and for asymptomatic participants [+39.03kPa, 9.21;68.84]. However, similar changes in lumbar PPT also occurred after rest only for task C [+35.46kPa, 16.36;54.55].
The stability of EIH effects was poor regardless of the group and task (ICC (3,1) ≤.303).

Conclusion(s):
In this study, significant changes indicative of EIH occurred in both CLBP and asymptomatic participants regardless of the nature of the task they were assigned (lifting (task A), walking (B), rest (C)). Furthermore, the poor stability of EIH requires further investigation.

Implications:

Current evidence supports inconsistent findings on whether EIH is altered in people with CLBP based on low-quality evidence. This exploratory research contributes to the understanding of EIH in people with/without CLBP, demonstrating EIH following local and remote tasks. Furthermore, it highlighted poor stability of EIH. This is critical, as stability is a prerequisite for future research to further elucidate EIH and the short-term benefits of exercise.

Background: Low back pain (LBP) represents a global burden, yet recovery from LBP is not well understood. There is no currently accepted definition for recovery from LBP, nor is there a gold standard for its measurement. In addition, it is currently unclear how the perspective of patients are used in making recovery determinations. While there has been some work to better understand recovery from LBP, no previous review has canvassed both surgical and non-surgical literature at the same time. By broadly surveying all available literature, it is hoped that a consistent definition of recovery in LBP can be created and therefore informed recommendations for measurement can be made.

Purpose: The purpose of this mixed study systematic review across quantitative and qualitative literature was to explore how recovery has been defined and measured for patients experiencing LBP, as well as examine how the perspectives of patients and providers for recovery of LBP align or differ.

Materials and Methods: Studies were eligible for inclusion if they included patients with musculoskeletal LBP and reported on recovery in either the abstract, methods or results. EMBASE, CINAHL, Cochrane, and PEDro databases were electronically searched from inception until February 20, 2023. Grey literature was searched through ProQuest Dissertations and Theses. Two reviewers independently evaluated studies for eligibility, performed quality assessment, and extracted relevant data. The Mixed Methods Appraisal Tool was used for quality assessment of included studies. Thematic analysis was used to explore definitions, measurements, and perspectives of recovery. Themes were developed in three phases for each of the objectives (definitions, measurements, perspectives), bringing themes from very specific to broad.

Results: 500 studies were included: 12 qualitative studies, 88 quantitative randomized control trials, 348 quantitative non-randomized studies, 16 quantitative descriptive studies, and two mixed methods studies. Most studies were rated as moderate (49%) or low (45.8%) quality. Across the corpus of literature, recovery was defined in seven main themes, and measured across six main themes. More than 1/3 of studies did not define recovery and used multiple measures to measure it. The perspectives of patients with LBP were largely not incorporated into making recovery determinations across surgical and non-surgical literature.

Conclusions and Implications: Recovery from LBP currently is measured and defined in a myriad of ways and thus continues to lack consensus. Furthermore, determinations of recovery from LBP are largely made without patient input. Consensus-driven methods are required regarding how recovery should be defined and measured with incorporation of perspective from patients, clinicians, and researchers alike.

The aim of this study was to examine the associations of spinal kinematics and physical activity (PA) with bodily pain, physical functioning, and work ability among health care workers with low back pain (LBP). Spinal kinematics and PA were measured with a wireless Inertial Measurement Unit system (ValedoMotion®) and a waist-worn tri-axial accelerometer (Hookie AM20), respectively. Their association was assessed in relation to Work Ability Index (WAI), bodily pain and physical functioning (RAND-36) in 210 health care workers with recurrent LBP. Greater lumbar movement variability/less deterministic lumbar movement (in angular velocity) during a “Pick Up a Box” functional task was correlated with higher amounts of step counts (r = -0.29, p = 0.01) and moderate PA (r = -0.24, p = 0.03). A higher amount of PA (p = 0.03) as well as less movement control impairment (p = 0.04) and movement variability (p = 0.03) were associated with greater work ability, whilst greater vigorous PA was the only parameter to explain higher physical functioning (p = 0.02). PA and movement variability were relative to each other to explain bodily pain (p = 0.01). These findings show the importance of considering the interaction between lumbar kinematics and physical activity while planning strategies to improve bodily pain, physical functioning and work ability among health care workers with LBP.

