Considerations and challenges in support of science and communication of fish consumption advisories for per- and polyfluoroalkyl substances.

Federal, state, tribal, or local entities in the United States issue fish consumption advisories (FCAs) as guidance for safer consumption of locally caught fish containing contaminants. Fish consumption advisories have been developed for commonly detected compounds such as mercury and polychlorinated biphenyls. The existing national guidance does not specifically address the unique challenges associated with bioaccumulation and consumption risk related to per- and polyfluoroalkyl substances (PFAS). As a result, several states have derived their own PFAS-related consumption guidelines, many of which focus on one frequently detected PFAS, known as perfluorooctane sulfonic acid (PFOS). However, there can be significant variation between tissue concentrations or trigger concentrations (TCs) of PFOS that support the individual state-issued FCAs. This variation in TCs can create challenges for risk assessors and risk communicators in their efforts to protect public health. The objective of this article is to review existing challenges, knowledge gaps, and needs related to issuing PFAS-related FCAs and to provide key considerations for the development of protective fish consumption guidance. The current state of the science and variability in FCA derivation, considerations for sampling and analytical methodologies, risk management, risk communication, and policy challenges are discussed. How to best address PFAS mixtures in the development of FCAs, in risk assessment, and establishment of effect thresholds remains a major challenge, as well as a source of uncertainty and scrutiny. This includes developments better elucidating toxicity factors, exposures to PFAS mixtures, community fish consumption behaviors, and evolving technology and analytical instrumentation, methods, and the associated detection limits. Given the evolving science and public interests informing PFAS-related FCAs, continued review and revision of FCA approaches and best practices are vital. Nonetheless, consistent, widely applicable, PFAS-specific approaches informing methods, critical concentration thresholds, and priority compounds may assist practitioners in PFAS-related FCA development and possibly reduce variability between states and jurisdictions. Integr Environ Assess Manag 2024;00:1-20. © 2024 SETAC.

Assessing the safety of physical rehabilitation in critically ill patients: a Delphi study.

BACKGROUND: Physical rehabilitation of critically ill patients is implemented to improve physical outcomes from an intensive care stay. However, before rehabilitation is implemented, a risk assessment is essential, based on robust safety data. To develop this information, a uniform definition of relevant adverse events is required. The assessment of cardiovascular stability is particularly relevant before physical activity as there is uncertainty over when it is safe to start rehabilitation with patients receiving vasoactive drugs. METHODS: A three-stage Delphi study was carried out to (a) define adverse events for a general ICU cohort, and (b) to define which risks should be assessed before physical rehabilitation of patients receiving vasoactive drugs. An international group of intensive care clinicians and clinician researchers took part. Former ICU patients and their family members/carers were involved in generating consensus for the definition of adverse events. Round one was an open round where participants gave their suggestions of what to include. In round two, participants rated their agreements with these suggestions using a five-point Likert scale; a 70% consensus agreement threshold was used. Round three was used to re-rate suggestions that had not reached consensus, whilst viewing anonymous feedback of participant ratings from round two. RESULTS: Twenty-four multi-professional ICU clinicians and clinician researchers from 10 countries across five continents were recruited. Average duration of ICU experience was 18 years (standard deviation 8) and 61% had publications related to ICU rehabilitation. For the adverse event definition, five former ICU patients and one patient relative were recruited. The Delphi process had a 97% response rate. Firstly, 54 adverse events reached consensus; an adverse event tool was created and informed by these events. Secondly, 50 risk factors requiring assessment before physical rehabilitation of patients receiving vasoactive drugs reached consensus. A second tool was created, informed by these suggestions. CONCLUSIONS: The adverse event tool can be used in studies of physical rehabilitation to ensure uniform measurement of safety. The risk assessment tool can be used to inform clinical practise when risk assessing when to start rehabilitation with patients receiving vasoactive drugs. Trial registration This study protocol was retrospectively registered on https://www.researchregistry.com/ (researchregistry2991).

An ensemble model predicts an upward range shift of the endemic and endangered Yellow-throated Apalis (Apalis flavigularis) under future climate change in Malawi.

