Background: Current evidence for cervical radiculopathy (CR) management has prioritised chronic CR, which creates a challenge for care of people with recent onset (less than 12 weeks) CR, presenting in primary care. Purpose: To investigate the effectiveness of conservative management available in primary care for adults with recent onset CR. Methods: We conducted a systematic review of randomised controlled trials investigating any conservative management involving adults with recent onset, single level CR of any aetiology, including one or more relevant outcome: pain, disability, overall improvement or satisfaction with intervention, quality of life or participation restriction. Exclusion criteria were chronic, multilevel or bilateral CR or radiculomyelopathy, major or systemic pathology, post-surgery interventions, or studies not in the English language. Electronic searching of Medline, CINAHL, EMBASE and the Cochrane Central Register of Controlled Trials (Central) was performed from database inception and completed by 12/01/22. Grey literature was searched using Open Access Theses & Dissertations (OATD) and Web of Science and SCOPUS was used for citation searching of included studies. Risk of bias (RoB) assessment using the Cochrane RoB tool 2.0 (Sterne et al., 2019) and certainty assessment using GRADE (Hultcrantz et al., 2017), was performed by two reviewers. Synthesis was planned for conservative management versus no treatment / sham / placebo, other conservative treatment, or surgery / spinal injections, for primary outcomes of pain and disability. The protocol was registered (INPLASY protocol 202220047) (Keating et al., 2022). Results: Seven studies (n=552 participants, mean age 43.4yrs) from 6 countries in Europe, Africa and North America were included. Interventions ranged from passive (collars, manual therapy, traction & electrophysical agents) to active (exercise). Three studies exhibited high RoB (Aksoy et al., 2018, Jellad et al., 2009, Ragonese, 2009) and only one exhibited low RoB (Langevin et al., 2015). Meta-analysis involved two studies with n=191 participants, comparing passive conservative management strategies to placebo or wait & see control (Konstantinovic et al., 2010, Kuijper et al., 2009). With moderate certainty, significant differences in the pooled effect estimate were found in favour of passive treatment (semi-rigid collar or LLLT) versus placebo or no treatment at short-term follow up (mean 4.5 weeks) for arm pain (SMD = -0.50 (95% CI -0.78, -0.21); I2 = 0%; p=0.0007), neck pain (SMD = -0.64 (95% CI -0.93, -0.35); I2 = 0%; p < 0.0001) and disability (SMD = -0.34 (95% CI -0.62, -0.05); I2 = 51%; p=0.02). Narratively, exercise was superior to no treatment in the short term with moderate certainty, but only for pain. Comparing conservative interventions against each other, alone or in combination, was of low to very low certainty resulting in less clarity for optimal multimodal inclusions. Conclusion: Offering passive (semi-rigid collar or LLLT) or active (exercise) interventions leads to immediate benefit in pain and disability, with no benefit over natural history within three to six months. Future trials of higher certainty, involving longer follow ups, may impact this assessment. Implications: Conservative management strategies improve short term outcomes only, compared to placebo or natural history.
Background: Neural mobilisations (NM) have been advocated for the treatment of nerve related cervicobrachial pain (NCBP), however, it is unclear what types of patients with NCBP (if any) may benefit.
Purpose: The primary aim of this systematic review was to assess the effectiveness of NM in patients with NCBP. The secondary aim was to explore if the effectiveness of NM varies between NCBP subgroups.
Methods: Databases were searched until December 2022. Randomised controlled trials were included if they assessed the effectiveness of NM in NCBP and outcome measures were pain intensity and/or disability. Studies were classified according to their inclusion/exclusion criteria as painful radiculopathy (signs of conduction loss), Wainner cluster (at least ¾ of: positive neurodynamic test, ipsilateral cervical rotation < 60°, positive distraction test, positive Spurling test), Hall and Elvey cluster (active/passive cervical movement dysfunction, positive neurodynamic test, sign of local cervical dysfunction) or other. Methodological quality was assessed using Cochrane Rob2 tool, and GRADE was used to rate the certainty of evidence.
