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Clinical guidelines make vague recommendations as to exercise training (ET) type and dosage to manage chronic non-specific neck pain (CNSNP). To synthesise evidence on the effectiveness of different ET programmes to reduce CNSNP and associated disability, and whether dosage affects outcomes. A systematic review and data synthesis was conducted according to a published registered protocol (PROSPERO CRD42018096187). A sensitive topic-based search was conducted of CINAHL, MEDLINE, EMBASE, PEDro, grey literature sources and key journals from inception to 6.sup.th January 2020 for randomised controlled trials, investigating ET for CNSNP or disability. Two reviewers independently completed eligibility screening, data extraction, risk of bias assessment (Cochrane Risk of Bias Tool) and rated the overall strength of evidence using Grading of Recommendations Assessment, Development and Evaluation. Data was tabulated for narrative synthesis and grouped by intervention, outcome and time point to compare across studies. Twenty-six trials from 3990 citations (n = 2288 participants) investigated fifteen ET programmes. High RoB and low sample sizes reduced evidence quality. Clinical heterogeneity prevented meta-analyses. A range of ET programmes reduce pain/disability in the short term (low to moderate evidence). Pillar exercises reduce pain/disability in the intermediate term (low level evidence). Moderate to very large pain reduction is found with ET packages that include motor control + segmental exercises (low to moderate evidence). No high-quality trials investigated long term outcomes. Increased frequency of motor control exercises and progressively increased load of pillar exercise may improve effectiveness. Motor control + segmental exercises are the most effective ET to reduce short term pain/disability, but long-term outcomes have not been investigated. Optimal motor control + segmental exercise variables and dosage is unknown and requires clarification. An adequately powered, low RoB trial is needed to evaluate the effectiveness and optimal dosage of motor control + segmental on long term outcomes.

Chronic non-specific neck pain is highly prevalent, resulting in significant disability. Despite exercise being a mainstay treatment, guidance on optimal exercise and dosage variables is lacking. Combining submaximal effort deep cervical muscles exercise (motor control) and superficial cervical muscles exercise (segmental) reduces chronic non-specific neck pain, but evaluation of optimal exercise and dosage variables is prevented by clinical heterogeneity. To gain consensus on important motor control and segmental exercise and dosage variables for chronic non-specific neck pain. An international 3-round e-Delphi study, was conducted with experts in neck pain management (academic and clinical). In round 1, exercise and dosage variables were obtained from expert opinion and clinical trial data, then analysed thematically (two independent researchers) to develop themes and statements. In rounds 2 and 3, participants rated their agreement with statements (1-5 Likert scale). Statement consensus was evaluated using progressively increased a priori criteria using descriptive statistics. Thirty-seven experts participated (10 countries). Twenty-nine responded to round 1 (79%), 26 round 2 (70%) and 24 round 3 (65%). Round 1 generated 79 statements outlining the interacting components of exercise prescription. Following rounds 2 and 3, consensus was achieved for 46 important components of exercise and dosage prescription across 5 themes (clinical reasoning, dosage variables, exercise variables, evaluation criteria and progression) and 2 subthemes (progression criteria and progression variables). Excellent agreement and qualitative data supports exercise prescription complexity and the need for individualised, acceptable, and feasible exercise. Only 37% of important exercise components were generated from clinical trial data. Agreement was highest (88%-96%) for 3 dosage variables: intensity of effort, frequency, and repetitions. Multiple exercise and dosage variables are important, resulting in complex and individualised exercise prescription not found in clinical trials. Future research should use these important variables to prescribe an evidence-informed approach to exercise.

