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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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