Exploratory Study of Associations and Agreement between Prognostic Patient-Registered Factors, Physiotherapists' Intuitive Synthesis, and Patient-Reported Factors in Whiplash-Associated Disorders.

BACKGROUND: A large proportion of people who sustain a whiplash injury will have persistent pain, disability, and participation problems. Several prognostic factors for functional recovery have been reported in the literature but these factors are often evaluated based on differing implementations in clinical practice. Additionally, physiotherapists also rely on their clinical intuition to estimate the functional prognosis of their patients, but this is seldom measured in experimental research. Furthermore, no study to date has explored the associations between clinical intuition, clinically estimated factors, and objectively measured factors for functional recovery of patients with Whiplash-Associated Disorders (WAD). AIM: The aim of this exploratory study is to evaluate associations between prognostic factors for functional recovery, based on routinely collected data in a specialized primary care physiotherapy practice in a consecutive sample of patients (n = 523) with WAD. METHODS: Three sources of prognostic factors were selected: (1) physiotherapists' synthesis of clinical intuition in terms of high-risk, inconclusive risk, or low-risk for functional recovery, (2) patient-registered factors from history taking, and (3) patient-reported prognostic factors derived from questionnaires. Prognostic factors were selected based on the literature, recommendations in Dutch clinical practice guidelines, and consensus between experts. Spearman's rank correlation coefficients were calculated to explore the associations between sources of prognostic factors, using a cutoff ≥0.25 for acceptable association. RESULTS: Associations between physiotherapists' intuitive synthesis and patient-registered variables were substantial (rs = 0.86), between patient-registered variables and patient-reported variables fair (ranging from 0.30 to 0.41) to substantial (ranging from 0.69 to 0.73), and between physiotherapists intuitive synthesis and patient-reported variables fair (ranging from 0.30 to 0.37). CONCLUSION: When estimating prognosis for functional recovery using clinical reasoning, physiotherapists should integrate patients' registered experience of their course of recovery, as well as the timeline after an accident, with their own synthesis of clinical intuition regarding prognostic factors in patients with WAD.

Clinical Characteristics and Patient-Reported Outcomes of Primary Care Physiotherapy in Patients with Whiplash-Associated Disorders: A Longitudinal Observational Study.

BACKGROUND: Whiplash-associated disorders (WADs) constitute a state of health characterized by a wide diversity of symptoms as a result of impairments of functions, activity limitations, and participation restrictions. Patient-reported outcome measurements (PROMs) and patient-reported outcomes (PROs) seem appropriate when describing and evaluating the health status of patients with WAD. AIM: To measure the use of PROMs and PROs as quality indicators in clinical reasoning, and to analyze and evaluate pre- and post-treatment 'pain intensity' and 'functioning', and for 'perceived improvement' in patients with WAD in primary care physiotherapy practice by year of referral, with the phase after accident and prognostic health profile embedded in the clinical reasoning process. MATERIALS AND METHODS: Data were collected over a period of 10 years. Pain intensity, functioning, and perceived improvement were measured using the Visual Analogue Scale for Pain (VAS-P), the Neck Disability Index (NDI) and the Global Perceived Effect scale (GPE). Pre- and post-treatment mean differences were tested for statistical significance and compared to minimal clinically important differences (MCID). Effect sizes were expressed as Cohen's d. Multivariable regression analysis was performed to explore independent associations of year of referral, phase after the accident, and the patient's prognostic health profile with post-treatment pain intensity and functioning. RESULTS: A consecutive sample of 523 patients was included. Pre- and post-treatment mean differences on VAS-P and NDI were statistically significant (P<0.000) and clinically relevant, with 'large' effect sizes for pain intensity and functioning. MCIDs were achieved by 80% for VAS-P and for 60% for NDI. Year of referral and phase after the accident were independently associated with worse post-treatment functioning. About half of the patients (n=241 [46.1%]) perceived themselves as improved. CONCLUSION: The PROMs and PROs pain intensity, functioning and perceived improvement were integrated as quality indicators in the physiotherapy clinical reasoning process for patients with WAD. Significant differences in pain intensity and functioning were found but were unrelated to year of referral, phase after whiplash-related injury or prognostic health profile. The MCID VAS-P scores did not differ depending on experienced pain.

Relationships Between Context, Process, and Outcome Indicators to Assess Quality of Physiotherapy Care in Patients with Whiplash-Associated Disorders: Applying Donabedian's Model of Care.

