International Framework for Examination of the Cervical Region for Potential of Vascular Pathologies of the Neck Prior to Musculoskeletal Intervention: International IFOMPT Cervical Framework

Implementation of the International IFOMPT Cervical Framework: A survey among IFOMPT organisations

BACKGROUND

The IFOMPT (International Federation of Orthopaedic Manual and Musculoskeletal Physical Therapists) Cervical Framework was first published in 2012 and reviewed in 2020. The document was a result of the IFOMPT Member Organisations' (MO) request for consistency and guidance regarding teaching and practice of safe assessment and management of individuals with neck and head pain and dysfunction.

OBJECTIVE

To evaluate the knowledge, dissemination, and implementation of the 2020 IFOMPT Cervical Framework by MOs.

METHODS

An international survey with closed- and open-ended questions was conducted among all IFOMPT MOs. Formal informed consent was requested, and data were collected anonymously.

RESULTS

Twenty-five of 42 invited organisations completed the survey. Respondents reported that the Framework was extensively disseminated to both members (100%) and educational programs (92%). 52% provided recommendations regarding implementation in the own country while only 12.5% towards educational programs. Five representatives (20%) reported having designed an information sheet for patients about cervical musculoskeletal interventions safety, mainly for thrust manipulation (84.3%) but none for exercise (0%). End-range thrust manipulation remains rarely recommended, especially for the upper cervical spine (8.7%).

CONCLUSIONS

The dissemination of the new IFOMPT Cervical Framework among members and educational programs was successful. However, only marginal recommendations were provided by the MOs/AMOs/RIGs regarding implementation of the Framework. Moreover, improvement is possible regarding providing information to patients and the Frameworks' recommendation to avoid end range treatment techniques.

Understanding degenerative cervical myelopathy in musculoskeletal practice

BACKGROUND

Degenerative cervical myelopathy (DCM) is a clinical syndrome characterized by a progressive compression of the spinal cord. DCM often looks like common symptoms of aging or bilateral carpal tunnel syndrome in its early stages, requiring careful differential diagnosis. Identifying DCM is a real challenge as no validated screening tools are available for making the DCM diagnosis. Potentially, individuals with DCM may experience misdiagnosis or substantial diagnostic delays, with an enhanced risk of irreversible neurological consequences if not promptly addressed. Despite the increasing prevalence, there is a lack of awareness about DCM among both the public and healthcare professionals. However, patients may seek physiotherapy to obtain a diagnosis or access treatment.

METHODS

A comprehensive (non-systematic) review of the literature about DCM epidemiology, pathophysiology, clinical presentation, diagnostic methods, and management was conducted.

RESULTS

A guide and essential knowledge to facilitate clinicians to understand DCM and to enhance clinical reasoning skills, performance and interpretation of the examination are provided. Interdisciplinary collaboration and optimal referral methods are also handled.

CONCLUSION

The aim of this article is to summarize and enhance physiotherapists' essential knowledge of the differential diagnosis and management of patients with DCM.

German translation, transcultural adaptation and test-retest reliability of the headache screening questionnaire

INTRODUCTION

Tension-type headache (TTH) and migraines are frequent headache types. For appropriate treatment, physiotherapists need to be able to recognize these two headache types. The Dutch Headache Screening Questionnaire (HSQ-DV) is the only screening questionnaire designed specifically for migraines and TTH, based on the latest International Classification of Headache Disorders and supporting evidence. The aim of this study is to translate the HSQ-DV into German and evaluate its test-retest reliability.

METHODS

A cross-sectional and prospective cohort study was conducted to answer the research questions. The HSQ-DV was translated according to the COMSIN checklist for patient-reported outcome measurement instruments. Test-retest reliability was assessed with a retest after two weeks. Weighted kappa values, intraclass-correlation coefficients (ICCs) and standard error of the measurements (SEMs) were calculated separately for migraines and THH, based on point scale ranging from 0 to 8.

RESULTS

The HSQ-DV was translated and culturally adapted into German. An introductory clarification was added to guide participants with multiple headaches, which headache type to consider. Sixty-one subjects were included in the reliability study. For migraine, the weighted kappa was 0.70 (95% Confidence Interval (CI) 0.52 to 0.87), the ICC was 0.84 (95% CI: 0.71 to 0.91), and the SEM was 0.39 points. For TTH, the weighted kappa was 0.73 (95% CI: 0.57 to 0.90), the ICC was 0.85 (95% CI: 0.74 to 0.92), and the SEM was 0.29 points.

