How do information and physiotherapy affect health-related quality of life among patients with spinal stenosis undergoing decompression surgery: A qualitative study.

BACKGROUND: There is a lack of qualitative research on how patients with lumbar spinal stenosis (LSS) undergoing surgery perceive their health-related quality of life (HRQOL). Research that increases our understanding in this area could facilitate a biopsychosocial approach to care. AIM: We aimed to investigate the experiences of patients with LSS undergoing decompression surgery regarding their pre- and post-surgery perceptions of HRQOL and the pre-and post-operative information and physiotherapy. METHOD: We used a qualitative design with semi-structured interviews to perform content analysis using an inductive approach. Twelve patients (7 female, 5 male) were included post-surgery and interviewed by phone. The interviews were recorded and transcribed verbatim. RESULTS: Four distinct categories with nine associated subcategories were identified: Patients' feelings of safety and empowerment are enhanced by healthcare professionals; Divided perceptions of information and physiotherapy in a group context; Health-related quality of life is associated with patients' perceived physical capacity; Patients' optimism and concerns influence health-related quality of life. CONCLUSION: Both physical and psychological factors pre- and post-surgery appear to influence patients' HRQOL. Inherent optimism and feelings of empowerment in the care process appear to be important factors, regardless of physical health status. A strong patient-provider relationship is important to promote self-efficacy, which may positively affect perceived HRQOL and is in line with the generally recommended biopsychosocial approach in the treatment of people with low back pain. As qualitative studies in this area are scarce, there is a need for further studies to validate our findings.

Factors associated with the Single Leg Squat test in female soccer players: a cross-sectional study.

BACKGROUND: The Single Leg Squat (SLS) test is widely used in the clinical setting to examine and evaluate rehabilitation goals. It is simple to perform and is proposed to have biomechanical and neuromuscular similarities to athletic movements. The aim of the present study was to investigate whether demographics, previous injuries, and biomechanical and psychosocial factors are associated with the outcome of the SLS, assessed as a total score for all segments and as a separate knee segment in elite and sub-elite female soccer players. METHODS: We conducted a cross-sectional study involving 254 female soccer players (22 yrs; SD ± 4, height 1.69 m; SD ± 0.1, weight 64 kg; SD ± 6) from divisions 1-3 of the Swedish Soccer League. During the preseason, we assessed the participants using the SLS and tested their hip strength and ankle mobility. Demographics, previous injury, sleep quality, fear of movement, anxiety, and perceived stress were assessed with questionnaires. Logistic regression models were built to analyse the association between the outcome of the SLS and the independent variables for the dominant and non-dominant leg. RESULTS: Significantly more participants failed the SLS on the dominant leg compared with the non-dominant leg (p < 0.001). The outcome of the SLS associated with various biopsychosocial factors depending on if the dominant or non-dominant leg was tested. The total score associated with hip strength for the dominant (OR 0.99, 95% CI 0.98-0.99, p = 0.04) and the non-dominant leg (OR 0.99, 95% CI 0.97-0.99, p = 0.03). The knee segment associated with division level for the dominant (div 2; OR 2.34, 95% CI 1.01-5.12, p = 0.033. div 3; OR 3.07, 95% CI 1.61-5.85, p = 0.001) and non-dominant leg (div 2; OR 3.30, 95% CI 1.33-8.00, p = 0.01. div 3; OR 3.05, 95% CI 1.44-6.43, p = 0.003). CONCLUSIONS: This study identified that leg dominance, division level, hip strength, and psychosocial factors were associated with the outcome of the SLS when assessed as a total score and as a separate knee segment. This indicates that clinicians need to understand that movement control is associated with factors from several domains. Whether these factors and, the results of the SLS are related to injury need to be studied prospectively. TRIAL REGISTRATION: Clinical Trials Gov, date of registration 2022-03-01. CLINICAL TRIALS IDENTIFIER: NCT05289284A.

Summarizing the effects of different exercise types in chronic neck pain - a systematic review and meta-analysis of systematic reviews.

