What is the diagnostic accuracy of red flags related to cauda equina syndrome (CES), when compared to Magnetic Resonance Imaging (MRI)? A systematic review.

OBJECTIVE: To review and statistically pool available evidence on the diagnostic accuracy of red flags to clinically identify MRI confirmed Cauda Equina Syndrome (CES). STUDY DESIGN: Systematic review. DATA SOURCES: Embase, Scopus, Ovid Medline, Ovid Healthstar, Amed and CINAHL from inception to January 30, 2018 and a grey literature search. INCLUSION CRITERIA: Primary diagnostic studies, published in English; comparing red flags for CES; to Magnetic Resonance Imaging (MRI) as reference standard; in humans; older than 18 years. METHODS: Data extraction, assessment of study quality using a modified QUADAS-2 tool and the use of GRADE to synthesize the results for each test was performed by three independent assessors. Diagnostic accuracy statistics applied to the identified data andpooled analysis performed using Meta-DiSc, version 1.4. Moderator analyses planned for pooled results. RESULTS: Seven studies (total N = 569 participants) were included. Potential signs or symptoms of CES were compared to MRI findings. Diagnostic data could be pooled for reduced anal tone, leg pain, back pain, saddle anaesthesia, urinary retention, urinary incontinence and bowel incontinence from six of seven studies. The pooled sensitivity for the signs and symptoms ranged from 0.19 (95% CI 0.09 to 0.33) to 0.43 (95% CI 0.30 to 0.56) while the pooled specificity ranged from 0.62 (95% CI 0.59 to 0.73) to 0.88 (95% CI 0.85 to 0.92). CONCLUSION: Red flags used to identify potential CES appear to be more specific than sensitive. As such, when these are present, they should be considered justification for prompt diagnostic workup.

A cross-sectional evaluation examining the use of the Achilles tendinopathy toolkit by physiotherapists in British Columbia, Canada.

PURPOSE: To evaluate the awareness and use of the Achilles tendinopathy toolkit (ATT), a knowledge translation (KT) strategy supporting evidence-informed management of midportion Achilles Tendinopathy (AT), by British Columbian physiotherapists (PTs). Secondarily, to assess PTs strategies for AT management by examining the association between exploring the ATT and following best practice in clinical care as recommended by the ATT. METHODS: Members of the Physiotherapy Association of British Columbia (BC) completed an online cross-sectional survey collecting information on demographics; awareness and exposure; perceptions, usability and applicability to clinical practice; knowledge; and attitudes. A clinical vignette assessed if respondents adhered to recommendations made by the ATT. Multi-variable logistic regression examined the association between exploring the ATT and following its recommendations. RESULTS: Of 238 participants, 81% (n = 154) were aware of the ATT and of those 53% (n = 81) explored its contents. Time was the most frequent barrier. Bi-variable analyses showed those who explored the ATT had over double the odds of following the best practice (odds ratio = OR = 2.8; 95% confidence interval = 95% CI = 1.3-6.0). This did not remain significant in the final adjusted model (OR = 2.2; 95% CI = 0.9-5.4). CONCLUSIONS: Evaluation of KT strategies is critical. This study revealed high awareness and moderate use of the ATT. Future work should consider the impact of toolkits on patient outcomes. Implications for Rehabilitation A toolkit is a novel knowledge translation (KT) strategy designed to provide accessibleevidence-informed resources to facilitate best practice by clinicians. The evaluation of the Achilles tendinopathy toolkit (ATT) revealed favourable findingsregarding the impact of this KT strategy on the knowledge and attitudes of British Columbia(BC) PTs and the possibility of a positive impact on best practice in clinical care. This research suggests toolkits are a feasible and meaningful KT strategy to provide clinicianswith valuable synthesized resources that have the potential to benefit patient outcomes.

The Traumatic Injuries Distress Scale: A New Tool That Quantifies Distress and Has Predictive Validity With Patient-Reported Outcomes.