CONCLUSION

The HSQ-GV is a reliable screening questionnaire for migraines and TTH in physiotherapy settings, demonstrating substantial to nearly perfect reliability.

Standardized Definition of Red Flags in Musculoskeletal Care: A Comprehensive Review of Clinical Practice Guidelines

Background and Objectives: The aging population and the COVID-19 pandemic have led to a rise in severe conditions, including musculoskeletal (MSK) disorders. Although MSK conditions are often managed in primary care, they may sometimes mask serious illnesses requiring urgent diagnosis. The red flag (RF) concept is essential for identifying signs and symptoms of potentially severe disease. However, RF criteria vary across clinical guidelines and lack consistency. With the growing role of direct access to physiotherapy-bypassing physician referral-physiotherapists must develop strong differential diagnostic skills to identify serious pathologies that mimic MSK disorders. This review aims to systematically map how RFs are defined in MSK clinical practice guidelines (CPGs), supporting the move toward a standardized definition for clinical and research use. Materials and Methods: A comprehensive literature search was conducted in PubMed, Web of Science, Scopus, and Cochrane databases. Included studies were CPGs and systematic reviews (SRs) of CPGs addressing MSK disorders and incorporating the RF concept. Data extraction followed a rigorous process, and RF definitions were synthesized and compared in table format. Results: Out of thirteen-thousand three-hundred and ninety-three articles identified, fourteen met inclusion criteria (seven CPGs and seven SRs of CPGs), spanning both physiotherapy and medical fields. All definitions described RFs as signs or symptoms indicating possible serious pathology requiring further investigation or referral. Some definitions referred broadly to "patterns of signs or symptoms", while others offered more precise criteria. Conclusions: This review highlights the lack of a standardized RF definition in MSK care, leading to inconsistencies in clinical decision-making and diagnosis. To improve patient safety and guide clinicians-especially in direct-access contexts-a unified, internationally recognized definition of RFs is needed in future guidelines.

Establishing the Neck Disability Index as a Valid Tool for Assessing Persistent Neck Pain in the Albanian Population

Background and Objectives: The Neck Disability Index (NDI) is one of the most widely used instruments for assessing self-reported neck-related functional limitations. However, a validated Albanian version has not previously existed, limiting its application in Albanian-speaking populations. This study aimed to translate, culturally adapt, and evaluate the psychometric properties of the Albanian version of the NDI (ANDI), focusing on its reliability and internal consistency. Materials and Methods: A standard forward-backward translation methodology was used to develop the Albanian version of the NDI, followed by cultural adaptation. A total of 83 participants with neck pain completed the ANDI at two time points, three days apart. Test-retest reliability was assessed using the intraclass correlation coefficient (ICC), while internal consistency was evaluated using Cronbach's alpha and the item-total correlation (ITC). Results: The ICC values for all 10 sections of the ANDI ranged from 0.95 to 0.99, indicating excellent test-retest reliability. The highest reliability was observed in (personal care) and (pain intensity) with ICCs of 0.99 and 0.98, respectively. All sections demonstrated strong internal consistency, with ITC values ranging from 0.91 to 0.98 and a Cronbach's alpha of 0.96. Mean scores between test sessions showed negligible variation, further confirming score stability. Conclusions: The Albanian version of the NDI demonstrated excellent reliability and internal consistency, confirming its validity for use in clinical and research settings. This represents the first validated neck disability assessment tool for the Albanian-speaking population, supporting more inclusive musculoskeletal health assessment.

Optimizing safety in conservative physical management of the cervical spine: A modified Delphi study

BACKGROUND

Conservative cervical spine treatment is generally safe, but serious adverse events (SAEs) still occur despite various available clinical guidelines. There have been several challenges in understanding the specific circumstances of these events to direct prevention such as inconsistent reporting, misuse of professional titles, and incomplete data. There are also differences in opinions between professions. It is now important to understand expert views and consensus across professions regarding prevention strategies and minimum requirements for reporting standards for future SAEs.

METHODS

A modified Delphi method was used, involving 28 international experts from various allied health professions, including chiropractic, physiotherapy, osteopathy, and medicolegal fields. The experts took part in three rounds of online surveys to reach a consensus on reporting, characteristics, risk factors, and prevention of SAEs associated with neck treatments. An agreement of >74 % was required before consensus was reached.