Traumatic injuries affect approximately 978 million people worldwide with 56.2 million requiring inpatient care. Quantitative sensory testing (QST) can be useful in predicting outcome following trauma, however the reliability of multiple QST including temporal summation (TS), heat and cold pain thresholds (HPT, CPT) and pressure pain thresholds (PPT) is unknown. We assessed intra (between day) and inter-rater (within day) reliability of QST in asymptomatic participants (n = 21), and inter-rater (within day) reliability in participants presenting with acute musculoskeletal trauma (n = 25). Intra-class correlations with 95% confidence intervals (ICC 3,2), standard error of measurement (SEM) and Bland Altman Plots for limits of agreement were calculated. For asymptomatic participants, reliability was good to excellent for HPT (ICC range 0.76-0.95), moderate to good for PPT (ICC range 0.52-0.93), with one site rated poor (ICC 0.41), and poor to excellent for TS scores (ICC range 0.20-0.91). For musculoskeletal trauma participants reliability was good to excellent for HPT and PPT (ICC range 0.76-0.86), and moderate to good reliability for TS (ICC range 0.69-0.91). SEM for HPT for both sets of participants was ~1°C and an average of 7N for asymptomatic participants and less than 8N for acute musculoskeletal trauma participants for PPT. This study demonstrates moderate to excellent intra and inter-rater reliability for HPT and PPT in asymptomatic participants and good to excellent inter-rater reliability for acute musculoskeletal trauma participants, with TS showing more variability for both sets of participants. This study provides foundations for future work evaluating the sensory function over time following acute musculoskeletal trauma.

Scoliosis Research Society-22 revised (SRS-22r) is the common questionnaire used to evaluate health related quality of life (HRQOL) for young people with adolescent idiopathic scoliosis (AIS). The aim of this study is to evaluate its content validity for this population. In-depth semi-structured interviews were conducted with a purposive sample of young people with AIS (Cobb angle ≥25˚, aged 10-18 years). Concept elicitation was used to evaluate the influence of AIS on participants' HRQOL. Participant information sheets and consent/assent forms were age relevant. Topic guide was informed by the SRS-22r and existing evidence. Interviews were audio and video recorded, transcribed verbatim, coded, and analysed using thematic analysis. Derived themes/codes were compared with SRS-22r contents (domains/items). Eleven participants (mean age 14.9 years [SD = 1.8]; 8 female) were recruited. The mean curve size was 47.5° [SD = 18°] and participants had been managed via different approaches. Four main themes emerged with associated subthemes: 1) Physical effects related to physical symptoms (back hurt, stiffness) and body asymmetry (uneven shoulders), 2) Activity-related effects showed impact on mobility (sitting for long periods), self-care (dressing), and school activities (focus during lessons), 3) Psychological effects revealed emotional (feel worried), mental (sleep quality), and body image effects (hide back from others), 4) Social effects (participation in school and leisure activities), and school, friends and mental health support. A weak association was found between items of the SRS-22r and the identified codes. The SRS-22r does not adequately capture important concepts that relate to HRQOL of adolescents with AIS. These findings support revision of the SRS-22r, or the development of a new patient reported outcome measure to evaluate HRQOL of adolescents with AIS.

The evaluation of muscle strength is frequently used as part of the physical examination process, with decreased trunk muscle strength reported in individuals with spinal disorders (e.g., low back pain). Access to practicable performance-based outcome measures (PBOM) to monitor patients' progress in spinal rehabilitation is essential. Knowledge of the psychometric properties of the available practicable PBOM for trunk strength evaluation is therefore needed to inform practitioners and further research. To synthesise evidence on the measurement properties of practicable measures of trunk muscle strength in adults with and without musculoskeletal pain. Following a published and registered protocol [PROSPERO CRD42020167464], databases were searched from the database inception date up to 30.sup.th of June 2021. Citations and grey literature were also searched. Eligibility criteria comprised: 1) studies which examined the psychometric properties of the trunk strength outcome measures, 2) included adults [greater than or equal to] 18 years, either asymptomatic or with spinal musculoskeletal pain. Non-English language studies were excluded. Two independent reviewers evaluated the quality and synthesized the data from included studies according to the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist. The overall quality of evidence was evaluated using a modified Grading of Recommendations Assessment Development and Evaluation (GRADE). From 34 included studies, 15 different PBOMs were identified that have been investigated for reliability and validity, none evaluated responsiveness. In asymptomatic individuals, high quality evidence supports intra-rater reliability of digital-loading cells and moderate quality evidence supports the criterion validity of the hand-held dynamometer. Very low quality evidence exists for the reliability and validity estimates of testing tools among individuals with spinal pain.