Background:
Following an accident, individuals face many limitations and disabilities that present them with the dilemma of choosing which activities to resume or not. Classification according to activity patterns (avoidance, modulation and persistence), although useful, does not provide insight into patients' activity management strategies or the factors underlying them. Though many studies have examined these activity patterns, little research has looked at the factors that lead people to adopt particular activity behaviours. Knowing more about these factors may help to promote optimal pain and activity management in patients, and develop their ability to use appropriate strategies depending on the circumstances.
Aims:
This qualitative study aimed to explore the relationship with activity in people with chronic musculoskeletal pain after musculoskeletal trauma and to highlight the dynamics between the factors underlying their engagement in one or another pattern. This study aimed to shed light on the meaning attributed to such practices and the factors underlying their activity behaviour during rehabilitation and in their life context.
Methods:
Thirty-three patients (6♀/27♂, 44.9±10.6 years old, 26 unemployed, 7 working at a reduced rate, 11+/-2 months since the accident) were included in this qualitative research, which used observation of professional workshops and semi-structured interviews. The activity strategies adopted by people undergoing rehabilitation for chronic musculoskeletal pain and the factors underlying their choices were explored. Content analysis was carried out by an interdisciplinary team (physiotherapists, anthropologists, psychologists).
Results:
Analysis of observations and patients' discourses showed that any one patient will alternate between all three activity profiles: the same person may adopt a strategy of avoidance, pacing or persistence, depending on the context (private or professional), the importance and nature of the activity, personal goals, and representations of self, pain and activity. Participants combined different activity management strategies based on their experience, lay knowledge and education gained during their care. Those who were flexible in their strategies were better able to resume their activities. They weighed the expected consequences and the importance of an activity in their decision to undertake it or not.
Conclusion(s):
The relationship to activity is a dynamic process of constant negotiation with oneself and others (health professionals, relatives, health and social welfare system) rather than a personal trait. People establish a dynamic and flexible relationship with activity according to different logics that weigh up the stakes of the envisaged activity. A better understanding of these logics could help to improve the effectiveness of rehabilitation by targeting the mechanisms that limit activity. Future research should investigate whether this approach could effectively improve activity recovery after orthopaedic trauma.
Implications
These findings suggest that it would be appropriate to train the flexible use of a range of skills and activity management strategies in rehabilitation, in order to promote the performance of valued activities by minimising their undesirable consequences. Therapeutic approaches in the rehabilitation context could take into account these adaptive capacities to provide patients with optimal pain and activity management and develop their ability to use different strategies depending on the circumstances.

Background: Low back pain can affect movement throughout the body, potentially placing individuals at risk for a subsequent injury outside of the low back region. That rate at which individuals will go on to experience a distal joint injury (hip, knee, or ankle) after an episode of low back pain is unknown. Therapeutic exercise has been shown to be effective for low back pain, and can potentially reduce the risk of recurrent episodes, but it’s effect on subsequent distal joint injury after an episode of low back pain has not been investigated.

Study Design: Retrospective cohort study

Methods: Participants were adults 18 to 65 years of age seeking care for low back pain in the US Military Health System from 2015-2019, and followed for 1 year. Cases with red flags were excluded (fracture, cauda equina syndrome, systemic arthropathies, infection, cancer). Care utilization in medical records were extracted from the Military Health System Data Repository (MDR), to include follow-on visits that included therapeutic exercise for low back pain within the first 90 days from injury, and any future visits with a diagnosis code for a hip, knee or ankle injury. Cox proportionate hazards models were run for each of the three adjacent injury types independently looking at days to adjacent injury. Adjustments were made for sex, age, and socioeconomic status.

Results: There were 650,993 participants that met all criteria and included into the cohort. The majority were male (65.2%) with a mean of 35.5 years of age (SD 12.3). Of these, almost 1 in 4 (23.3%) sustained a distal joint injury during the 1-year follow-up (8.4% ankle, 7.2% knee, 4.4% hip, and 3.3% to multiple joints). Receipt of therapeutic exercise for low back pain resulted in significantly reduced likelihood of a subsequent knee injury (HR 0.87; 95CI 0.85-0.99), ankle injury (HR 0.92; 95CI 0.89-0.93), or hip injury (HR 0.97; 95CI 0.95-0.999).

Conclusion: Distal joint injury in the lower extremity was common in the year following a low back pain episode, but those who received therapeutic exercise as part of their treatment plan were less likely to sustain a follow-on injury. These may be potential downstream health effects associated with low back pain that merit consideration when establishing a treatment plan.

Low back pain (LBP) is the world’s most disabling condition and leading cause of work absenteeism. Manual workers are exposed to repeated lifting tasks and lifting is a common risk factor for LBP. Engaging in manual tasks that are repeated or awkward has been reported to increase the risk of LBP persistence. Strategies targeted at reducing lifting-related LBP have not been effective.

Strategies to prevent and manage lifting related LBP have had a biomechanical focus. Advice to lift with a straight back, use the legs, lift slowly and tense the core are the dominant paradigm. These strategies are not evidence based. Recent systematic reviews have found that people with LBP follow this advice more than people without LBP.