RESULTS

Consensus was reached for more standardised reporting of SAEs across different types of treatments and professions. Addressing underlying health conditions and improving the recognition of potential risks, precautions, and contraindications during treatment were highlighted. Recommendations for strategies to improve safety, including early identification of risk factors and careful application of techniques, especially in vulnerable populations were also provided.

CONCLUSION

Experts called for the development of universally accepted clinician friendly clinical guidelines that focus on improving SAE reporting, early identification of SAEs, and safer technique application, particularly in special populations. Implementing these recommendations will help reduce the occurrence of SAEs and improve the safety of conservative cervical spine management across professions.

Signs and symptoms of vertebrobasilar insufficiency secondary to atherosclerosis: a systematic review

CONTEXT

Clinicians face a difficult challenge in identifying vertebrobasilar insufficiency (VBI) resulting from atherosclerosis. VBI is a term utilized to describe a reduction in blood flow to the vertebral and basilar arteries that supply the posterior cerebral system. For musculoskeletal clinicians, diagnostic differentiation of VBI is essential, because its presence directly impacts the clinical use of manual treatment interventions. Clinical guidelines provide a set of cardinal symptoms (inclusive of Coman's 5D's) in which VBI may manifest, the accuracy of which is under contestation because literature provides evidence suggesting a wider set of symptoms.

OBJECTIVES

The objectives of this study were to gather all relevant literature reporting features of VBI pertaining to atherosclerosis, with the aim to help provide evidence that may guide clinical practice in the use of manual therapy interventions and to raise awareness of the manifestations that VBI may present.

METHODS

Six databases were searched from inception to September 2024 (Allied and Alternative Medicine Database [AMED], AgeLine, SPORTDiscus, Medical Literature Analysis and Retrieval System Online [MEDLINE], Cochrane, and Cumulative Index of Nursing and Allied Health (CINAHL Plus). Articles were screened in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards, The included articles required a diagnosis of VBI through clinical examination with radiological evidence of atherosclerotic lesions, without evidence of existing or previous neurological infarcts, concomitant arterial pathology, or any other form of pathological mechanism. Primary data were extracted utilizing a template, and the methodological quality was assessed utilizing the Joanna Briggs Institute critical appraisal tool. Findings were summarized utilizing a narrative synthesis and a table of descriptive statistics.

RESULTS

Two hundred and eighty-three papers were identified, and 15 were included (93 cases, 50M/43F, age 64 years old ± 9 standard deviation [SD] yrs). Vertigo was the most common reported symptom, within a total of 37 different symptoms reported either in isolation or combination. Symptoms inclusive to Coman's 5D's accounted for 22 % of reported features.

CONCLUSIONS

Vertigo is the most common symptom (27.7 %) of VBI induced by atherosclerosis. However, there is not sufficient data to make concrete conclusions, although results do instill doubt over the sole use of Coman's 5D's in clinical practice. Prospective observational studies with standardized data extraction for VBI symptoms and their pattern of behavior are warranted.

Information needs for people with neck pain seeking physiotherapy neck manipulation or mobilization: an exploratory study

OBJECTIVE

To explore the foundational needs for a decision aid on receiving physiotherapy neck manipulation and mobilization from a broad age spectrum.

METHOD

An e-survey was conducted from January to 30 April 2024, targeted child/infant-parent dyads, adolescents, adults, and adult-caretaker dyads with neck pain who received physiotherapy treatment in Canada and the United States. The survey method captured knowledge and attitudes to manual therapy, treatment expectations (10 items from the Treatment Expectation Questionnaire (TEX-Q), decision conflict (Decisional Conflict Scale (DCS)) and participant demographics. Descriptive analyses were used to assess responses.

RESULTS

Out of 146 participants who started the survey, 48 adults (mean age 48) completed it fully. Due to low response rates, the survey lacked insights into adolescent, child/infant-parent, or adult-caretaker dyads. Most respondents were familiar with mobilization (86%) and manipulation (82%). Mobilization was preferred (67%) and viewed more favorably compared to manipulation (7%), which was seen as riskier. Stroke was identified as the top risk/adverse event for techniques and was more commonly associated with manipulation (52%) than mobilization (25%). Other perceived risks included soreness, pain, headache, stiffness, tenderness, dizziness, and fatigue, reported more often for mobilization (57%) than manipulation (41%). The TEX-Q showed that respondents' treatment expectations were largely met, indicating positive expectations. Additionally, low scores on the DCS subscales and total scores (mean 16.26, SD 21.00) reflected minimal decisional conflict among respondents.