Climate change poses a significant threat to endemic and endangered montane bird species with limited elevation and temperature ranges. Understanding their responses to changes in climate is essential for informing conservation actions. This study focused on the montane dwelling Yellow-throated Apalis (Apalis flavigularis) in Malawi, aiming to identify key factors affecting its distribution and predicting its potential distribution under different climate change scenarios. Using an ensemble species distribution modeling approach, we found that the mean temperature of the driest quarter (Bio9), mean temperature of the wettest quarter (Bio8), and precipitation seasonality (Bio15) were the most important variables that influenced the distribution of this species. Across future climate scenarios, the species' geographic range declined where range losses varied from 57.74% (2050 RCP 6.0) to 82.88% (2070 RCP 6.0). We estimate its current range size to be 549 km2 which is lower than some previous estimates of its spatial distribution. Moreover, our projections indicate that under future climate scenarios, the species will shift to higher elevations with a large proportion of suitable areas located outside forests, posing challenges for adaptation. Our results suggest that the species may be under greater threat than previously thought; hence, urgent conservation actions are required. We recommend reinforcing the protection of areas predicted to remain suitable under future climate scenarios and the development of a species conservation action plan.

Associations between teacher stress and school leadership: A mixed methods study with implications for school psychologists.

School psychologists have the psychological and consultative expertise necessary to support teachers who are vulnerable to stress. Transactional theory offers a lens to guide such support, as it posits that each teacher's unique appraisals of their work demands and resources determine the degree to which they are at risk for stress. This study used a multiphase sequential mixed method design with a transactional theory lens to examine the association of leadership quality and stability with teachers' ratings of workplace conditions. The four phases consisted of (a) input from an expert panel, (b) scale development and validation, (c) interviews with key informants, and (d) multilevel modeling informed by all previous phases. Through key informant interviews, district-level administrators provided ratings of the quality and stability of school leadership. The researchers examined the associations between these ratings and teacher appraisals of classroom demands, classroom resources, job satisfaction, and perceived levels of instructional support collected via a district-wide climate survey. Multilevel models with key informant ratings and school characteristics at Level 2 (Nschools = 47) and teacher characteristics and perceptions at Level 1 (Nteachers = 1,850) demonstrated that the quality and stability of school leadership were associated with teachers' appraisals of their occupational demands and resources, job satisfaction, and ratings of instructional support. Findings show that the quality and stability of school leadership play an important role in the incidence of stress vulnerability, suggesting important pathways for school psychologists seeking to promote the occupational health of teachers. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Teachers' psychological stress and wellbeing during a pandemic: Exploring latent profiles.

Teacher stress is at an all-time high. The COVID-19 pandemic created unprecedented challenges for teachers, which resulted in a record number of teachers intending to leave the classroom citing stress as a contributing factor. Understanding teachers' positive and negative psychological experiences, or well-being, during the height of the COVID-19 pandemic will inform teacher wellness interventions intended to keep teachers in the classroom. Two hundred forty-six teachers from a suburban school district participated in a survey of well-being indicators, including affect, perceived stress, teaching self-efficacy, and preventive coping. A latent profile analysis identified four patterns of well-being: strained, resilient, lower teaching self-efficacy, and lower emotional well-being. While many teachers were resilient during the crisis, approximately two-thirds experienced global or isolated areas of strain. Additionally, the Classroom Appraisal of Resources and Demands-Revised, a theory-driven assessment of teachers' workplace appraisal of demands and resources, was associated with teachers' strained and resilient well-being profiles, making it a suitable screening tool for these groups. Layered screening and tailored intervention, based on teachers' well-being patterns, may help minimize teacher attrition during and postcrises. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Cannabis Use Is Associated With Fewer Filled Opioid Prescriptions After Treatment of Proximal Humerus Fractures.

The purpose of this study was to use a large claims database to determine if there is a difference in opioid use after operative intervention for proximal humerus fractures in patients with known cannabis use compared with those who do not report cannabis use. The PearlDiver database was queried to find all patients who underwent proximal humerus open reduction and internal fixation. A group of patients with reported cannabis use or dependence was matched to a cohort without known cannabis use. Between the two groups, differences in the number of opioid prescriptions filled in the postoperative period (within 3 days), the morphine milligram equivalents (MMEs) prescribed in total and per day, and the number of opioid prescription refills were explored. There were 66,445 potential control patients compared with 1260 potential study patients. After conducting the propensity score match, a total of 1245 patients were included in each group. The patients in the cannabis group filled fewer opioid prescriptions (P=.045) and were prescribed fewer total MMEs (P=.044) in the first 3 days postoperatively. Results of this study indicate that patients who use cannabis products may use fewer opioids after proximal humerus open reduction and internal fixation. [Orthopedics. 202x;4x(x);xx-xx.].