BACKGROUND: To date, no consensus exists as to whether one exercise type is more effective than another in chronic neck pain. This systematic review and meta-analysis of systematic reviews aimed to summarize the literature on the effect of various exercise types used in chronic neck pain and to assess the certainty of the evidence. METHODS: We searched the databases Ovid MEDLINE, Embase, Cochrane Library, SportDiscus, and Web of Science (Core Collection) for systematic reviews and meta-analyses on adults between 18 and 70 years with chronic neck pain lasting ≥ 12 weeks which investigated the effects of exercises on pain and disability. The included reviews were grouped into motor control exercise (MCE), Pilates exercises, resistance training, traditional Chinese exercise (TCE), and yoga. Study quality was assessed with AMSTAR-2 and the level of certainty for the effects of the exercise through GRADE. A narrative analysis of the results was performed and in addition, meta-analyses when feasible. RESULTS: Our database search resulted in 1,794 systematic reviews. We included 25 systematic reviews and meta-analyses including 17,321 participants (overlap not accounted for). The quality of the included reviews ranged from critically low to low (n = 13) to moderate to high (n = 12). We found low to high certainty of evidence that MCE, Pilates exercises, resistance training, TCE, and yoga have short-term positive effects on pain and that all exercise types except resistance training, show positive effects on disability compared to non-exercise controls. We found low to moderate certainty of evidence for conflicting results on pain and disability when the exercise types were compared to other exercise interventions in the short-term as well as in intermediate/long-term apart for yoga, as no long-term results were available. CONCLUSION: Overall, our findings show low to high certainty of evidence for positive effects on pain and disability of the various exercise types used in chronic neck pain compared to non-exercise interventions, at least in the short-term. Based on our results, no optimal exercise intervention for patients with chronic neck pain can be recommended, since no large differences between the exercise types were shown here. Because the quality of the included systematic reviews varied greatly, future systematic reviews need to increase their methodological quality. TRIAL REGISTRATION: Prospero CRD42022336014.

The Swedish version of the STarT MSK Tool: cross-cultural adaption, test-retest reliability, and aspects of validity.

BACKGROUND: Musculoskeletal disorders (MSDs) are a common reason for seeking primary health care. The STarT Musculoskeletal (MSK) tool is designed to stratify patients suffering from MSDs to risk groups, based on prognostic factors. AIM: The aim was to translate and cross-culturally adapt the STarT MSK tool in a Swedish primary health care context through testing of reliability and construct validity. METHODS: We included consecutive patients with MSDs seeking primary care (n = 99). The STarT MSK was translated using international recommendations. Construct validity was investigated by correlation analysis (Spearmans Rho) with the following reference instruments: the Örebro Musculoskeletal Pain Questionnaire (ÖMPQ), the EuroQol 5-dimension (EQ-5D) and the Musculoskeletal Health Questionnaire (MSKHQ). Reliability was tested using test-retest (Intra Class Correlation, ICC2.1) (n = 31). Known-groups validity was calculated with a difference of 10% between risk groups based on how the participants had answered. RESULTS: The STarT MSK was successfully translated into Swedish. The participants were grouped into low risk (n = 28), medium risk (n = 60) and high risk (n = 11). The construct validity showed a moderate to high correlation with the ÖMPQ (r = .61), EQ-5D (r = .59) and MSK-HQ (r = .56). All separate items except item 2 and 9 correlated according to predefined hypotheses. Test-retest demonstrated an excellent reliability for the total score (ICC2.1 0.85) (n = 31). The STarT MSK tool was able to differentiate by 10% between the risk groups, based on how the participants had answered. CONCLUSION: The STarT MSK has been successfully translated and adapted into Swedish and shows acceptable measurement properties regarding test-retest reliability and aspects of validity and seems to be able to discriminate between the proposed risk groups. The tool can therefore be useful in a Swedish primary health care context. A future study needs to determine the tools predictive validity and to investigate if stratification to risk groups leads to a faster recovery and to lower health care costs.

Coaches' experiences of injury prevention in youth elite athletes: An interview study of 10 coaches.

INTRODUCTION: Injury prevention is important to reduce the high injury risk in youth elite athletes studying at sports high schools. Coaches are considered important in youth elite sports and injury prevention. OBJECTIVES: The aim was to investigate perceptions and experiences of injury prevention among coaches at sports high schools. METHODS: A manifest qualitative content analysis with an inductive approach was used based on ten semi-structured interviews with coaches who work at sports high schools. RESULTS: An overarching theme "Coaches of youth athletes value injury prevention but have limited knowledge and support" was identified and five main categories were formed. Coaches perceived themselves to play an important role in injury prevention, yet they described limited time for knowledge acquisition and highlighted the close collaboration with other professions as a key in injury prevention. CONCLUSION: A coach's knowledge and support are critical factors in injury prevention of youth elite athletes. Evidence-based as well as non-evidence-based approaches are used, and the biopsychosocial perspective was not always taken into consideration. A need for more interprofessional collaboration and knowledge acquisition regarding injury prevention is warranted.