Muscle activity around the core during lifting remains a topic of contention. The evidence surrounding how people with and without LBP lift from a muscle activity perspective is limited to few studies, where pain and fatigue were low and lift repetitions were less than 10, not replicating a manual workplace environment.

This study addressed a number of previous limitations in the research. A 12 sensor trunk muscle EMG protocol was used to compare peak and average muscle activity over a 100 lift task between manual workers with and without a history of LBP. This task induced pain and fatigue and therefore associations between trunk muscle activity, pain and fatigue in manual workers with and without a history of LBP could be explored.

We found no differences in trunk muscle activity between people with and without LBP during a 100-lift task. There were within group changes across the 12 channels over time in both groups. These changes were inconsistent and only involved few muscle channels. There was also no relationship with fatigue or pain and trunk muscle activity.

This study was a comprehensive EMG study of a 100-lift task that compared muscle activity between manual workers with and without a history of LBP. It adds to recent systematic reviews suggesting that the dominant paradigm to prevent and manage lifting-related LBP has no research evidence to support it at a group level.

At a group level, trunk muscle EMG during lifting does not seem important, as people with and without LBP lift similarly despite differences in lifting kinematics, pain and fatigue. This study addressed important gaps in the literature but ultimately adds to a growing body of evidence suggesting the focus of preventing and managing lifting-related LBP requires reconsidering.

BACKGROUND- Hip abductor weakness is a major risk factor for lower extremity (LE) pathologies. Gluteus medius (Gmed) insufficiency leads to compensatory tensor fasciae latae (TFL) activity, altering LE movement. Previous studies focused on TFL/Gmed-ratios using surface electromyography (EMG) without assessing Gmed subdivisions (anterior [AGM], intermedius [IGM], posterior [PGM]). Moreover, trunk stability’s impact on lumbopelvic control during hip functional movement has not been sufficiently evaluated.
PURPOSE- This study’s purpose was to explore TFL’s, AGM’s, IGM’s, and PGM’s neuromuscular activity and lumbopelvic kinematics during side-lying hip abduction (SLHA) with and without volitional preemptive abdominal contraction (VPAC).
METHODS- A within-subjects, repeated measures design was incorporated. Nineteen healthy male and female subjects aged 27 ± 7 years performed SLHA in an internal rotation (SLHA-IR) versus external rotation (SLHA-ER) pre-position. Hip abduction activities were performed with and without VPAC using an abdominal bracing maneuver (ABM). Outcome measures included muscle output amplitudes (% maximum voluntary isometric contraction) collected through surface and indwelling fine-wire EMG. Three-dimensional lumbopelvic kinematics were measured using the Vicon Nexus system.
RESULTS- Performing SLHA produced a significant interaction for hip pre-position and hip muscle during the no-VPAC and yes-VPAC conditions (each p < .001). The 2(VPAC) x 2(hip pre-position) within-subject repeated measures ANOVAs revealed significantly higher TFL (p < .001) and PGM (p = .010) EMG amplitudes during the yes-VPAC versus no-VPAC-condition. The same analyses reported significantly greater AGM (p < .001) and IGM (p < .001) EMG amplitudes with hip IR versus ER pre-position. For kinematics, no significant (VPAC) x (hip pre-position) interactions or main effects were found for lumbopelvic complex range-of-motion (ROM). VPAC-use produced a significant reduction (p < .025) in: sagittal plane minimum pelvic angle; transverse plane (TP) maximum and minimum lumbar spine (LS) angles; and TP maximum pelvic angle. Several significant hip pre-position main effects (p < .025) were found, where IR reduced minimum LS angles in all three planes, as well as TP and frontal plane maximum LS angles and both maximum and minimum pelvic angles.
CONCLUSION- This study suggests SLHA with pre-positioned hip IR and/or ER cannot be thoroughly recommended to emphasize Gmed while de-emphasizing TFL. The myofascial chain model may explain the significant increase in TFL and PGM activity during VPAC-use, but more data are needed to support this. The overall increased muscle activation levels with VPAC-use suggest ABM could enhance hip muscle performance during SLHA-IR and SLHA-ER. Finally, VPAC-use during SLHA-IR and SLHA-ER performance does not limit functional ROM but enhances lumbopelvic anterior-posterior and rotational stability.
IMPLICATIONS: This study widens clinicians' understanding of the most effective means to activate and optimize Gmed function without simultaneously allowing TFL compensatory dominance in response to insufficient Gmed activation. Such knowledge is essential for adequately supervising patients with lower extremity disorders and reducing the consequences associated with hip sensorimotor dysfunction.