Results: Twenty-six studies were included. For pain and disability reduction, NM was found more effective than no treatment (pooled pain MD= -2.81, 95%CI= -3.81 to -1.81; pooled disability SMD= -1.55, 95%CI= -2.72 to -0.37), increased the effectiveness of standard physiotherapy as an adjuvant when compared to standard physiotherapy alone (pooled pain MD= -1.44, 95%CI= -1.98 to -0.89; pooled disability MD= -11.07, 95%CI= -16.38 to -5.75 ), but was no more effective than cervical traction (pooled pain MD= -0.33, 95%CI= -1.35 to 0.68; pooled disability MD= -10.09, 95%CI= -21.89 to 1.81). Compared to exercise, NM was found more effective in reducing disability (pooled MD= -18.27, 95%CI= -20.29, -17.44). Fifteen studies were classified as Wainner cluster, four as Hall and Elvey cluster, one as radiculopathy and six as other. In most meta-analyses, there were significant differences in the effectiveness of NM between subgroups. NM was more effective than all alternative interventions (no treatment, traction, exercise, and standard physiotherapy alone) in 13 out of 15 studies (one reported no difference) classified as Wainner cluster. NM was more effective than varied alternative interventions in three out of 4 studies (one reported no difference) classified as Hall and Elvey cluster. In studies classified as other, findings differed. NM was not effective in the only study classified as radiculopathy. Evidence was only of moderate quality and GRADE revealed high uncertainty.
Conclusions: NM was found more effective than varied alternative interventions in most studies classified as Wainner cluster and Hall and Elvey cluster, but not in those classified as others or radiculopathy. Uncertainty of evidence is high.
Implications: NM may be a treatment of choice for those patients with NCBP that meet Wainner cluster. There is some evidence for its use in patients that fulfil Hall and Elvey cluster. Evidence is overall of moderate quality and is still highly uncertain. Research to establish the preferential effect of NM in different NCBP subgroups is required.
Background:
Cauda equina syndrome (CES) is a serious spinal pathology where dysfunction of the S2–S5 spinal nerves results in various combinations of bladder, bowel and sexual dysfunction and/or saddle anaesthesia. CES is rare, but its symptoms are not, and musculoskeletal physiotherapists frequently encounter persons with suspected CES. Given that delayed diagnosis of CES can result in devastating consequences for the affected person and costly litigation for healthcare organisations, it is imperative that a person presenting with suspected CES is well managed. There have been substantial changes to guidelines for the management of suspected CES in the past decade. Implementation of these in practice have been associated with a number of challenges for physiotherapists.
Purpose:
The aim of this study was to explore physiotherapists' experiences of managing persons with suspected CES.
Methods:
In this interpretive study, semi‐structured interviews were conducted with eight musculoskeletal physiotherapists. Verbatim transcripts were analysed by the first author using reflexive thematic analysis. An inductive approach to analysis was taken by the first author and followed the steps outlined by Braun and Clake (2012). During each step of the analysis, she entered into a dialogic discussion with the second author to probe and consider alternative interpretations.
Findings:
Five interlinking themes were generated. Two themes conveyed the challenges of clinical practice; Worry in relation to risk management and communication difficulties. Participants expressed a ‘fear-driven’ desire to avoid delayed diagnosis, which was related to panic, worry, sleepless nights and anticipation of ‘horrendous guilt’ if they were to miss anything. There were also accounts of self-doubt, frustration, power struggles and lack of mutual understanding in communications with persons with suspected CES and with other healthcare professionals.
The remaining three themes were described as antidotes to these challenges; Lightening the load with teamwork and shared responsibility, the usefulness of a clear pathway, and perceptions of improved confidence and competence with experience and training.
These findings will be presented in an interactive session which uses technology to explore the experiences of audience members. The resonance of their quotes with the research findings will then be explored.
Conclusions:
Findings suggest that it is important to be aware of and address the challenges faced by physiotherapists, in order to ensure a safe and smooth journey for persons with suspected CES and to care for clinicians' wellbeing.