The Swedish version of the Lumbar Spine Instability Questionnaire: A clinimetric study of validity and reliability.

INTRODUCTION: The Lumbar Spine Instability Questionnaire (LSIQ) is a patient-reported outcome measure (PROM) suggested to measure clinical instability of the spine. OBJECTIVE: The aim was to translate and cross-culturally adapt the LSIQ into Swedish and to test its measurement properties. METHODS: We included people with low back pain (LBP) seeking primary care (n = 101). The LSIQ was translated using international recommendations. Construct validity was investigated via the Roland Morris Disability Questionnaire (RM) and the Numeric Pain Rating Scale (NPRS). Reliability was tested via test-retest (Intra Class Correlation, ICC2.1) (n = 50) and by analyzing internal consistency (Cronbach Alpha). A suggested cutoff score was used to study discriminative ability. RESULTS: The LSIQ was successfully translated into Swedish. For construct validity, a moderate correlation was shown with the RM (rho 0.58) and the NPRS (rho 0.47). Test-retest demonstrated high reliability for the total score (ICC2.1 0.94, 95% CI 0.86-0.96). Internal consistency reached a Cronbach Alpha of 0.64. Participants scoring higher on the LSIQ (≥9) showed significantly higher pain and lower disability levels, were of higher age and less physically active. CONCLUSION: The Swedish LSIQ shows acceptable measurement properties regarding test-retest reliability and validity. To further study the usefulness of the LSIQ and the suggested cutoff score, the dimensionality needs to be investigated.

A comparison of health-related factors between patients diagnosed with ME/CFS and patients with a related symptom picture but no ME/CFS diagnosis: a cross-sectional exploratory study.

BACKGROUND: In chronic fatigue syndrome/myalgic encephalomyelitis (ME/CFS), the capacity for activity and participation is strongly limited. The disease definition is very broad, and considering the lack of evidence for best treatment, it is important to understand what is ME/CFS-specific in the biopsychosocial perspective in comparison with similar syndromes. The objective was to study the difference between those diagnosed with ME/CFS and those with similar symptoms but no ME/CFS diagnosis for self-perceived level of physical activity, work ability, anxiety/depression, and health-related quality of life. METHODS: This was a clinical cross-sectional study with data collected from mailed questionnaires. The following variables were compared between patients diagnosed with ME/CFS (n = 205) and those with similar symptoms but no diagnosis (n = 57); level of physical activity, Work ability index (WAI), Hospital anxiety and depression scale (HAD-A/HAD-D), and RAND-36 Physical functioning, Role limitations due to physical health problems, Role limitations due to personal or emotional problems, Social functioning, Energy/fatigue, Bodily pain, Emotional well-being, and General health perceptions. The Chi-squared test (nominal data), the Mann-Whitney U test, the Student's t test and regression analysis were used to analyze the data. RESULTS: The group diagnosed with ME/CFS had a more impaired physical and mental exertion ability as compared to the group that had similar symptoms but was not diagnosed with ME/CFS, shown by a RAND-36 lower index of physical role functioning, social functioning, energy, worse pain and poorer overall health (p ≤ 0.05). In contrast, no significant group differences emerged for weekly level of physical activity, work ability, anxiety/depression, and RAND-36 Emotional role limitation and well-being. CONCLUSION: Our results indicate that those with a diagnosis of ME/CFS are characterized by an impaired ability for physical or mental exertion, worse pain, and poorer overall health as compared to individuals with similar symptoms but for whom ME/CFS-diagnosis was not established. The results may be cautiously interpreted as support when focusing on patients' self-care in terms of management of energy levels. The results must however be verified in future studies.

The Significance of Pain Drawing as a Screening Tool for Cervicogenic Headache and Associated Symptoms in Chronic Fatigue.