Manual Therapy versus Localisation (Tactile, Sensory Training) in Patients with Non-Specific Neck Pain: A Randomised Clinical Pilot Trial.

Manual therapy (MT) techniques typically incorporate localised touch on the skin with the application of specific kinetic forces. The contribution of localised touch to the effectiveness of MT techniques has not been evaluated. This study investigated the immediate effects of MT versus localisation training (LT) on pain intensity and range of movement (ROM) for neck pain. In this single-blind randomised controlled trial thirty eligible neck pain volunteers (23 females and 7 males), aged 28.63 ± 12.49 years, were randomly allocated to MT or to a motionless (LT) group. A single three-minute treatment session was delivered to each group's cervico-thoracic area. The LT involved tactile sensory stimulation applied randomly to one out of a nine-block grid. Subjects were asked to identify the number of the square being touched, reflecting a different location on the region of skin. MT involved three-minute anteroposterior (AP) glides and sustained natural apophyseal glides (SNAG) techniques. Pre- and post-intervention pain intensity were assessed using a pressure pain threshold (PPT) algometer and the numeric pain rating scale (NPRS). Neck ROM was recorded with a bubble inclinometer. Improvements in ROM and self-reported pain were recorded in both groups (p < 0.001) without differences in NPRS, ROM or PPT scores between groups (p > 0.05). Tactile sensory training (localisation) was as effective as MT in reducing neck pain, suggesting a component of MT's analgesic effect to be related with the element of localised touch rather than the forces induced during passive movements.

Barriers to and Facilitators for Teachers' Wellbeing.

Teaching is widely recognized as a stressful profession, which has been connected to burnout and high turnover of qualified teachers. Despite increasing attention on teacher wellbeing, stress management interventions are often underutilized and demonstrate small effect sizes, and research on teachers' informal stress management practices and desired resources is limited. It is likely that formal and informal intervention effectiveness is limited by teachers' ability to access existing resources and navigate the complex educational systems they inhabit. The study explored the barriers to and facilitators for teachers' engagement in formal and informal stress management interventions and desired resources across socioecological levels. Thirty-two teachers participated across four focus groups. Inductive thematic analysis was used to identify relevant themes. Personal barriers (e.g., guilt about self-prioritization), environmental barriers (e.g., mixed messages about self-care), and improved campus resources (e.g., scheduled opportunities to destress) were common themes. Recommendations for supporting teachers' wellbeing include self-care affirming messages from peers and administrators, campus- and district-level changes to remove logistical barriers to stress management, and increased connectedness among campus community members.

Species- and Tissue-Specific Chronic Toxicity Values for Northern Bobwhite Quail (Colinus virginianus) Exposed to Perfluorohexane Sulfonic Acid and a Binary Mixture of Perfluorooctane Sulfonic Acid and Perfluorohexane Sulfonic Acid.

Per- and polyfluoroalkyl substances (PFAS) are globally distributed and present in nearly every environmental compartment. Characterizing the chronic toxicity of individual PFAS compounds and mixtures is necessary because many have been reported to cause adverse health effects. To derive toxicity reference values (TRVs) and conduct ecotoxicological risk assessments (ERAs) of PFAS-contaminated ecosystems for wildlife, species-specific PFAS chronic toxicity values (CTVs) are needed. The present study quantified PFAS residues from liver and eggs of birds chronically exposed to perfluorohexanoic acid (PFHxA) or a mixture of perfluorooctane sulfonate (PFOS) and PFHxA that produced a no-observable-adverse-effect level (NOAEL) and/or a lowest-observable-adverse-effectlevel (LOAEL). The CTVs we present are lower than those previously reported for birds and should be considered in future regulatory evaluations. From the estimated species- and tissue-specific PFAS CTVs, we found that PFOS and perfluorohexane sulfonate (PFHxS) were more bioaccumulative than PFHxA in avian tissues, but PFHxA was more toxic to reproducing birds than either PFOS or a PFOS:PFHxS mixture. We further determined that avian toxicity was not necessarily additive with respect to PFAS mixtures, which could have implications for PFAS ERAs. The PFAS LOAEL CTVs can be used to predict reproductive and possible population-level adverse health effects in wild avian receptors. Environ Toxicol Chem 2022;41:219-229. © 2021 SETAC.