Implications:
This study resulted in a number of practical implications for clinical practice. Clinicians and organisations should work to develop clear pathways for the management of persons with suspected CES, including access to other clinicians for advice. Supervisors should be aware of the potential for management of suspected CES to cause stress, anxiety and worry to physiotherapists, and mechanisms to support staff wellbeing should be integrated into the working schedule. Use of pre-existing communication aids and training tools for assessment and management of suspected CES is advocated. New resources will be presented to support translation of this research in to practice. Reference will be made to the United Kingdom’s national CES pathway (GIRFT, 2023).
Background:
The expanding scope of physiotherapists worldwide has come with an increased responsibility to identify serious pathologies such as fracture, infection, tumour and cauda equina syndrome (CES). Guidelines recommend a low threshold for emergency MRI to avoid the potentially devastating consequences of CES, but a balanced approach is required to prevent excessive strain on emergency resources.
The international framework for red flags for potential serious spinal pathologies (Finucane et al., 2020) offers support for clinical reasoning relating to CES and in some countries, national pathways have been developed. It is important to evaluate how these guidelines are implemented in clinical practice, at local level.
Purpose:
This study aimed to evaluate the management of patients presenting to an outpatient physiotherapy service with suspected cauda equina syndrome.
Methods:
This study was a service evaluation with an embedded case series of patients with radiological CES. The records of patients who were identified by their outpatient physiotherapists as having suspected CES (n=231) over a 27-month period were included. Data was extracted from patients’ medical records by a team of Advanced Clinical Practitioners (ACPs). The lead author further analysed the records of patients with clinical and radiological CES, in order to present the embedded case series.
Results:
In 79% of cases, it was decided that emergency referral was not required. The remaining 21% (n=49) of patients were referred to the emergency department and 49% (n=24) of these had an emergency MRI. Seven of these patients had MRI-confirmed CES and were included in the case series. Of these, four had a disc bulge and underwent emergency surgery, one had non-emergency surgery for a disc bulge combined with anterolisthesis and scoliosis and two patients with stenosis decided against surgical intervention. Five of these seven patients with MRI-confirmed CES had reported leg pain which predated the onset of their CES symptoms.
Conclusion(s):
The results of this service evaluation suggest support for an effective communication chain to facilitate escalation of concerns and appropriate use of emergency resources within local CES pathways. The case series showed that five of the seven patients with confirmed CES had experienced back and leg pain prior to developing bladder and/or bowel and or saddle anaesthesia symptoms. This reinforces the importance of considering provision of safety netting information for patients presenting with sciatica without other CES symptoms.
Future research could include long term follow up of patients who were not referred for consideration of MRI and qualitative inquiry might provide further insight into the clinical reasoning processes which inform decision making surrounding suspected CES.
Implications:
Local implementation of national guidelines and pathways for CES should include safety netting and a robust communication chain to support escalation of concerns and management of available resources. Practical tools to support safety netting are already available in many languages. Following this service evaluation, the lead author developed a downloadable CES handover tool and a perianal sensation testing prompt card to support clinicians in assessment and management of patients with suspected CES.