CONCLUSION

The study found that adults with neck pain who received physiotherapy involving neck manipulation or mobilization were well informed about the benefits, risks, and potential major and minor adverse events of their treatment. Their expectations for treatment were generally positive, and they experienced minimal decisional conflict. To further support shared decision-making, we recommend adding a qualitative component, such as structured interviews or focus groups with inter-professional child/infant-parent dyads, to help clinicians improve patient counseling and decision-making guidance.

Serious adverse events associated with conservative physical procedures directed towards the cervical spine: A systematic review

BACKGROUND

Previous reviews on serious adverse events (SAEs) following physical interventions involving the neck have focused on vascular SAEs or those related to cervical manipulation.

OBJECTIVE

To review the evidence for all serious adverse events associated with any physical cervical procedures and describe SAE characteristics.

METHODS

Searches were conducted in PubMed, EMBASE, CINAHL, Scopus, Cochrane, Web of Science and Index to Chiropractic Literature from inception to May 2023 for studies reporting characteristics of SAE following any neck intervention and patient demographics.

RESULTS

Two hundred and thirty-three studies describing 334 SAE cases were identified. Forty-one were reported in the last 5 years. The results confirmed findings of past reviews with most events being vascular (58%) and mainly arterial dissection or vertebral artery related and the majority involving manipulation (75%). However lesser-known SAES ie neurological (25%), combined vascular/neurological (12%) and others (5%) which included cases such as cerebrospinal fluid leaks, phrenic nerve palsies and retinal detachments were identified. Further, some followed procedures such as vestibular testing, gentle mobilization, exercises, acupuncture or even massage. Initial symptoms included sharp increases in headache/neck pain, nausea, vomiting, dizziness and altered sensation, during treatment or within 48 h, often preceding neurological signs. Most recovered favourably (62%), 16% with disability, 6% died, the rest were unspecified.

CONCLUSION

Most SAEs were vascular and associated with manipulation but awareness of potential neurological and orthopaedic injuries and other procedures should be raised. Monitoring for early signs of SAEs for up to 48 h post-intervention is advisable if a SAE is suspected.

Recommendations for Mobilization and Manipulation Treatment and Screening for Vascular Complications in Clinical Practice Guidelines for Neck Pain: A Systematic Review

OBJECTIVE

This systematic review aimed to determine the methodological quality of international clinical practice guidelines (CPGs) and the clinical credibility and implementability of recommendations regarding manipulation or mobilization treatment recommendations proposed in CPGs for the management of people with neck pain. A secondary aim of this review was to provide an overview of recommendations for manipulation or mobilization in patients with neck pain. Manipulation or mobilization treatment of patients with neck pain is under debate for its potential risk of serious adverse events. Serious adverse events are rare, but it is the clinicians' responsibility to thoroughly screen patients at risk of vascular complications. A third aim of this review was to describe the extent to which the included guidelines inform clinical practice about screening for the risk of complications due to vascular pathology in the cervical spine.

METHODS

A systematic review of 13 electronic databases and 4 repositories was performed for potentially relevant guidelines published between January 1, 2000 and September 22, 2022. Two reviewers independently appraised eligible guidelines using Appraisal of Guidelines for Research and Evaluation II (AGREE II) and Appraisal of Guidelines for Research and Evaluation: Recommendation EXcellence (AGREE-REX) criteria. A best evidence synthesis was performed, and screening of risk factors was assessed.

RESULTS

A total of 19 CPGs were included, of which 5 were of high quality. All high-quality guidelines recommend the use of manipulation or mobilization, with or without exercise. Eight (42%) guidelines described the screening of risk factors for adverse events. Two (11%) guidelines met the a priori defined criteria for screening and scored present and complete.

CONCLUSION

International CPGs consistently recommend the use of manipulations and mobilizations in the treatment of neck pain. There is a notable absence of recommendations regarding the identification of patients at risk for vascular complications.

IMPACT

The findings of this study allow guideline developers to improve the quality of future neck pain guidelines and consider including vascular screening tools. Furthermore, it proposes recommendations to physical therapists interested in applying manipulations and mobilizations in the treatment of patients with neck pain.

LAY SUMMARY

International clinical practice guidelines consistently recommend the use of manipulations and mobilizations in the treatment of neck pain. There is a notable absence of recommendations regarding identifying patients at risk for vascular complications.