Purpose: Patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) present with a broad spectrum of symptoms, including headache. A simple, yet powerful tool - the pain drawing identifies essential aspects such as pain distribution. The aim with this study was to 1) evaluate the significance of pain drawing as a screening tool for cervicogenic headache using a predefined C2 pain pattern, 2) assess whether there was an association between dizziness/imbalance and a C2 pain pattern, and 3) compare subgroups according to the pain drawing with respect to pain characteristics and quality of life. Patients and Methods: Pain drawings and clinical data from 275 patients investigated for ME/CFS were stratified into: 1) cervicogenic headache as determined by a C2 pain pattern, 2) headache with no C2 pain pattern, and 3) no headache. For inference logistic regression presented with odds ratios (OR) and 95% confidence intervals (95% CI) and Kruskal-Wallis test were applied. Results: One hundred sixteen participants (42%) were stratified to the group for which the pain drawing corresponded to the C2 pain pattern, thus indicating putative cervicogenic origin of the headache. Dizziness/imbalance was strongly associated with a C2 pain pattern; OR 6.50 ([95% CI 2.42-17.40] p ˂ 0.00), whereas this association was non-significant for patients with headache and no C2 pain pattern. Those demonstrating a C2 pain pattern reported significantly higher pain intensity (p = 0.00) and greater pain extent (p = 0.00) than the other groups, and lower health-related quality of life (p = 0.00) than the group with no headache. Conclusion: For patients with chronic fatigue who present with a C2 pain pattern (interpreted as cervicogenic headache) the pain drawing seems applicable as a screening tool for signs associated with neuropathic and more severe pain, dizziness and reduced quality of life as detection of these symptoms is essential for targeted treatment.

Summarizing the effects of different exercise types in chronic low back pain - a systematic review of systematic reviews.

BACKGROUND: In chronic LBP (CLBP), guideline-endorsed treatment is to stay active, return to normal activity, and to exercise. Several reviews on various exercise types used in CLBP have been published. We aimed to identify systematic reviews of common exercise types used in CLBP, to appraise their quality, and to summarize and compare their effect on pain and disability. METHODS: We searched the databases OVID MEDLINE, EMBASE, COCHRANE LIBRARY, and WEB OF SCIENCE (Core collection) for systematic reviews and meta-analyses on adults between 18 and 70 years of age suffering from chronic or recurrent LBP for a period of at least 12 weeks, which investigated the effects of exercises on pain and disability. All searches were conducted without language restriction. The search was performed up until 2022-01-26. The included reviews were grouped into nine exercise types: aerobic training, aquatic exercises, motor control exercises (MCE), resistance training, Pilates, sling exercises, traditional Chinese exercises (TCE), walking, and yoga. The study quality was assessed with AMSTAR-2. For each exercise type, a narrative analysis was performed, and the level of evidence for the effects of exercise was assessed through GRADE. RESULTS: Our database search resulted in 3,475 systematic reviews. Out of the 253 full texts that were screened, we included 45 systematic reviews and meta-analyses. The quality of the included reviews ranged from high to critically low. Due to large heterogeneity, no meta-analyses were performed. We found low-to-moderate evidence of mainly short-term and small beneficial effects on pain and disability for MCE, Pilates, resistance training, TCE, and yoga compared to no or minimal intervention. CONCLUSIONS: Our findings show that the effect of various exercise types used in CLBP on pain and disability varies with no major difference between exercise types. Many of the included systematic reviews were of low-to-moderate quality and based on randomized controlled trials with high risk of bias. The conflicting results seen, undermine the certainty of the results leading to very-low-to-moderate quality of evidence for our results. Future systematic reviews should be of higher quality to minimize waste of resources. TRIAL REGISTRATION: PROSPERO: Reg no 190409 Registration date 01AUG 2020.

Visual assessment of movement quality: a study on intra- and interrater reliability of a multi-segmental single leg squat test.

BACKGROUND: The Single Leg Squat test (SLS) is a common tool used in clinical examination to set and evaluate rehabilitation goals, but there is not one established SLS test used in the clinic. Based on previous scientific findings on the reliability of the SLS test and with a methodological rigorous setup, the aim of the present study was to investigate the intra- and interrater reliability of a standardised multi-segmental SLS test. METHODS: We performed a study of measurement properties to investigate the intra- and interrater reliability of a standardised multi-segmental SLS test including the assessment of the foot, knee, pelvis, and trunk. Novice and experienced physiotherapists rated 65 video recorded SLS tests from 34 test persons. We followed the Quality Appraisal for Reliability Studies checklist. RESULTS: Regardless of the raters experience, the interrater reliability varied between "moderate" for the knee variable (ĸ = 0.41, 95% CI 0.10-0.72) and "almost perfect" for the foot (ĸ = 1.00, 95% CI 1.00-1.00). The intrarater reliability varied between "slight" (pelvic variable; ĸ = 0.17, 95% CI -0.22-0.55) to "almost perfect" (foot variable; ĸ = 1.00, 95% CI 1.00-1.00; trunk variable; ĸ = 0.82, 95% CI 0.66-0.97). A generalised kappa coefficient including the values from all raters and segments reached "moderate" interrater reliability (ĸ = 0.52, 95% CI 0.43-0.61), the corresponding value for the intrarater reliability reached "almost perfect" (ĸ = 0.82, 95% CI 0.77-0.86). CONCLUSIONS: The present study shows a "moderate" interrater reliability and an "almost perfect" intrarater reliability for the variable all segments regardless of the raters experience. Thus, we conclude that the proposed standardised multi-segmental SLS test is reliable enough to be used in an active population.