Background
Low back pain (LBP) may lead to sensorimotor alterations such as disturbed proprioception and balance. Balance is commonly assessed with posturography on a force plate in a movement science laboratory. However, affordable technology such as the Wii Balance Board (WBB) can be used in the clinical setting. Although proprioception is vital for balance, balance tests are not specific tests of proprioception since it involves all parts of sensory and motor control functions. In the cervical spine, the influence of proprioception on postural sway has been explored using posturography with the cervical spine in a torsioned position. This was proposed to adversely affect the afferent input from the cervical proprioceptors and showed increased sway in people with neck pain. It is possible that similar torsion test, but directed to the lumbar spine, can be useful in the assessment of people with low back pain.

Purpose:
The study aims were to assess if a lumbar torsion postural stability test using a WBB could identify postural sway difference between participants with mechanical LBP compared to healthy controls (CON), and to assess the test-retest reliability of the lumbar torsion postural stability test.

Methods:
Fifty-five participants (42.3 ±9.8 years, 67% females), 27 with mechanical LBP and 28 CON participated in this cross-sectional test-retest study. Postural sway during quiet stance, eyes closed, was evaluated in a neutral and torsioned (rotated) lumbar position tests for 60 seconds for path velocity, medio-lateral amplitude and antero-posterior amplitude. The procedure was repeated one hour later to evaluate test-retest reliability. Data was analysed with independent T-test or Mann-Whitney U-tests to explore group differences. Test-retest reliability was analysed using intra class correlation (ICC) and standard error of measurement (SEM).

Results:
There was a significant increased postural sway in LBP compared CON in neutral position in antero-posterior amplitude (p=0.03, effect size 0.6) while the other outcome variables showed no significant differences. Interestingly, all sway measures were smaller in torsioned position compared to neutral position for both groups. This difference (i.e., between torsioned and neutral position) was close to significantly larger for LBP compared to CON in antero-posterior amplitude (p=0.08, effect size 0.5). Test-retest reliability of postural sway in neutral and torsioned positions was moderate to excellent.

Conclusion(s):
The WBB is useful for clinical measure of postural sway in neutral quiet stance. The fact that the sway decreased in torsioned position compared to neutral, and that this decrease was larger (although not significantly) in the group with mechanical LBP, was unexpected and needs further investigation. Are there differences in postural strategies that can be revealed using this test? Future research should investigate other groups of LBP, e.g., neuropatic pain (sciatica), but also more challenging tests such as standing on soft surface or various types of perturbations to the postural control.

Implications:
Clinical evaluation of postural sway in quiet stance in neutral and lumbar torsioned position using a WBB has acceptable reliability. Neutral posture is more useful compared to torsioned position to identify postural disturbance in mechanical LBP.

Background
The gap between clinical guidelines and their application in clinical practice is reflected in the fact that not the recommended exercise and education, but still non-evidence-based interventions, such as passive modalities and surgery are used as first-line interventions in the management of HK-OA and LBP. GLA:D (Good Life with osteoArthritis in Denmark) translates the international guidelines for hip and knee osteoarthritis (HK-OA) and for persistent or recurrent low back pain (LBP) into standardized but individualized programmes (GLA:D-OA and GLA:D-Back).

Purpose
Given the high prevalence of OA and LBP, the evidence-based GLA:D programmes should be implemented in clinical practice to overcome the evidence-performance gap.

Methods
The three core elements of the GLA:D programmes have been systematically implemented internationally, and in Switzerland, GLA:D-HK-OA since 2019 and GLA:D-Back since 2021: 1) certification of physiotherapists (PTs) for uniform implementation; 2) training of the affected persons by the certified PTs in their institution: 4 individual sessions and 14 group sessions (2 patient education sessions and 12 supervised training sessions); 3) collection of all assessment and questionnaire data in a national registry at entry, after completion, after 6 months (LBP only) and after 1 year. The data are evaluated annually as part of the quality monitoring.

Results
A total of 848 certified GLA:D-PTs for HK-OA and 402 PTs for LBP treated a total of 4662 HK-OA and 574 LBP patients in all three language regions in Switzerland in GLA:D courses. After the intervention, the 2462 KOA and 741 HOA patients with complete data showed improvements in pain of 24% and 23%, walking speed of 12% and 6%, quality of life of 22% and 16%, and pain medication use of 18% and 15%, respectively. Pain, function and quality of life remained substantially improved also after one year. The 300 LBP patients with complete data improved by 30% in pain intensity, 26% in pain medication consumption, 18% in physical function, and 20% in fear of physical activity. These improvements remained after 6 months.

Conclusions:
These evaluations showed that the standardized, individually adapted, and evidence-based GLA:D programme achieved substantial improvements immediately after participation in the programme and at 6 or 12 months. The number of participants is satisfactory, however more effort and systematic implementation strategies are necessary to further and successfully implement the GLA:D programmes in the Swiss health care system.