Study Design Observational cohort. Background Outcomes for acute musculoskeletal injuries are currently suboptimal, with an estimated 10% to 50% of injured individuals reporting persistent problems. An early risk-targeted intervention may hold value for improving outcomes. Objectives To describe the development and preliminary concurrent and longitudinal validation of the Traumatic Injuries Distress Scale (TIDS), a new tool intended to provide the magnitude and nature of risk for persistent problems following acute musculoskeletal injuries. Methods Two hundred participants recruited from emergency medicine departments and rehabilitation clinics completed the TIDS and a battery of other self-reported questionnaires. A subcohort (n = 76) was followed at 1 week and at 12 weeks after the inciting event. Exploratory factor analysis and concurrent and longitudinal correlations were used to evaluate the ability of the TIDS to predict acute presentation and 12-week outcomes. Results Exploratory factor analysis revealed 3 factors explaining 62.8% of total scale variance. Concurrent and longitudinal associations with established clinical measures supported the nature of each subscale. Scores on the TIDS at baseline were significantly associated with variability in disability, pain intensity, satisfaction, anxiety, and depression at 12 weeks postinjury, with adequate accuracy to endorse its use as part of a broader screening protocol. Limitations to interpretation are discussed. Conclusion We present the initial psychometric properties of a new measure of acute posttraumatic distress following musculoskeletal injury. The subscales may be useful as stratification variables in subsequent investigations of clinical interventions. J Orthop Sports Phys Ther 2016;46(10):920-928. Epub 3 Sep 2016. doi:10.2519/jospt.2016.6594.

Clinical pressure pain threshold testing in neck pain: comparing protocols, responsiveness, and association with psychological variables.

BACKGROUND: Quantitative sensory testing, including pressure pain threshold (PPT), is seeing increased use in clinical practice. In order to facilitate clinical utility, knowledge of the properties of the tool and interpretation of results are required. OBJECTIVES: This observational study used a clinical sample of people with mechanical neck pain to determine: (1) the influence of number of testing repetitions on measurement properties, (2) reliability and minimum clinically important difference, and (3) associations between PPT and key psychological constructs. DESIGN: This study was observational with both cross-sectional and prospective elements. METHODS: Experienced clinicians measured PPT in patients with mechanical neck pain following a standardized protocol. Subcohorts also provided repeated measures and completed scales of key psychological constructs. RESULTS: The total sample was 206 participants, but not all participants provided data for all analyses. Interrater and 1-week test-retest reliability were excellent (intraclass correlation coefficients [2,1]=.75-.95). Potentially important differences in reliability and PPT scores were found when using only 1 or 2 repeated measures compared with all 3. The PPT over a distal location (tibialis anterior muscle) was not adequately responsive in this sample, but the local site (upper trapezius muscle) was responsive and may be useful as part of a protocol to evaluate clinical change. Sensitivity values (range=0.08-0.50) and specificity values (range=0.82-0.97) for a range of change scores are presented. Depression, catastrophizing, and kinesiophobia were able to explain small but statistically significant variance in local PPT (3.9%-5.9%), but only catastrophizing and kinesiophobia explained significant variance in the distal PPT (3.6% and 2.9%, respectively). LIMITATIONS: Limitations of the study include multiple raters, unknown recruitment rates, and unknown measurement properties at sites other than those tested here. CONCLUSIONS: The results suggest that PPT is adequately reliable and that 3 measurements should be taken to maximize measurement properties. The variance explained by the psychological variables was small but significant for 3 constructs related to catastrophizing, depression, and fear of movement. Clinical implications for application and interpretation of PPT are discussed.

Pressure pain threshold testing demonstrates predictive ability in people with acute whiplash.

STUDY DESIGN: Longitudinal cohort study. OBJECTIVES: To determine whether pressure pain threshold (PPT), tested at 2 standardized sites, could provide additional prognostic ability to predict short-term outcomes in people with acute whiplash, after controlling for age, sex, and baseline pain intensity. BACKGROUND: PPT may be a valuable assessment and prognostic indicator for people with whiplash-associated disorder. The extent to which PPT can predict short-term disability scores has yet to be explored in people with acute (of less than 30 days in duration) whiplash-associated disorder in a clinical setting. METHODS: Eligible patients were recruited from community-based physiotherapy clinics in Canada. Baseline measurements included PPT, as well as pain intensity, age, and sex. Neck-related disability was collected with the Neck Disability Index 1 to 3 months after PPT testing. Multiple linear regression models were constructed to evaluate the unique contribution of PPT in the prediction of follow-up disability scores. RESULTS: A total of 45 subjects provided complete data. A regression model that included sex, baseline pain intensity, and PPT at the distal tibialis anterior site was the most parsimonious model for predicting short-term Neck Disability Index scores 1 to 3 months after PPT testing, explaining 38.6% of the variance in outcome. None of the other variables significantly improved the predictive power of the model. CONCLUSION: Sex, pain intensity, and PPT measured at a site distal to the injury were the most parsimonious set of predictors of short-term neck-related disability score, and represented promising additions to assessment of traumatic neck pain. Neither age nor PPT at the local site was able to explain significant variance beyond those 3 predictors. Limitations to interpretation are addressed.