Do psychological factors affect outcomes in musculoskeletal shoulder disorders? A systematic review.

BACKGROUND: Psychological factors may impact recovery in patients undergoing treatment for shoulder complaints. The aim of this review is to systematically analyse the evidence for the effect of modifiable psychological factors (MPF) on outcome, for patients with musculoskeletal shoulder disorders undergoing conservative or surgical treatment. MPF refers to factors that may change with intervention. METHODS: This is a systematic literature review. Five databases searched (MEDLINE, CINAHL, Cochrane Library, Embase and PsycInfo), for longitudinal studies investigating the influence of MPF on prognosis of patients with shoulder disorders, all diagnoses, undergoing clinical interventions (conservative or surgical). Level of evidence was determined using Scottish Intercollegiate Guidelines Network (SIGN) methodology. Moderate and high quality evidence was included. We extracted all MPF, categorized constructs into the following domains: beliefs (self-efficacy, expectation of recovery), coping (catastrophizing, avoidant coping), and affect (depression, anxiety). We evaluated constructs for its predictive value of at least one outcome. Outcomes were informed by this review. Evidence was classified into three categories: evidence for, inconclusive evidence, and evidence against. RESULTS: Of 1170 references, 40 distinct publications based on 35 datasets were included (intervention type: 20 surgical; 20 conservative). Overall, 22 studies (20 cohort studies and 2 RCTs) were classified as high quality and 18 studies (16 cohort studies, 2 RCTs) were classified as moderate quality. Outcomes reported included pain, disability/function, perceived recovery, physical and mental health, and work status. Based on the review, of the psychological constructs explored, these data would suggest that expectation of recovery, catastrophizing, avoidant coping, depression, and anxiety may predict outcome for patients managed surgically. In patients undergoing conservative intervention the evidence was either against (catastrophizing, depression, anxiety) or inconclusive (self-efficacy, expectation of recovery, avoidant coping) for the predictive value of psychological factors on outcome. CONCLUSIONS: Five constructs were predictive of outcome for surgically managed patients. This suggests that implementing the biopsychosocial approach (i.e., preoperative screening, intervention by a trained clinician) may be advantageous for patients recommended for shoulder surgery,,. The same is not indicated for conservatively managed patients as no conclusive association of MPF with outcomes was noted. The importance of other MPF on outcome requires further investigation.

Are patient reported outcome measures (PROMs) useful in low back pain? Experiences of physiotherapists in primary health care in Sweden.

BACKGROUND: Physiotherapists in primary health care are required to use patient reported outcome measures (PROMs) to manage patients with low back pain (LBP). OBJECTIVE: Our aim was to explore and describe how physiotherapists in primary care managing patients with LBP, experience the use of PROMs with a focus on facilitating and hindering factors. METHODS: We undertook a qualitative study with semi-structured interviews. Fifteen physiotherapists (9 female and 6 male) were included. The interviews were audio-recorded and transcribed verbatim and analysed by inductive manifest content analysis. RESULTS: Our findings resulted in eight main categories: PROMs give structure and increase patient involvement; Patients' motivations to use PROMs; Time and the physiotherapist's clinical priorities; Physiotherapists' routines steer their use of PROMs; Physiotherapists' competences in using PROMs; Organizations and managers steer the use of PROMs; Prerequisites for future use of PROMs; Using PROMs develops the physiotherapy profession. CONCLUSION: Our findings show that using PROMs gives structure and increases patient involvement, but the patient's motivation to use PROMs needs to be taken into consideration. Time and routines influence the use of PROMs and these factors depend on organizational and managerial levels. Using PROMs is believed to help develop the physiotherapy profession. Prerequisites for future use, such as digitalization and increased competence, need to be fulfilled. Future studies should focus on increasing physiotherapists' knowledge about relevant PROMs, and study implementation in clinical practice, thereby improving the physiotherapy profession's quality of care.

"How does physical examination findings influence physiotherapists' decision-making when matching treatment to patients with low back pain?"