Establishing a province-wide referral network to improve access to gender-affirming primary healthcare services.

ABSTRACT: It is possible and necessary to provide trans and gender nonconforming (TGNC) individuals with gender-affirming care (GAC) in primary care settings. A known risk of increased suicidality among TGNC individuals and a lack of provider training on prescribing gender-affirming hormones (GAH) in the Canadian province of Nova Scotia highlighted a need for building capacity around GAC delivery. A referral network was established across the province, which reduced wait times to access GAH by several months.

Toxicological Response of Chironomus dilutus in Single-Chemical and Binary Mixture Exposure Experiments with 6 Perfluoralkyl Substances.

Few studies have determined the toxicity of perfluoralkyl substances (PFAS) to aquatic invertebrates. We exposed Chironomus dilutus to 6 different PFAS to assess single-chemical toxicity and relative or proportional toxicity among substances. A 10-d range-finding test was conducted to inform 20-d assays for the following PFAS: perfluorooctane sulfonate (PFOS), perfluorooctanoic acid (PFOA), perfluorononanoic acid (PFNA), perfluorobutanesulfonic acid (PFBS), perfluorohexanesulfonic acid (PFHxS), and perfluoroheptanoic acid (PFHpA). A 20-d binary mixture study of PFOS+PFHxS followed the single-chemical tests. Measurement endpoints for 20-d tests included larval survival and biomass. Log-logistic concentration response models were used to estimate 10, 20, and 50% effect concentrations (EC20, EC50) for PFOS, PFHxS, and PFOA. Survival EC50s for PFOS, PFHxS, and PFOA were 2.49, 3860, and 192 000 µg/L, respectively, whereas survival EC20s were 1.70, 913, and 119 000 µg/L for PFOS, PFHxS, and PFOA, respectively. Biomass as a combined survival and growth endpoint resulted in EC20s of 1.89, 896, and 137 000 µg/L for PFOS, PFHxS, and PFOA, respectively. Maximum concentrations tested (no-observed-effect concentrations) for PFNA, PFBS, and PFHpA were 2 to 3 orders of magnitude greater than the PFOS EC50s and showed no toxicity to C. dilutus, even at exposure concentrations well above what would be considered environmentally relevant. The binary mixture of 2.5 µg/L PFOS+1000 µg/L PFHxS showed reduced survival compared to controls and some indication of potential additive or synergistic interaction between PFOS and PFHxS. Overall, the present study supports previous studies showing PFOS to be the most toxic PFAS to aquatic life and suggests that PFOS could be more toxic to the freshwater midge than previously reported. Environ Toxicol Chem 2021;40:2319-2333. © 2021 SETAC.

Considerations for toxicity experiments and risk assessments with PFAS mixtures.

Per- and polyfluoroalkyl substances (PFAS) have been around for decades and have been the subject of laboratory and field research studies for nearly as long. Although attention to PFAS has grown in recent years, many unanswered questions remain. Accordingly, the number of research projects designed to improve our understanding of PFAS toxicity, bioaccumulation, and biomagnification, and to improve our ability to predict the interactions of PFAS mixtures, is also increasing. The growing number of ongoing and future research projects focusing on these chemicals will benefit from lessons learned in previous studies. This perspectives article discusses available approaches to mixture risk assessment with specific focus on application to PFAS mixtures. We discuss ongoing research as well as lessons learned from approaches to handling mixtures of other groups of chemicals. Many of these approaches require some detailed understanding of a manageable number of representative chemicals, yet only limited toxicological data are available for most PFAS. With the limited amount of published data currently available, the need for single-chemical and binary-mixture studies persists. Based on our previous work with single-chemical exposures for understudied PFAS, we explored some of the challenges of trying to design and interpret an aquatic concentration-response experiment for a binary mixture of two commonly detected PFAS: perfluorooctane sulfonate (PFOS) and perfluorohexane sulfonic acid (PFHxS). Based on our findings, we propose that addressing risk from PFAS mixtures will likely require combinations of approaches incorporating findings from traditional whole-organism toxicity studies and novel methods relying on in vitro assays, read-across, or quantitative structure activity relationships. Complicating a limited understanding of PFAS mixture toxicity is that relative concentrations of PFAS mixtures vary across sites and time, even at one site. Thus, reliance on empirical data, such as site-specific toxicity sampling or community structure studies, may be needed to fully understand potential impacts of mixtures. Integr Environ Assess Manag 2021;17:697-704. © 2021 SETAC.