Spinal and peripheral joint manipulation and mobilization are interventions used by many healthcare providers to manage musculoskeletal conditions. Although there are many reports of adverse events (or undesirable outcomes) following such interventions, there is no common definition for an adverse event or clarity on any severity classification. This impedes advances of patient safety initiatives and practice. This scoping review mapped the evidence of adverse event definitions and classification systems following spinal and peripheral joint manipulation and mobilization for musculoskeletal conditions in adults. An electronic search of the following databases was performed from inception to February 2021: MEDLINE, EMBASE, CINAHL, Scopus, AMED, ICL, PEDro, Cochrane Library, Open Grey and Open Theses and Dissertations. Studies including adults (18 to 65 years old) with a musculoskeletal condition receiving spinal or peripheral joint manipulation or mobilization and providing an adverse event definition and/or classification were included. All study designs of peer-reviewed publications were considered. Data from included studies were charted using a standardized data extraction form and synthesised using narrative analysis. From 8248 identified studies, 98 were included in the final synthesis. A direct definition for an adverse event and/or classification system was provided in 69 studies, while 29 provided an indirect definition and/or classification system. The most common descriptors to define an adverse event were causality, symptom severity, onset and duration. Twenty-three studies that provided a classification system described only the end anchors (e.g., mild/minor and/or serious) of the classification while 26 described multiple categories (e.g., moderate, severe). A vast array of terms, definition and classification systems were identified. There is no one common definition or classification for adverse events following spinal and peripheral joint manipulation and mobilization. Findings support the urgent need for consensus on the terms, definition and classification system for adverse events related to these interventions.

A plethora of evidence supports the existence of neuromuscular changes in people with chronic spinal pain (neck and low back pain), yet it is unclear whether neuromuscular adaptations persist for people with recurrent spinal pain when in a period of remission. This systematic review aimed to synthesise the evidence on neuromuscular adaptations in people with recurrent spinal pain during a period of remission. Electronic databases, grey literature, and key journals were searched from inception up to the 4 th of September 2020. Eligibility criteria included observational studies investigating muscle activity, spine kinematics, muscle properties, sensorimotor control, and neuromuscular performance in adults (≥ 18 years) with recurrent spinal pain during a period of remission. Screening, data extraction, and quality assessment (Newcastle-Ottawa Scale) were conducted independently by two reviewers. Data synthesis was conducted per outcome domain. A meta-analysis with a random-effects model was performed where possible. The overall strength of evidence was rated using the Grading of Recommendations, Assessment, Development and Evaluation guidelines (GRADE). From 8292 records, 27 and five studies were included in a qualitative and quantitative synthesis, respectively. Very low level of evidence supports muscle activity changes in people with recurrent low back pain, especially greater co-contraction, redistribution of muscle activity, and delayed postural control of deeper trunk muscles. Reduced range of motion of the lumbar spine was also found. Meaningful conclusions regarding other outcome domains or people with recurrent neck pain could not be drawn. In conclusion, people with recurrent low back pain during a period of remission show muscle activity and spine kinematics adaptations. Future research should investigate the long-term impact of these changes, as well as adaptations in people with recurrent neck pain.

The aim of this umbrella review was to establish which biopsychosocial factors are associated with development of chronic musculoskeletal pain. Ovid Medline, Embase, Web of Science Core Collection, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, PsycINFO, CINAHL, PEDro, PROSPERO, Google Scholar and grey literature were searched from database inception to 4th April 2023. Systematic reviews of observational prospective longitudinal studies, including populations with <3 months (not chronic) musculoskeletal pain, investigating biopsychosocial factors that contribute to development of chronic (>3 months) musculoskeletal pain. Two reviewers searched the literature, assessed risk of bias (Assessing the Methodological Quality of Systematic Reviews-2), and evaluated quality (Grading of Recommendations, Assessment, Development and Evaluation) to provide an overall statement on the certainty of evidence for each biopsychosocial factor. Data analysis was performed through random effects meta-analysis (including meta-analysis of meta-analyses where possible) and descriptive synthesis. 13 systematic reviews were included comprising 185 original research studies (n = 489,644 participants). Thirty-four biopsychosocial factors are associated with development of chronic musculoskeletal pain. Meta-analyses of odds and/or likelihood ratios were possible for 25 biopsychosocial factors. There is moderate certainty evidence that smoking (OR 1.24 [95%CI, 1.14-1.34), fear avoidance (LR+ 2.11 [95%CI, 1.59-2.8]; LR- 0.5 [95%CI, 0.35-0.71]) poorer support networks (OR 1.21 [95%CI, 1.14-1.29]), lower socioeconomic status (OR 2.0 [95%CI, 1.64-2.42]), and high levels of pain (OR 5.61 [95%CI, 3.74-8.43]) are associated with development of chronic musculoskeletal pain (all P<0.001). Remaining factors are of low or very low certainty evidence. There is moderate certainty evidence that smoking, fear avoidance, poorer support networks, lower socioeconomic status, and high levels of pain are associated with development of chronic musculoskeletal pain. High risk of bias was evident in most included reviews; this highlights the need for higher quality systematic reviews.