Enhancing Clinical Confidence: Effects of Medical Screening and Differential Diagnosis Training for Low Back Pain

Purpose

Direct access to physical therapy (PT) requires PTs to act as primary care providers, making differential diagnosis a critical component of patient assessment. We investigated how participation in postgraduate training in differential diagnosis and medical screening influences PTs' confidence, self-efficacy, attitudes and beliefs about treating patients with low back pain (LBP).

Patients and Methods

This prospective, two-arm study involved 49 PTs in an intervention group and 70 in a control group. The intervention included 40-hours of training on medical screening and differential diagnosis, focusing on red flags, clinical reasoning and referral pathways, while the control group received no intervention. Clinical confidence, self-efficacy, attitudes and beliefs were measured before, immediately after, and 6-months after training. Outcomes included the Primary Care Confidence Scale (PCCS), which assesses confidence in primary care practice, detection of serious pathology, and medical screening; the Physiotherapy Self-Efficacy (PSE) questionnaire, evaluating clinical self-efficacy in assessing and treating patients with LBP; and the Attitudes to Back Pain Scale for Musculoskeletal Practitioners (ABS-mp), which measures clinicians' attitudes and beliefs about LBP.

Results

The intervention group showed significant immediate improvements in PCCS scores (40.26 ± 5.23 to 45.24 ± 4.20, Cohen's d = 1.08, p < 0.001) and PSE scores (51.06 ± 6.46 to 54.65 ± 5.78, Cohen's d = 0.6, p < 0.001). At six-month, significant interaction effects were observed for PCCS (F = 17.49, Partial η² = 0.131, p < 0.001) and PSE scores (F = 5.87, Partial η² = 0.06, p < 0.05) and PSE scores (55.32 ± 6.09, p < 0.05), with the intervention group maintaining improvements while the control group showed no significant changes. No significant changes were observed in ABS-mp scores.

Conclusion

This study highlights the positive impact of training in medical screening and differential diagnosis on reducing concerns and increasing clinical confidence and self-efficacy.

An overview of systematic reviews investigating clinical features for diagnosing neck pain and its associated disorders

BACKGROUND

Neck pain is a common condition that is often difficult to diagnose. Previous literature has investigated diagnostic accuracy of examination measures, but the strength and clinical applicability are limited. This overview of systematic reviews aimed to investigate clinical features for diagnosing neck pain and its associated disorders.

METHODS

An overview of systematic reviews was conducted searching four electronic databases for systematic reviews evaluating diagnostic criteria for neck pain. Quality and risk of bias were assessed using the AMSTAR 2 and ROBIS. Clinical features for neck pain were investigated for diagnostic utility.

RESULTS

Twenty-seven systematic reviews were included. Hand radiculopathy and numbness have good specificities (0.89-0.92) for facet and uncinate joint hypertrophy. For facet-related dysfunction, the extension rotation test (ERT) and manual assessment have good sensitivities and moderate-good specificities. Positive ERT combined with positive manual assessment findings (+LR = 4.71; Sp = 0.83) improves diagnostic accuracy compared to positive ERT alone (+LR = 2.01; Sp = 0.59). Canadian C-spine Rules and Nexus criteria have excellent validity in screening for cervical fracture or instability. Imaging appears to have validity in diagnosing ligamentous disruption or fractures but lacks clarity on predicting future neck pain. Increased fatty infiltrates have been found with whiplash-associated disorders and mechanical neck pain.

CONCLUSIONS

This review found limited indicators providing strong diagnostic utility for diagnosing neck pain. Strength of recommendations are limited by heterogeneous outcomes, methodology, and classification systems. Future research should investigate new differential diagnostic criteria for specific structures contributing to neck pain.

Validation of a diagnostic support tool for early recognition of cervical arterial dissection in primary care

BACKGROUND

Cervical arterial dissection (CeAD) is a leading cause of stroke in young adults with an early presentation often mimicking musculoskeletal pain. Currently, no validated tests exist and CAD may be missed. A diagnostic support tool could help guide urgent referral for imaging, when to monitor, or when safe to proceed with treatment, and ultimately help stroke prevention.

OBJECTIVES

To validate a 4-criteria diagnostic support tool for early recognition of CeAD in primary care, to refine tool descriptors as needed, and propose optimal cut-offs for clinical application.