Key Considerations for Accurate Exposures in Ecotoxicological Assessments of Perfluorinated Carboxylates and Sulfonates.

Toxicity reference values for per- and polyfluoroalkyl substances (PFAS) vary even when the same test organism is studied. Although the need to confirm dosing solution concentrations is widely accepted, there are no experimental data to inform best practices when PFAS solutions are prepared. Laboratory data indicate that dissolution time of PFAS solids causes statistically significant deviations between nominal and measured concentrations. Mixing times for select PFAS varied between 2 and 5 h, depending on carbon fluorine chain-length. Environ Toxicol Chem 2021;40:677-688. © 2020 SETAC.

Response Differences in Appraisals of Working Conditions among Elementary and High School Teachers.

Research using the National Teacher and Principal Survey (NTPS) has consistently demonstrated that teachers' reported working conditions are related to both intentions to leave the profession and attrition (Tickle, Chang, and Kim, 2011). However, limited research evaluates teacher appraisals of job-related demands and resources as an antecedent to job dissatisfaction. We tested for differential item functioning (DIF) using a partial credit model approach within a Rasch modeling context to examine whether elementary and secondary teachers with similar overall stress levels respond to the NTPS Demands and Resources items in similar ways. For the Demands items, seven of the items displayed differences that were negligible, four were intermediate, and three items indicated large DIF contrasts. For the Resources items, 10 items displayed differences that were negligible, two were intermediate, and zero items indicated large DIF contrasts. These results indicate elementary and secondary teachers exhibit different appraisal patterns, suggesting implications for the development and use of survey data in public school settings in general, and for the use of the NTPS data in particular.

Comparing targeted thrust manipulation with general thrust manipulation in patients with low back pain. A general approach is as effective as a specific one. A randomised controlled trial.

BACKGROUND: Spinal manipulation is commonly used to treat back pain. The application of spinal manipulation has traditionally involved an element of targeting the technique to a level of the spine where the proposed movement dysfunction is sited. We evaluated the effects of a targeted manipulative thrust versus a thrust applied generally to the lumbar region. METHODS: A randomised controlled clinical trial in patients with low back pain following CONSORT (Consolidated Standards of Reporting Trials) guidelines. Sixty subjects were randomly allocated to two groups: one group received a targeted manipulative thrust (n=29) and the other a general manipulation thrust (GT) (n=31) to the lumbar spine. Thrust was either localised to a clinician-defined symptomatic spinal level or an equal force was applied through the whole lumbosacral region. We measured pressure-pain thresholds (PPTs) using algometry and muscle activity (magnitude of stretch reflex) via surface electromyography. Numerical ratings of pain and Oswestry Disability Index scores were collected. RESULTS: Repeated measures of analysis of covariance revealed no between-group differences in self-reported pain or PPT for any of the muscles studied. SUMMARY: A GT procedure-applied without any specific targeting-was as effective in reducing participants' pain scores as targeted approaches. TRIAL REGISTRATION NUMBER: ISRCTN11994230.

Attitudes and diagnostic practice in low back pain: A qualitative study amongst Greek and British physiotherapists.

AIM: To explore current diagnostic practice and attitudes of Greek and United Kingdom physiotherapists (PTs) on assessing low back pain (LBP) patients. METHODS: Three focus groups were undertaken, followed by a structured questionnaire-type survey comprising 23 health professionals and a random stratified sample of 150 PTs, respectively. Twenty-nine themes relating to LBP diagnostic practice emerged. These were then given to 30 British PTs assessing their level of agreement with their Greek counterparts. Analysis was performed by percentage agreements and χ (2) tests. RESULTS: The survey was divided into three subsections; PTs' attitudes on LBP assessment, patients' attitudes and diagnostic/healthcare issues, each constituting 14, 7 and 8 statements, respectively. Over half of the statements fell within the 30%-80% agreement between Greece and United Kingdom whereas, 5 statements reported low (< 10%) and 8 statements demonstrated high (> 90%) PT percentage agreement. Similarities across British and Greek PTs were detected in history taking methods and in the way PTs feel patients perceive physiotherapy practice whereas, re-assessment was undertaken less frequently in Greece. Diagnosis according to 91% of the Greek PTs is considered a "privilege" which is exclusive for doctors in Greece (only 17% British PTs agreed) and is accompanied with a great overuse of medical investigations. Forty percent of Greek PTs (compared to 0% of British) consider themselves as "executers", being unable to interfere with treatment plan, possibly implying lack of autonomy. CONCLUSION: Although similarities on history taking methods and on patients' attitudes were detected across both groups, gross differences were found in re-assessment procedures and diagnostic issues between Greek and British physiotherapists, highlighting differences in service delivery and professional autonomy.