BACKGROUND: Quality indicators (QIs) are measurable elements of practice performance and may relate to context, process, outcome and structure. A valid set of QIs have been developed, reflecting the clinical reasoning used in primary care physiotherapy for patients with whiplash-associated disorders (WAD). Donabedian's model postulates relationships between the constructs of quality of care, acting in a virtuous circle. AIM: To explore the relative strengths of the relationships between context, process, and outcome indicators in the assessment of primary care physiotherapy in patients with WAD. MATERIALS AND METHODS: Data on WAD patients (N=810) were collected over a period of 16 years in primary care physiotherapy practices by means of patients records. This routinely collected dataset (RCD-WAD) was classified in context, process, and outcome variables and analyzed retrospectively. Clinically relevant variables were selected based on expert consensus. Associations were expressed, using zero-order, as Spearman rank correlation coefficients (criterion: rs >0.25 [minimum: fair]; α-value = 0.05). RESULTS: In round 1, 62 of 85 (72.9%) variables were selected by an expert panel as relevant for clinical reasoning; in round 2, 34 of 62 (54.8%) (context variables 9 of 18 [50.0%]; process variables 18 of 34 [52.9]; outcome variables 8 of 10 [90.0%]) as highly relevant. Associations between the selected context and process variables ranged from 0.27 to 0.53 (p≤0.00), between selected context and outcome variables from 0.26 to 0.55 (p≤0.00), and between selected process and outcome variables from 0.29 to 0.59 (p≤0.00). Moderate associations (rs >0.50; p≤0.00) were found between "pain coping" and "fear avoidance" as process variables, and "pain intensity" and "functioning" as outcome variables. CONCLUSION: The identified associations between selected context, process, and outcome variables were fair to moderate. Ongoing work may clarify some of these associations and provide guidance to physiotherapists on how best to improve the quality of clinical reasoning in terms of relationships between context, process, and outcome in the management of patients with WAD.

Routinely collected data as real-world evidence for physiotherapy practice.

Evidence-based practice is the current undisputed predominant paradigm within medicine and allied health care, particularly in physiotherapy. Despite its potential benefits, over the years various points of criticism have been formulated one of which is the overreliance on randomized clinical trials as the highest level of evidence for treatment effectiveness. In the current era, where the availability of large amounts of clinical data gathered during the course of care delivery is rapidly increasing as well as our ability to access, process, link, and analyze these data in fairly efficient ways, alternative sources to supplement rather than replace evidence from RCTs look promising. In this Editorial, we discuss the opportunities and limitations of these routinely collected data in physiotherapy research and provide several examples from the literature. We conclude that the use of routinely collected data in physiotherapy research has the potential to increasingly contribute to real-world evidence, particularly in musculoskeletal primary care physiotherapy, provided that researchers are aware of methodological limitations and adhere to reporting standards.

Intra/interrater reliability of measurements on body posture photographs.

Intra/interrater's reliability of the coordinates of ten anatomical landmarks on a frontal and a dorsal body posture photograph of 18 subjects was tested. The measurements were conducted by two testers with an interval of seven days between each session. The repeated measurements of each examiner (intrarater) and the first and second measurement of both examiners (interrater) were assessed for reliability. Statistical testing was performed to confirm the data to fit a normal distribution according to Shapiro-Wilks (alpha = 0.05). Intraclass correlation coefficients and Pearson Product-Moment correlation coefficients were used to assess reliability at the alpha level of 0.05. Pearson's correlation coefficients were between 0.72 and 1.0, Intraclass correlation coefficients (ICC) between 0.66 and 1.0. In further analysis of the results, repeated-measures paired T-tests were used to test for differences between repeated measures. After adjustment of the alpha level for the total number of comparisons, 10 of the paired T-tests were significant (2 intra; 8 inter). The results indicate that the measuring method provides reliable data and that two different test modes produce consistent measurements.

Body posture photographs as a diagnostic aid for musculoskeletal disorders related to temporomandibular disorders (TMD).

The purpose of this study was to test the hypothesis that body posture could be an etiologic factor in patients with temporomandibular disorders. "Faculty" body posture has been considered to be an initiating and perpetuating etiologic factor in some temporomandibular disorders (TMD). Although in patients with temporomandibular disorders a significant craniocervical dysfunction has been established, a causal relationship between posture and TMD has not yet been proved. Two samples of 40 subjects each were selected, age and gender matched. The experimental group consisted of 40 patients, who were not previously treated for temporomandibular dysfunction. TMD of these patients was diagnosed on the basis of a questionnaire and a thorough intra- and extraoral examination. The clinical symptoms of TMD were confirmed with transcranial x-rays and the condylar tracings of the performed axiography. A clinical examination was done to confirm the good health of the control group. In addition, symptoms of craniocervical dysfunction within the experimental group were evaluated to make a proper referral to a physical therapist. Four photographs of the orthostatic posture were taken. In accordance with anthropometric guidelines, the following anatomical landmarks were palpated and applied on the skin with a dark lipstick on forehand: both acromiones of the scapula and the anterior (ASIS) and posterior superior iliac spine (PSIS). Statistical testing was performed to confirm the data fit a normal distribution. The differences between the experimental group and the control group were tested with Student's two sample T-test. Within the experimental group, a significant correlation existed between the shoulder line and the pelvis line, on the frontal as well as on the dorsal photograph. The results suggest a somatic basis for the observed postural imbalances in patients with temporomandibular disorders. The results, however, must be interpreted with reservation.