Implications: 
The GLA:D programmes strengthen the importance of exercise and education in HK-OA and LBP and makes an important contribution to best practice. The expertise of PTs is increased by the GLA:D certification and strengthens evidence-based and high-quality physiotherapeutic care.

Background:
Current evidence suggests that the clinical outcomes from health interventions in patients with musculoskeletal (MSK) disorders could be significantly improved by integrating prognostic factors into the decision-making process. The Measures Associated to PrognoStic (MAPS) tool, a set of standardized questionnaires that integrates validated prognostic tools and unique prognostic factors, was developed to systematically identify the various prognostic factors that could influence recovery for patients presenting with MSK disorders. Through this tool, physiotherapists might depict their patients’ prognostic profile and optimize their interventions

Purpose:
The main objectives of this study were to: 1) assess the feasibility of implementation of the MAPS tool within everyday clinical practice; 2) assess the acceptability of the clinical dashboard by the clinicians; 3) assess the acceptability of the MAPS tool by patients.

Methods:
Feasibility study within the context of true clinical practice. Physiotherapists working in outpatient MSK clinics were recruited. Over a period of three months, they were asked to use the MAPS tools as part of the initial assessment of new patients. Patients were invited to complete an acceptability survey about the MAPS tool. At the end of the 3-month period, clinicians were invited to complete an acceptability survey about the dashboard provided by the MAPS tool and to participate to a semi-structured interview about their experience using the tool.

Results:
Eleven physiotherapists completed all portions of the study. One hundred and thirty-six patients accessed the MAPS tool and 78% totally completed the questionnaire. Of them, 106 gave consent to participate to the acceptability survey. 7/10 feasibility criteria (70%) and 19/24 acceptability criteria (79%) reached the a priori threshold for success. The 3 criteria that did not get acceptability from the patients were the: 1) degree of appreciation (73%), 2) pertinence (79%) and 3) perceived usefulness (77%) of the tool. Nine clinicians completed the acceptability survey and the semi-structured interview. The acceptability criterion deemed the most limiting one by 44% of the clinicians was the added administrative burden. The semi-structured interviews provided more insight on the reasons behind the least acceptable elements. Three main themes were identified to facilitate implementation of the tool: 1) limiting the burden, 2) ensuring patients’ understanding of the tool’s purpose and 3) integrating the dashboard as a clinical information tool.

Conclusion(s):
Depicting the patients’ prognostic profile seems feasible and acceptable by both clinicians and patients as our results support the feasibility of implementation and acceptability of the MAPS tool pending minor adjustments. The next step would be to implement the MAPS tool on a large scale in outpatient practice and proceed to an impact study on clinical practice. It would also be relevant to consider its feasibility of implementation in other types of settings (e.g., public sector). In its current form, the MAPS tool comprises prognostic models for MSK conditions, yet other versions could be considered to assess different populations like in neurology, cardiorespiratory or geriatrics.

Implications:
Depicting the patients’ prognostic profile has the potential to help clinicians optimize their interventions for patients presenting with MSK disorders.

Introduction
Many physiotherapists still manage their patients mainly from a biomedical point of view. The purpose of this study was to analyze the effect of two different e-learning interventions on knowledge, attitudes and beliefs of physiotherapists managing low back pain (LBP).
Methods
Physiotherapists were allocated (1/1) either to an experimental or a traditional e-learning. Baseline and post- intervention assessment included the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS), Back Pain Attitudes Questionnaire (Back-PAQ), Neurophysiology of Pain Questionnaire (NPQ) and a clinical vignette. Participants had two weeks to complete the post-intervention assessment. Statistics were processed using ANCOVA and Fisher’s t-tests.
Results
419 physiotherapists were included in the analysis. Mean scores of HC-PAIRS, Back-PAQ and NPQ significantly improved post-intervention in both groups. There was a significant effect of the intervention type (experimental or traditional) on the scores of HC-PAIRS (p < .001; η2p = .243) and Back-PAQ (p < .001; η2p = .135), but not on NPQ scores. Return to work recommendations assessed with the clinical vignette were significantly more guideline-consistent in the experimental group (p < .001) post-intervention.
Conclusion
An interactive e-learning intervention focusing on patient’s reassurance, self-management and importance of psycho-social factors seems the most promising way to enhance physiotherapists’ attitudes, beliefs and work recommendations regarding LBP.