Limited knowledge exists on current use of patient reported outcome measures (PROMs) and performance measures for adolescents with idiopathic scoliosis (AIS), as well as health care professionals' (HCPs) perceived barriers and facilitators towards their use. This study's objectives were: 1) to explore current practice of HCPs when assessing outcomes for AIS 2) to understand perceived barriers and facilitators of HCPs to use PROMs 3) to understand perceived barriers and facilitators of HCPs to use performance measures. A qualitative study recruited a purposive sample of HCPs from a tertiary hospital in the United Kingdom. Mean years of experience managing individuals with AIS was 11.8 years; and included surgeons, physiotherapists and nurses, educated at Bachelor, Masters and Doctoral level. Consent to participate and demographic information were collected in advance of the interviews. In-depth, virtual semi-structured interviews were informed by a topic guide based on current evidence. Interviews of approximately 45 minutes were audio and video recorded and transcribed verbatim alongside written field notes. Data were coded and analysed using inductive thematic analysis, involving researchers with topic and methodological expertise and input from a patient representative. Two themes emerged regarding current practice of using PROMs routine practice and personal evaluations. Four themes emerged as barriers to using PROMs for individuals with AIS: priority and support (e.g., HCPs focus on providing care), practical challenges (e.g., inadequate PROMs), patient-related challenges (e.g., patient preferences) and knowledge, education, and perceived value. Two themes emerged as facilitators: quality existing measure (e.g., sufficient psychometric properties), and priority and support (e.g., research department/culture). Themes for barriers to use performance measures were practicality (e.g., need physical space) and perceived value and knowledge (e.g., PROMs are more important), while the one theme for facilitators was practical consideration (e.g., acceptability). Although HCPs perceived the value of using outcome measures, current practice indicates limited use for individuals with AIS. The findings revealed different barriers and facilitators to implement PROMs in practice. Adopting performance measure are limited due to lack of knowledge and perceived value alongside the practicality, while considering practical factors can improve the use of these measures in practice.

The aim of this qualitative phenomenology study using two methods (semi-structured interviews, focus groups), was to explore patients’ and physiotherapists’ views and perceptions of recovery, and what constitutes successful recovery following musculoskeletal trauma within the early stages of recovery. Participants were recruited from one major trauma centre in the United Kingdom and data collected via Microsoft Teams, or via a telephone call. Inclusion criteria for patient interviews: purposive sample of adults (≥18 years) who sustained a traumatic musculoskeletal injury, admitted as an inpatient within 4 weeks of injury, mental capacity, and able to communicate in English. Purposive sampling included age, gender, and injury characteristics. Focus group inclusion criteria: physiotherapists with experience managing patients with musculoskeletal trauma. Interviews and focus groups were informed by an evidenced based topic guide, audio recorded and transcribed verbatim. Trustworthiness of the data was strengthened using multiple strategies, e.g., member checking. Interpretative Phenomenological Analysis was used for the patient interviews and the Kreuger Framework for the focus groups. Participants included 17 patient interviews and 10 physiotherapists in two focus groups. Three themes emerged from patient interviews: understanding and impact of the accident and injuries, the early stages of recovery and physiotherapy, and healthcare and setting influences. Eight themes emerged from the focus groups: process of recovery, what is being fully recovered, it’s more than just communicating with the patient, psychological impact of trauma affecting recovery, system influences/resources for recovery, influencers to recovery, barriers to using patient reported outcome measures to evaluate recovery, and what actually is useful to measure in trauma? Recovery following musculoskeletal trauma is complex, individual and focused on returning to ‘normal’. Similarities across patient and physiotherapist views of recovery exist. Differences between participant groups were evident, centred on communication and what is important to the patient in their recovery.