Differences and similarities in electrical muscle activity for the abductor pollicis longus muscle divisions.

The abductor pollicis longus (APL) has to be viewed as an important muscle for moving and stabilizing the human thumb(10). This muscle has two divisions, a distal superficial division and a more proximal deep one. The electromyographic (EMG) signals from these divisions were measured for several motor tasks in order to investigate differences in activation and function. EMG signals were recorded with intramuscular wire electrodes in isometric as well as in dynamic contractions in different directions, both for the thumb and for the hand. The EMG signals of the right hand of eight subjects were scaled relative to the mean EMG value at the maximum voluntary isometric contraction (MVC) in order to compare relative muscle activity in various directions for different subjects. In 18 out of the 22 directions the EMG activity in the two divisions of the APL was modulated differently, indicating a different activation. The differences were most prominent in dorsal and palmar flexion of the hand. The results suggested that the APLdeep is activated to stabilize the carpal joint. The APLdeep is a direct mover of the carpal joint in dorsal flexion of the hand.

Nationwide survey on nutritional habits in elite athletes. Part II. Mineral and vitamin intake.

The nutritional habits of elite athletes competing at a national and international top level were determined. Groups of endurance strength, and team sport athletes participated. All athletes trained at least 1-2 h daily. The purpose of the study was to quantify the mineral and vitamin intake and to identify the magnitude of the nutrient supplementation use. Information on food intake was obtained by a 4- or 7-day food diary. It was found that calcium and iron intake was positively related to energy intake. In low energy intakes (less than 10 MJ) iron intake might be insufficient. In general, vitamin intake with food was in agreement with the Dutch recommendations. However, if energy intake is high (greater than 20 MJ) the amount of refined carbohydrate is increased. Consequently, the nutrient density for vitamin B1 drops. Therefore, under these conditions, supplementation for vitamin B1 must be considered. The low vitamin intake found in lower energy intakes can be improved by proper nutritional advice. In body building and in professional cycling, high dosages of vitamins are used. The other groups of athletes used only moderate quantities of vitamin supplements. It is concluded that vitamin and mineral intake is sufficient, when energy intake ranges between 10 and 20 MJ/day.

Nationwide survey on nutritional habits in elite athletes. Part I. Energy, carbohydrate, protein, and fat intake.

Information about habitual food intake was systematically obtained from elite endurance, strength, and team sport athletes. The athletes (n = 419) trained at least 1-2 h daily and competed on an international level. A 4- or 7-day food diary was kept. For analysis of the data, a computerized food table was used. Mean energy intake varied from 12.1-24.7 MJ per day for male and 6.8-12.9 MJ per day for female athletes. Protein intake was in agreement with or higher than the Dutch recommendations. Contribution of carbohydrate intake to total energy intake varied from 40%-63%. Fat intake tended to meet the criteria for a prudent diet (less than 35%). Snacks contributed about 35% to the total energy intake and the bread/cereals and dairy food groups were the most important energy sources. It is concluded that in general there are two major concerns. In those sports in which body composition plays an important role, energy and thus nutrient intake is often marginal. In all groups of athletes intake of carbohydrate is insufficient.

Reproducibility of urinary 3-methylhistidine excretion in human subjects consuming freely selected diets.

Eight males and six females consumed their normal diet for 9 weeks, except for weeks 3 and 9 when they followed a self-selected diet free of 3-methylhistidine (3MH) for five subsequent weekdays (days 1 to 5). Timed 24-hours urine collections were obtained on days 3, 4, and 5 of these 3MH-free dietary periods and on one day during weeks 1 and 7. At the group level, no differences in 3MH excretion (P greater than .05) between days 3, 4, and 5 in weeks 3 and 9 and between these weeks were observed. Reproducibility at the individual level was indicated by the within-subject coefficient of variation (CVw). CVw within weeks 3 and 9 was 2.5% and 5.1% for men and 4.8 and 8.0% for women. CVw between these weeks was highest when more than one measurement per week was performed. Relating 3MH to creatinine decreased the CVw between weeks. If muscle protein breakdown is to be measured at the individual level, a reasonably large biologic variation is to be taken into account and repeated measurements should be done to decrease the CVw.