Background
The Center for Disease control reported in 2021 that 59% of individuals over the age of 18 have had an incidence of low back pain (LBP) within the past 3 months. (2021 CDC) Exercise and manual therapy are the interventions currently advocated in published clinical practice guidelines. Implementing guideline-based care in practice is shown to improve outcomes. Risk stratification based and psychologically informed care is also advocated in the treatment of LBP. Hodges (2019) proposed an integrated model of care for those with LBP to blend these approaches.
Use of standardized outcome tools in patient care enables measurement of the impact of LBP on disability. Implementing a systematic approach to use of outcome measures in practice allows the ability to measure change overtime. Failure to improve on a standardized measurement may indicate lack of improvement over time.
Purpose:
The purpose of this quality improvement initiative was to determine if targeted education regarding the hybrid model described by Hodges combined with management controls such as electronic health record modifications enhanced outcomes for patients with non-surgical LBP.
Methods:
An analysis of retrospective patient reported outcomes collected in our center from 9/1/2016 to 12/31/2017, as part of standard care on 664 patients with non-surgical low back pain, identified the probability of meeting the MCID on the Modified Disability Questionnaire (MDQ) was 0.668. A quality improvement initiative was subsequently delivered over the next 14 months that included evidence-based approaches to examination and intervention and management controls to facilitate implementation. A hybrid model as put forth by Hodges (2019) was the framework for improvement alongside content on treatment-based classification, pain mechanisms, OPTIMAL theory, and central sensitization. Development and implementation of a clinical decision algorithm was introduced using stop points in the electronic medical record that facilitated compliance. Following completion of the quality improvement initiative, data collected between 9/1/2021 and 12/31/2021 were analyzed using a logistical regression.

Results:
The “pre” sample included data on 664 patients with a probability of success on the MDQ of 0.668. The “post” sample which encapsulates patients treated after the intervention consisted of 47 patients who demonstrated a probability of success on the MDQ of 0.778 (p-value: 0.06). Additionally, pain measured by the Numeric Pain Rating Scale (NPRS) showed improvement but no significant difference with the “pre” probability of success of 0.520 improving to 0.642 (p-value: 0.10)

Conclusion(s):
The success of this evidence-based quality improvement initiative highlights the importance of continuing to bridge the divide between clinician knowledge gaps and current evidence. Targeted identification of knowledge deficits combined with well researched and implemented education interventions can improve the quality of patient outcomes in individuals with low back pain, specifically in this case in integrating a hybrid model of treating low back pain.

Implications: 
This project gives impetus for even a single clinic to embark on steps necessary to become a learning health clinic through systematic collection of patient reported outcomes, focused quality improvement work, and well researched and implemented evidence-based practice.

Musculoskeletal disorders are the leading contributor to disability worldwide. Workforce capacity building to manage this growing burden of disease is crucial. Clinical practice guidelines for the management of musculoskeletal disorders emphasise a biopsychosocial approach. However, healthcare professionals learning about the biopsychosocial model does not necessarily translate to effective adoption of the model in clinical practice. A multitude of biopsychosocial constructs are mediators or moderators to pain. Coupled with gaps about what tools or strategies can be used to effectively translate the biopsychosocial model into musculoskeletal practice, this makes designing effective pain education programs to upskill the physiotherapy workforce challenging.

There are three aims to this research:
(1) Understand the barriers and enablers that influence healthcare professionals’ adoption of a biopsychosocial approach to musculoskeletal pain from a whole-of-health perspective.
(2) Identify the behavioural determinants and behavioural change techniques to support the implementation of high value musculoskeletal pain care.
(3) Investigate physiotherapy educators’ perspectives on what approaches, strategies and tools they adopt in teaching to translate knowledge about the biopsychosocial model into practice.

(i) A qualitative review was undertaken to investigate the experiences of primary healthcare professionals engaged in biopsychosocial pain care for musculoskeletal disorders.
(ii) A five-step process informed by the Behaviour Change Wheel methodology was used to identify the behavioural determinants and behavioural change techniques that may improve the implementation of biopsychosocial pain care.
(iii) Qualitative study using semi-structured interviews were used to gather information from experienced physiotherapy educators across Australia to understand how the biopsychosocial model was taught in undergraduate, postgraduate physiotherapy and health workforce training programs.

1.The review identified barriers and enablers across the whole-of-health.
At the
(i). Micro-level: healthcare professionals’ personal factors, knowledge and skills, and their perception of clinical practice guidelines, perception of patients’ factors and time;
(ii). Meso-level: clinical practice guideline adoption, community factors, funding models, health service provision, resourcing issues and workforce training issues; and
(iii). Macro-level: health policy, organizational and social factors, influenced the adoption of a biopsychosocial approach.
2. Six behaviour change techniques were relevant to facilitate behaviour change to improve training and support for healthcare professionals: “Instruction on how to perform a behaviour”, “behavioural practice/rehearsal”, “social support (unspecified)”, “social support (practical)”, “prompts/cues”, and “restructuring the physical environment”. Behavioural intervention priorities included building effective communication to strengthen therapeutic alliance (clinical-level); re-design of curricula to strengthen interdisciplinary pain competencies (service provision/health workforce training); and encouraging multi-sectoral partnerships (systems-level).
3. A variety of frameworks were used by physiotherapy educators to teach the biopsychosocial model: the Musculoskeletal Clinical Translation Framework, Pain and Movement Reasoning Model, case formulation approach, Clinical Reasoning model, and the International Classification of Functioning, Disability and Health.