Background Whiplash associated disorder 2 (WAD2) is defined by the Quebec task force as neck pain and musculoskeletal signs, with no nerve injury. However, neuropathic pain has been demonstrated in a number of studies (Fundaun et al., 2021). Additionally, people with persistent pain and WAD2 show signs of elevated T2 signals on MRI scans, consistent with brachial plexus inflammation(Greening et al., 2018). It is not known whether similar signs of nerve inflammation are present in acute whiplash, or if there is a relationship between these findings and clinical measures. This analysis is part of an ongoing cohort study which aims to establish the contribution of peripheral nerve pathology to WAD2 and assess its role in prognosis (Ridehalgh et al., 2022). Purpose: To establish if the brachial plexus becomes inflamed acutely after a WAD2 injury, and to establish if such signs of inflammation relate to clinical measures. Methods: Ninety-five participants were recruited from emergency departments of 2 NHS trusts in the South East of England within 4 weeks of WAD2. Thirty healthy age/sex matched controls were also recruited. All participants completed the painDETECT and neck disability questionnaires. Quantitative sensory testing was performed at the index finger on the most affected side, and clinical tests including neurological integrity and heightened nerve mechanosensitivity were undertaken. All participants underwent a T2-weighted, fat supressed, MRI scan of the brachial plexus. Data was checked for normality using visual inspection and Kolmogorov-Smirnov tests. Wilcoxon and Mann-Whitney U tests or t-tests were used to look for differences between variables. Pearson’s and Spearman’s Rank correlation were used to assess the association between nerve signal intensity and clinical measures. Results: The T2 signal intensity for all roots of the brachial plexus was greater on the most symptomatic side in people with WAD2 compared to healthy controls (C5, C7, C8: p < 0.05, C6: P < 0.01). There was a significant correlation between cold pain thresholds (CPT) and C5 (p < 0.05, r= 0.24, 95%CI 0.03 to 0.43) and C6 T2 signal intensity (P < 0.01, r = 0.30, 95%CI 0.09 to 0.48). There were no significant correlations between T2 signal intensity and NDI and painDETECT questionnaires or tests for heightened nerve mechanosensitivity. Conclusion(s): The increase in T2 signal intensity in the roots of the brachial plexus in people with WAD2 is consistent with the presence of nerve inflammation. The relationship between C5 and C6 T2 signal intensity and CPT suggests that nerve inflammation may contribute to cold hypersensitivity. However, it is not yet known if such changes are important in prognosis of the condition. Implications: Nerve inflammation of the roots of brachial plexus may contribute to the pathophysiology of acute whiplash in those with no obvious sign of nerve injury and may be in part responsible to a decreased tolerance to cold pain. We are currently analysing data to establish if increased T2 signal is a predictor of poorer outcome. Acknowledgements: We would like to acknowledge Jane Greening for her considerable contribution to this study.
Objective: To explore indicators that predict whether patients with extremity pain have a spinal or extremity source of pain.
Methods: The data were from a prospective cohort study (n = 369). Potential indicators were gathered from a typical Mechanical Diagnosis and Therapy (MDT) history and examination. A stepwise logistic regression with a backward elimination was performed to determine which indicators predict classification into spinal or extremity source groups. A Receiver Operating Characteristic (ROC) curve was constructed to examine the number of significant indicators that could predict group classification.
Results: Five indicators were identified to predict group classification. Classification into the spinal group was associated with the presence of paresthesia [odds ratio (OR) 1.984], change in symptoms with sitting/neck or trunk flexion/turning neck/when still (OR 2.642), change in symptoms with posture change (OR 3.956), restrictions in spinal movements (OR 2.633), and no restrictions in extremity movements (OR 2.241). The optimal number of indicators for classification was two (sensitivity = 0.638, specificity = 0.807).
Discussion: This study provides guidance on clinical indicators that predict the source of symptoms for isolated extremity pain. The clinical indicators will allow clinicians to supplement their decision-making process in regard to spinal and extremity differentiation so as to appropriately target their examinations and interventions.
Background
Individuals with low back pain may have sinister or specific pathology necessitating appropriate neurological examination. Failure to adequately identify neurological compromise can have serious consequences for the patient and health service alike.
Accelerated by the global COVID-19 pandemic, there has been a recent shift towards telehealth. While experts have provided their perspectives regarding how individual neurological examination tests can be modified to a telehealth environment, no studies have established the accuracy of performing these tests via telehealth.
Purpose
The overarching aim of this study was to address concerns regarding the accuracy and appropriateness of performing a neurological examination via telehealth (specifically video-conferencing) for individuals with back pain.
Specifically, objectives were to:
1. Establish agreement between telehealth and in-person (reference standard) for a battery of physical tests routinely performed as part of a lumbar spine neurological examination.
2. Determine inter-rater reliability when performing individual physical tests of a lumbar spine neurological examination in-person.
Methods
A repeated-measures agreement study was undertaken at a hospital physiotherapy outpatient setting (Brisbane, Australia). Participants were current patients of the service ≥18 years of age with symptoms necessitating a lower limb neurological examination.