BACKGROUND: Further clinical data how low-back pain (LBP) symptoms and signs manifests in physiotherapy clinical reasoning and treatment decision-making is needed. OBJECTIVE: The aim was to explore and describe how symptoms and signs portrayed in three case descriptions of LBP influences physiotherapy treatment decision-making. DESIGN: This was an exploratory interview study using inductive content analysis. METHOD: Fifteen semi-structured individual interviews were used to collect data of physiotherapists' treatment decision-making regrading three diverse LBP case descriptions. The participants were men, women, experienced and novice, working in primary healthcare settings in one sparsely populated region and in one larger city in Sweden. FINDINGS: Two overarching themes were identified influencing decision-making for the treatment of LBP:1) Explicit assessment features distinguish treatment approaches; with categories describing how symptoms and signs were used to target treatment (nature of pain induce reflections on plausible cause; narrative details trigger attention and establishes knowledge-enhancing foci; pain-movement-relationship is essential; diverse emphasis of pain modulation and targeted treatment approaches): and 2) Preconceived notion of treatment, with categories describing personal treatment rationales, unrelated to the presented symptoms and signs (passive treatment avoidance and motor control exercise ambiguity). CONCLUSION: This study identifies how assessment details lead to decisions on diverse treatment approaches for LBP, but also that treatment decisions can be based on preconceived beliefs unrelated to the clinical presentation. The results underpin the mix of knowledge sources that clinicians need to balance and the necessity of self-awareness of preconceptions for informed and meaningful clinical decision-making.

The influence of comorbidities on the treatment outcome in symptomatic lumbar spinal stenosis: A systematic review and meta-analysis.

BACKGROUND: Lumbar spinal stenosis (LSS) affects mainly elderly patients. To this day, it is unclear whether comorbidities influence treatment success. The aim of this systematic review and meta-analysis was to assess the impact of comorbidities on the treatment effectiveness in symptomatic LSS. METHODS: We conducted a systematic review and meta-analysis and reviewed prospective or retrospective studies from Medline, Embase, Cochrane Library and CINAHL from inception to May 2020, including adult patients with LSS undergoing surgical or conservative treatment. Main outcomes were satisfaction, functional and symptoms improvement, and adverse events (AE). Proportions of outcomes within two subgroups of a comorbidity were compared with risk ratio (RR) as summary measure. Availability of ≥3 studies for the same subgroup and outcome was required for meta-analysis. RESULTS: Of 72 publications, 51 studies, mostly assessing surgery, there was no evidence reported that patients with comorbidities were less satisfied compared to patients without comorbidities (RR 1.06, 95% confidence interval (CI) 0.77 to 1.45, I 2 94%), but they had an increased risk for AE (RR 1.46, 95% CI 1.06 to 2.01, I 2 72%). A limited number of studies found no influence of comorbidities on functional and symptoms improvement. Older age did not affect satisfaction, symptoms and functional improvement, and AE (age >80 years RR 1.22, 95% CI 0.98 to 1.52, I 2 60%). Diabetes was associated with more AE (RR 1.72, 95% CI 1.19 to 2.47, I 2 58%). CONCLUSION: In patients with LSS and comorbidities (in particular diabetes), a higher risk for AE should be considered in the treatment decision. Older age alone was not associated with an increased risk for AE, less functional and symptoms improvement, and less treatment satisfaction.

Reliability and validity of a novel Kinect-based software program for measuring a single leg squat.

BACKGROUND: The Single leg squat (SLS) is a movement screening test widely used in clinical settings. The SLS is highly subjective in its nature. Objective measures, such as 3D-motion analyses, are seldom used in daily clinical work. An interactive, Kinect-based 3D-movement analysis system, the Qinematic™, is proposed to be easily used in clinical settings to assess the SLS. The aim of this study was to establish the test-retest reliability and construct validity of Qinematic™ for assessing the SLS. A further aim was to identify angles of medial knee displacement, to summarise the discriminative ability of the SLS measured by Qinematic™. METHODS: We performed a test-retest reliability study (n = 37) of the SLS using Qinematic™ and a construct validity study, in which Qinematic™ data were compared with visual assessment of video-recorded SLS. RESULTS: Three variables (left knee down, right knee up and down) reached "substantial reliability" (ICC = 0.64-0.69). One variable, "left knee up", showed a significant difference between the two test occasions (T1-6.34°, T2 0.66°, p = 0.013, ICC = 0.50), and "poor absolute reliability" was seen for all variables (SEM = 9.04-10.66, SDC = 25.06-29.55). A moderate agreement between the visual assessment and Qinematic™ data for various knee angles was shown (Kappa = 0.45-0.58). The best discriminative ability of the SLS was found at a knee angle of 6° (AUC = 0.82, sensitivity = 0.86, specificity = 0.78, PPV = 0.58, NPV = 0.94). CONCLUSIONS: Qinematic™ shows a poor absolute reliability, and a substantial relative reliability, in measuring a SLS at the way down. This indicates that Qinematic™ should not be recommended for the use on an individual level, but it can possibly be used on a group level. The merged results of the construct validity study indicate that Qinematic™ at 6° of medial displacement can identify subjects with a knee over foot position. In summary, the use of the Qinematic™ net trajectory angle, which estimates the "line of best fit" cannot be recommended to assess a knee medial to foot position and should be reconsidered.