Addressing the barriers from a whole-of-health perspective, considering training priorities from a behavioural approach, aligned with current educational practices, can help improve the translation of the biopsychosocial model into clinical practice.

This research can potentially inform better design of biopsychosocial pain education for various musculoskeletal disorders, in scope and at scale. It also highlights the existing gaps in the training and education of musculoskeletal pain.

Background
The global burden of spinal pain has increased significantly over the past two decades to become the leading cause of years lived with disability with high personal and healthcare economic implications; driving a need for physiotherapy. Research to date has had little impact and a new approach is required. Many chronic health conditions benefit from large registries to track health-related metrics, predict outcomes, and inform practice. There is promise for patient reported and clinician collected data to inform predictive modelling and development of complex precision musculoskeletal physiotherapy interventions. Currently, no registry of physiotherapy specific data exists.

Purpose
To create a registry to enable international big data for understanding and development of precision interventions for spinal pain to improve patient care pathways and outcomes. Objectives are to: 1] create a longitudinal minimum core dataset for spinal problems, 2] facilitate extended datasets for spinal problems, 3] establish a source for recruitment of potential participants for research.

Methods
Prospective observational longitudinal registry with data collection (commenced 1st August 2023) at defined intervals (intake, 1 3 6 and 12 months, yearly) through an electronic platform (EmPower Health Research). The minimum core dataset was informed by the Report of the NIH Task Force on Research Standards for Low Back Pain, research-based recommendations for registry construction, literature reviews and authentic partnerships with patients and clinicians. Adults (≥18 years) experiencing spinal pain/symptoms (neck, upper/mid-back, low back) of musculoskeletal cause are eligible to participate and recruited through contact with a physiotherapist or responding to advertisements online/healthcare locations. For patients recruited through physiotherapist contact, parallel clinician data (intake, 1 month) are collected. Patient data include demographics, symptom characteristics, functional interference, resilience, work status etc. Clinician data include nature of spinal pain, physical examination findings, physiotherapy diagnosis etc. Extended datasets include physical measures and biomarkers. A system of reminders including email, text, and phone calls reduces loss to follow up. Planned recruitment is n=20,000 patients over 20 years.

Results
SPINA allows patients and clinicians ownership over their data. Patients download their data trends over time. Physiotherapy clinical sites download their clinic data trends over time. Current recruitment is from Canada, awaiting ethical approval in the UK and Australia. Data analysis will include pre-post physiotherapy intervention analyses, and development and validation of models for predicting outcome from low back, cervical and thoracic problems using a range of outcomes (e.g. pain and disability) and outcomes important to patients, at a range of timepoints.

Conclusion(s)
This physiotherapy-focused registry is the first of its kind to support spine research enabling investigation of clinical phenotypes, recovery pathways, identification of risk, and prediction of outcomes to inform precision intervention. SPINA, for the first time enables research across lumbar, cervical and thoracic regions.

Implications
Longitudinal tracking will allow for care pathways to be visualized through data for model development and systems-based improvement. SPINA also forms the foundation for parallel data-banking of biomarkers and physical measures for comprehensive profiling of spinal pain. It is anticipated that SPINA will be a valuable resource internationally for researchers and clinicians.

Low back pain (LBP) is the leading cause of disability worldwide. Therapeutic exercise is a recommended core treatment for LBP with many randomised controlled trials (RCTs) investigating effectiveness. However, many RCTs are incompletely reported, and the rationale for how the prescribed exercise intervention is anticipated to ‘work’ is poorly described. RCTs which do not include process evaluations and conventional systematic reviews are seldom designed to explain why an intervention ’works’, or to identify the most important components and mechanisms underpinning treatment effects. Realist reviews explore how underlying mechanisms (M) may be active in the context (C) of certain settings or populations to create intended or unintended outcomes (O). Our objective was to explore and understand the mechanisms by which therapeutic exercise prescription creates change in outcomes for people with LBP.
Methods.
This was a realist review reported following RAMESES guidance. We developed initial programme theories, modified with input from a steering group (experts, n=5), stakeholder group (patients and clinicians, n=10) and a scoping search of the published literature (n=37 studies). Subsequently, an information specialist (AB) designed and undertook an iterative search strategy. We refined, and tested CMO configurations using iterative review with the stakeholder and steering groups.

