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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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