Participants completed an identical, structured neurological examination in-person and via telehealth, by two independent assessors, within a single session. A sub-group of participants completed a second in-person assessment, performed by a third assessor, within the same session to establish inter-rater reliability. Tests included lumbar dermatomes (light touch), myotomes, deep tendon reflexes (DTR), neural mechanosensitivity (SLR), and tests for long tract signs. Outcomes were recorded as either binary or categorical responses where relevant agreement and reliability statistics were undertaken.
Results
Data from 33 participants indicate variable exact agreement between modes of delivery (telehealth, in-person) across dermatomes (70% to 97%), myotomes (38% to 75%) and DTRs (57% to 75%). Agreement between delivery modes for long tract signs ranged from fair to almost perfect. Fifteen participants completed the second in-person examination. Inter-rater reliability of the in-person examination also demonstrated a wide variation in agreement across tests. Results provide some insight as to which neurological tests appear suitable for assessment via telehealth and which may need confirmation in-person. Additional resources, including video-recordings of all tests performed both in-person and via telehealth, has been developed for educational/training purposes.
Conclusion
Variable agreement was observed when comparing individual tests of a lumbar spine neurological examination between telehealth and in-person. Inter-rater reliability of tests performed in-person also yielded wide variation in agreement, suggesting that factors external to the delivery medium influence outcomes. Due to the low prevalence of long tract signs observed in this study, further research is required that specifically targets this sub-population.
Implications
This is the first known study that has sought to modify a lumbar spine neurological examination to a telehealth environment and investigate concurrent validity, as well as establish inter-rater reliability of an in-person physiotherapy examination. Findings can be used by a wide range of health professions to aid their decision-making towards the appropriateness of telehealth for their patients.
Background
Headache and neck pain are common presentations to primary care, and many patients may present with concerning symptoms in otherwise benign conditions. Limited information exists about red flags in headache and neck pain, but early recognition of serious pathology is critical to expedite medical evaluation and treatment and prevent mismanagement.
Purpose
This study aimed to identify, categorise and characterise cases of headache and neck/throat pain presenting to a metropolitan emergency department to improve recognition of serious pathology.
Methods
Cases were gathered from patients presenting to the Emergency Department of a Brisbane hospital with primary presenting complaint of headache or neck/throat pain. Hospital records were used to classify patients according to condition and identify common characteristics in serious pathologies. Patients were excluded if notes were unavailable, or the resultant diagnosis was not relevant to the study, such as respiratory conditions.
Results
10,165 cases were collected between January 2019 and January 2023, 4,235 were excluded. Headaches comprised approx. 80% of cases, with 76% of these being primary headache. Of the 5,0930 eligible cases of head and neck pain, 286 cases (4.8%) of serious pathology were identified, 1-2 cases per week. Of these, 56% were related to cerebrovascular conditions, most commonly haemorrhagic stroke, 22.5% to tumours/ space occupying lesions, 11% were related to infection such as meningitis and 3% to orthopaedic injuries e.g., cervical fracture/dislocation. Cervical arterial dissection (CAD) was identified in 33 cases (10%). Cerebrovascular pathologies showed higher proportions of sudden onset, unusual, severe headache (p = 0.015) and neurological symptoms (p < 0.001) than benign primary headaches. Tumours were generally known diagnoses, presenting with ongoing or worsening pain, dizziness, visual disturbance and altered neurology. Meningitis typically presented with fever, neck stiffness into flexion, photophobia, nausea and vomiting and were generally unwell. Orthopaedic injuries generally followed trauma.
Conclusions
Most patients presenting to emergency departments with acute onset headache are benign primary headaches or can be attributed to known conditions such as migraine. Serious pathology is uncommon but may be differentiated by typical features such as the presence of unusual headache with presenting or progressing neurological symptoms, fever, general unwellness, worsening pain. In comparison to other serious pathology. CAD cases were infrequent and less obvious to recognise.
Implications
Clinicians need to understand the possible types of serious pathology causing headache and their indicative presenting signs and symptoms as red flags. Clinicians should be especially vigilant in their history taking and objective examination for new or unusual headaches and subtle or transient neurological features and consider all possible underlying causes. If concerned, immediate referral on for imaging and medical evaluation is imperative before treatment is commenced. More specific screening tools are needed to identify for CAD.