Cross-cultural adaption and validation of the Swedish version of the Core Outcome Measures Index for low-back pain.

PURPOSE: There is a wide selection of instruments and questionnaires available, but many are time consuming in their administration, for patients, practitioners and researchers alike. The Core Outcome Measures Index (COMI) is a short, self-administrated, multidimensional instrument translated into several languages that covers five domains recommended in the assessment of outcome in patients with low-back pain. The purpose of this study was to cross-culturally adapt the COMI from English to Swedish and to test the face and construct validity and reproducibility of its results in patients with low-back pain. METHODS: Participants (n = 102) were included from primary and secondary care. The participants reported moderate pain and disability levels. All participants filled in the COMI, the Oswestry Disability Index and the EQ5D at baseline. Forty-nine filled in the COMI again after 7 days for the reproducibility part of the study. RESULTS: The instrument was successfully forward and back-translated. In the validation process, there were low floor/ceiling effects, with the exception of the symptom-specific well-being (floor) and work disability (ceiling) items. The specific COMI domains and whole score correlated significantly with the chosen reference scale scores to the hypothesised extent (Rho 0.30-0.60 and > 0.60 respectively). COMI reached ICC 0.63 (95% CI 0.42-0.77) in the reproducibility test and the separate items, ICC 0.41-0.78. CONCLUSIONS: The Swedish COMI shows acceptable psychometric properties and is thus suitable to use as a short instrument for measuring important domains in patients with low-back pain. A future study should investigate the instrument's sensitivity to measure change after treatment. These slides can be retrieved under Electronic Supplementary Material.

Low Back Pain in the Emergency Department: Prevalence of Serious Spinal Pathologies and Diagnostic Accuracy of Red Flags.

BACKGROUND: Very little evidence is available on the prevalence of serious spinal pathologies and the diagnostic accuracy of red flags in patients presenting to the emergency department (ED). This systematic review aims to investigate the prevalence of serious spinal pathologies and the diagnostic accuracy of red flags in patients presenting with low back pain to the ED. METHODS: We systematically searched MEDLINE, PUBMED, EMBASE, Cochrane Library, and SCOPUS from inception to January 2019. Two reviewers independently reviewed the references and evaluated methodological quality. RESULTS: We analyzed 22 studies with a total of 41,320 patients. The prevalence of any requiring immediate/urgent treatment was 2.5%-5.1% in prospective and 0.7%-7.4% in retrospective studies (0.0%-7.2% for vertebral fractures, 0.0%-2.1% for spinal cancer, 0.0%-1.9% for infectious disorders, 0.1%-1.9% for pathologies with spinal cord/cauda equina compression, 0.0%-0.9% for vascular pathologies). Examples of red flags which increased the likelihood for a serious condition were suspicion or history of cancer (spinal cancer); intravenous drug use, indwelling vascular catheter, and other infection site (epidural abscess). CONCLUSION: We found a higher prevalence of serious spinal pathologies in the ED compared to the reported prevalence in primary care settings. As the diagnostic accuracy of most red flags was reported only by a single study, further validation in high-quality prospective studies is needed.

Exercise treatment effect modifiers in persistent low back pain: an individual participant data meta-analysis of 3514 participants from 27 randomised controlled trials.