Results.
Of 522 initial papers identified, 75 papers were included to modify and test the CMO configurations. Twenty-two of the 75 included studies comprised qualitative research designs, followed by quantitative designs (n=15), RCTs (n=15), systematic reviews (n=15), mixed methods (n=3), commentary (n=2), case reports (n=2) and narrative reviews (n=1). Trust emerged as a mechanism and was identified as a key mechanism to all identified outcomes (adherence, engagement, and clinical outcomes)in 27 studies (seven CMOcs high confidence, three CMOcs moderate confidence). Motivation was a key mechanism to engagement and adherence (10 CMOcs high confidence level, 2 CMOcs moderate confidence, 1 low confidence). Confidence was a mechanism to the outcome of adherence to exercise, with high confidence in all six CMOcs). The patient-clinician consultation incorporating therapeutic alliance, holistic assessment and previous experience builds the foundation of and maintains trust, and was related to adherence, engagement, and clinical outcomes. Individualised exercise prescription, including considerations of patient preference, increases motivation to adhere to exercise and thus impacts clinical outcomes. Provision of support such as timely follow-up, education and reassurance, supervision and peer support can further facilitate motivation and confidence to improve adherence to therapeutic exercise for LBP.

Conclusions.
To develop and harness the benefits of a strong therapeutic alliance, clinicians may wish to consider performing a holistic assessment to build and win the patient’s trust, to co-design and individualise the exercise prescription around the patient’s own goals, accounting for their previous experience, preferences, and available time to perform exercises. Engagement and adherence to therapeutic exercise for LBP, and clinical outcomes, are optimised using the mechanisms of trust, motivation, and confidence. These CMO configurations provide a deeper understanding of ways to optimise exercise prescription. Further research is required to explore the relationship between adherence and clinical outcomes, and how to implement and optimise these mechanisms in clinical practice.

Background:
There is an ongoing need for scientific validation of the effects of physiotherapeutic interventions and elucidation of the underlying mechanisms. Ultrasound shear wave elastography (SWE) could be a valuable method in this process.

Purpose:
Through a series of studies, we aimed to examine the changes in tendon and muscle stiffness after various exercise and therapeutic interventions. Additionally, we sought to verify if the changes of stiffness measured by SWE coincide with the ones assessed by measuring passive joint torque.

Methods:
In all studies, muscle stiffness was assessed with SWE, using an ultrasound device (Resona 7, Mindray, Shenzen, China). Specifically, sound touch quantification in musculoskeletal mode was utilized to obtain shear modulus values (in kPa), assuming tissue density of 1000 kg/m3.

In the initial study, the effects of eccentric exercise were examined in 14 individuals. SWE measurements of hamstring muscles (biceps femoris, BF, semitendinosus, ST, and semimembranosus, SM) were compared with passive knee extension torque (PKT). PKT was measured on an isokinetic dynamometer device (Humac Norm, Computer Sports Medicine Inc., Massachusetts, USA) at a speed of 5°/s from 35° to 0° knee flexion.

In the second study, the effects of isometric fatigue (three sets of 6/6/3 minutes consisting of 6 seconds exertion at 50% of MVC interspersed with 4 seconds of rest) on the stiffness of the erector spinae and multifidus muscles at rest were measured in 22 participants. Measurements were also taken during two submaximal contractions of the trunk extensors at different intensities: the prone arm lift (low-level contraction) and trunk extension (high-level contraction).

In the third study, employing a crossover study design, 10 participants performed 3 sets of 30 consecutive hops. The following day manual massage or foam rolling (with order randomized between sessions) of the entire lower limb was performed. Changes in stiffness of the Achilles tendon (AT) and gastrocnemius muscle (GM) were measured.

Results:
One-way repeated measures analysis of variance (ANOVA) showed a significant effect of eccentric exercise on stiffness of BF (p=0,009; η2=0,22) and ST (p=0,001; η2=0.31) but not the SM muscle (p=0,096). Unlike with the SWE-based outcomes, there were no statistically significant effects of eccentric exercise on PKT (p=0.096-0.340). There were no correlations between changes in SWE outcomes and changes in passive joint torque at any time point. In the second study, the two-way ANOVA has shown a statistically significant main effect of fatigue for passive shear modulus (p=0.004; η2=0.33) and active shear modulus during high-level contraction (p=0.003; η2=0.37) but not during low-level contraction (p=0.551). In the third study, the two-way ANOVA showed no main effects of time or treatment (p≥0.362) on GM and AT stiffness. There was a trend of interaction effect nearly reaching the level of significance for AT (p=0.069), indicating an opposite effect of foam rolling and massage therapies.

Conclusions:
Our studies indicate that SWE holds promise as a valuable method for evaluating muscular and tendon changes resulting from diverse physiotherapeutic interventions. The potentially contrasting effects of similar therapeutic procedures underscore the necessity for further research in this domain.