A comparison of FreeSurfer-generated data with and without manual intervention.

This paper examined whether FreeSurfer-generated data differed between a fully-automated, unedited pipeline and an edited pipeline that included the application of control points to correct errors in white matter segmentation. In a sample of 30 individuals, we compared the summary statistics of surface area, white matter volumes, and cortical thickness derived from edited and unedited datasets for the 34 regions of interest (ROIs) that FreeSurfer (FS) generates. To determine whether applying control points would alter the detection of significant differences between patient and typical groups, effect sizes between edited and unedited conditions in individuals with the genetic disorder, 22q11.2 deletion syndrome (22q11DS) were compared to neurotypical controls. Analyses were conducted with data that were generated from both a 1.5 tesla and a 3 tesla scanner. For 1.5 tesla data, mean area, volume, and thickness measures did not differ significantly between edited and unedited regions, with the exception of rostral anterior cingulate thickness, lateral orbitofrontal white matter, superior parietal white matter, and precentral gyral thickness. Results were similar for surface area and white matter volumes generated from the 3 tesla scanner. For cortical thickness measures however, seven edited ROI measures, primarily in frontal and temporal regions, differed significantly from their unedited counterparts, and three additional ROI measures approached significance. Mean effect sizes for edited ROIs did not differ from most unedited ROIs for either 1.5 or 3 tesla data. Taken together, these results suggest that although the application of control points may increase the validity of intensity normalization and, ultimately, segmentation, it may not affect the final, extracted metrics that FS generates. Potential exceptions to and limitations of these conclusions are discussed.

A case of myelopathy because of enchondromas from Maffucci syndrome with successful surgical treatment.

BACKGROUND CONTEXT: Maffucci syndrome is a rare disorder comprising multiple enchondromas associated with multiple hemangiomas. Less than 200 cases have been reported in the literature. Most reported cases comprised lesions of the long bone metaphyses, hands, and feet. No previous case of myelopathy due to enchondroma from Maffucci syndrome has been reported. PURPOSE: To highlight an interesting and rare presentation of thoracic myelopathy because of enchondromas from Maffucci syndrome. STUDY DESIGN: This is a case report of a single patient presenting with myelopathy in whom enchondromas from Maffucci syndrome were removed from the spinal canal with the return of normal function. METHODS: Clinical examination, magnetic resonance imaging, surgical resection, and histologic analysis. RESULTS: The patient experiencing myelopathy symptoms underwent a surgical resection of the offending lesions that resulted in return to normal function. CONCLUSIONS: Maffucci syndrome is a rare condition; however, in affected patients the possibility of structural spinal abnormalities causing cord compression must be considered, as discrete surgical resection can result in a good outcome.

Sub-grouping patients with non-specific low back pain based on cluster analysis of discriminatory clinical items.

OBJECTIVE: To identify potential subgroups amongst patients with non-specific low back pain based on a consensus list of potentially discriminatory examination items. DESIGN: Exploratory study. PARTICIPANTS: A convenience sample of 106 patients with non-specific low back pain (43 males, 63 females, mean age 36 years, standard deviation 15.9 years) and 7 physiotherapists. METHODS: Based on 3 focus groups and a two-round Delphi involving 23 health professionals and a random stratified sample of 150 physiotherapists, respectively, a comprehensive examination list comprising the most "discriminatory" items was compiled. Following reliability analysis, the most reliable clinical items were assessed with a sample of patients with non-specific low back pain. K-means cluster analysis was conducted for 2-, 3- and 4-cluster options to explore for meaningful homogenous subgroups. RESULTS: The most clinically meaningful cluster was a two-subgroup option, comprising a small group (n = 24) with more severe clinical presentation (i.e. more widespread pain, functional and sleeping problems, other symptoms, increased investigations undertaken, more severe clinical signs, etc.) and a larger less dysfunctional group (n = 80). CONCLUSION: A number of potentially discriminatory clinical items were identified by health professionals and sub-classified, based on a sample of patients with non-specific low back pain, into two subgroups. However, further work is needed to validate this classification process.