BACKGROUND: Low back pain is one of the leading causes of disability worldwide. Exercise therapy is widely recommended to treat persistent non-specific low back pain. While evidence suggests exercise is, on average, moderately effective, there remains uncertainty about which individuals might benefit the most from exercise. METHODS: In parallel with a Cochrane review update, we requested individual participant data (IPD) from high-quality randomised clinical trials of adults with our two primary outcomes of interest, pain and functional limitations, and calculated global recovery. We compiled a master data set including baseline participant characteristics, exercise and comparison characteristics, and outcomes at short-term, moderate-term and long-term follow-up. We conducted descriptive analyses and one-stage IPD meta-analysis using multilevel mixed-effects regression of the overall treatment effect and prespecified potential treatment effect modifiers. RESULTS: We received IPD for 27 trials (3514 participants). For studies included in this analysis, compared with no treatment/usual care, exercise therapy on average reduced pain (mean effect/100 (95% CI) -10.7 (-14.1 to -7.4)), a result compatible with a clinically important 20% smallest worthwhile effect. Exercise therapy reduced functional limitations with a clinically important 23% improvement (mean effect/100 (95% CI) -10.2 (-13.2 to -7.3)) at short-term follow-up. Not having heavy physical demands at work and medication use for low back pain were potential treatment effect modifiers-these were associated with superior exercise outcomes relative to non-exercise comparisons. Lower body mass index was also associated with better outcomes in exercise compared with no treatment/usual care. This study was limited by inconsistent availability and measurement of participant characteristics. CONCLUSIONS: This study provides potentially useful information to help treat patients and design future studies of exercise interventions that are better matched to specific subgroups. PROTOCOL PUBLICATION: https://doi.org/10.1186/2046-4053-1-64.

Visual assessment of movement quality in the single leg squat test: a review and meta-analysis of inter-rater and intrarater reliability.

Single leg squat (SLS) is a common tool used in clinical examination to set and evaluate rehabilitation goals, but also to assess lower extremity function in active people. OBJECTIVES: To conduct a review and meta-analysis on the inter-rater and intrarater reliability of the SLS, including the lateral step-down (LSD) and forward step-down (FSD) tests. DESIGN: Review with meta-analysis. DATA SOURCES: CINAHL, Cochrane Library, Embase, Medline (OVID) and Web of Science was searched up until December 2018. ELIGIBILITY CRITERIA: Studies were eligible for inclusion if they were methodological studies which assessed the inter-rater and/or intrarater reliability of the SLS, FSD and LSD through observation of movement quality. RESULTS: Thirty-one studies were included. The reliability varied largely between studies (inter-rater: kappa/intraclass correlation coefficients (ICC) = 0.00-0.95; intrarater: kappa/ICC = 0.13-1.00), but most of the studies reached 'moderate' measures of agreement. The pooled results of ICC/kappa showed a 'moderate' agreement for inter-rater reliability, 0.58 (95% CI 0.50 to 0.65), and a 'substantial' agreement for intrarater reliability, 0.68 (95% CI 0.60 to 0.74). Subgroup analyses showed a higher pooled agreement for inter-rater reliability of ≤3-point rating scales while no difference was found for different numbers of segmental assessments. CONCLUSION: Our findings indicate that the SLS test including the FSD and LSD tests can be suitable for clinical use regardless of number of observed segments and particularly with a ≤3-point rating scale. Since most of the included studies were affected with some form of methodological bias, our findings must be interpreted with caution.PROSPERO registration numberCRD42018077822.

Aspects influencing clinical reasoning and decision-making when matching treatment to patients with low back pain in primary healthcare.

BACKGROUND: It is unclear how physiotherapists match treatment to patients with low-back pain (LBP) in primary healthcare. A further exploration of physiotherapists' perspective of matching treatments to the individual patient in this setting is needed. OBJECTIVE: The aim of this study was to explore and describe aspects influencing physiotherapists' clinical reasoning in the decision-making on individualized treatment of LBP in primary healthcare. DESIGN: This was an explorative study using qualitative content analysis. METHOD: Fifteen semi-structured individual interviews were conducted with physiotherapists, men and women, experienced and novice, working in primary healthcare settings in one sparsely populated region and in one larger city in Sweden. FINDINGS: Two overarching themes were identified influencing decision-making for individualized treatment of LBP: 1) Matching requires differentiation and adaptation, with categories describing specific patient characteristics, assessment findings and treatment adaptations (classification of pain and bodily findings; patient physical capacity and emotions; patient awareness and motivation; treatment combinations and atypical treatment rationales): and 2) The tension between trust and barriers; with categories describing aspects of physiotherapists' convictions, constraints and working environment (confidence in treatments and oneself; physiotherapists' terms overrule patients' preferences; personal constraints and workplace approach and priorities). CONCLUSION: This study describes aspects of the patients, the physiotherapists and their workplaces that influence decisions for individualized treatment of LBP. The findings underpin the need for clinician self-reflection, initiatives for skilled clinical competence and the weight clinician observations carry on the complex treatment selection process which need to be appreciated when implementing evidence-based recommendations in clinical practice.