DESIGN

Prospective observational study METHOD: Participants with radiologically confirmed CeAD and controls without CeAD were identified from adults >18 years presenting to a tertiary metropolitan hospital with initial diagnosis of headache or neck pain. All were scored with criteria out of7 (acute onset pain [2], recent trauma/infection [1], neurological features [2], age <55 years [2]). Diagnostic values were calculated to determine cut offs and the tool was refined based on the analysis.

RESULTS

Thirty participants with CeAD and 261 controls with non-CeAD causes of headache and neck pain were included. The diagnostic support tool was an 'excellent' predictor of CeAD (AUC 0.83) but demonstrated poor specificity. Refining the tool to 'acute/sudden onset' [1], 'unusual/unfamiliar headache/neck pain' [1], recent trauma/infection [1] and neurological features ≥2 [1], scored out of 4, showed 100 % sensitivity and 74 % specificity to detect CeAD at a cut-off of 3/4 (AUC 0.87).

CONCLUSIONS

The refined tool shows acceptable clinical utility at a cut-off ≥3, where referral for vascular imaging is recommended. Further validation in Emergency and primary care is needed.

Presentation and physical therapy management using a neuroplasticity approach for patients with hypermobility-related upper cervical instability: a brief report

Background

Upper cervical instability (UCI) is a potentially disabling complication of the connective tissue disorders hypermobile Ehlers-Danlos Syndrome and Hypermobility Spectrum Disorders (hEDS/HSD). UCI can impact various neurological structures, including the brainstem, spinal cord, cranial nerves, and blood supply to and from the brain, resulting in complex neurological signs and symptoms in this population. The current study was an observational study applying recent expert consensus recommendations for physical therapy assessment and management of patients with UCI associated with hEDS/HSD.

Methods

This was a retrospective observational study describing how the clinical decision-making model was used to screen, examine, and treat three patients with highly irritable hEDS/HSD-related UCI, resulting in complex neurological presentation. The treatment used a neuroplasticity approach, including proprioception and motor control training emphasizing patient education and biofeedback. Outcome measures tracked progress.

Results

All patients started with significant disability associated with UCI. One patient returned to full function with intermittent flares that he was able to manage. The second patient continued to have mild-moderate irritability but returned to parenting responsibilities and full-time work. The third patient required cervical fusion and remained disabled but was better able to minimize flares. The number of initial red and yellow flags was associated with the final outcomes, suggesting that the decision-making model might be useful for predicting patient prognosis.

Conclusion

This brief report applies recent recommendations for safely evaluating and managing hypermobility-related UCI and provides a first step in experimental studies to test both the assessment and physical therapy treatment approaches.

Applying an osteopathic intervention to improve mild to moderate mental health symptoms: a mixed-methods feasibility randomised trial

BACKGROUND

The increasing prevalence of mental health disorders in the United Kingdom necessitates the exploration of novel treatment modalities. This study aimed to assess the feasibility and acceptability of conducting a randomised controlled trial (RCT) evaluating the efficacy of four osteopathic interventions on psychophysiological and mental health outcomes.

METHODS

A mixed-methods feasibility study with an explanatory sequential design was implemented. The quantitative phase involved randomising 42 participants into four intervention groups: (1) high-velocity and articulation techniques (HVAT), (2) soft-tissue massage (STM), (3) craniosacral therapy (CST), and (4) a combination approach. Primary outcome measures encompassed recruitment rate, assessment duration, questionnaire completion, intervention attrition, and adverse events. Secondary outcomes included validated assessments of depression, anxiety, stress, psychological flexibility, heart rate variability (HRV), and interoception, administered pre- and post-intervention. Analysis of variance (ANOVA) was employed to evaluate pre-post intervention changes. The qualitative phase comprised semi-structured interviews analysed using thematic analysis.

RESULTS

The study achieved a recruitment rate of 21 eligible participants per month, with 54.8% of respondents meeting eligibility criteria. All 33 participants who completed the study underwent interventions and assessments within the allocated one-hour timeframe, with full questionnaire completion. The attrition rate was 21%. No adverse events were reported. Qualitative analysis revealed positive participant experiences, with themes highlighting good practitioner communication, intervention accessibility, and increased bodily awareness. Some participants found the questionnaire battery burdensome. Exploratory quantitative analyses showed variations in effects across interventions for heart rate variability, interoceptive accuracy, and mental health measures, but these results should be interpreted cautiously due to the small sample size.

CONCLUSIONS

This study provides evidence supporting the feasibility and acceptability of a larger-scale RCT investigating osteopathic interventions for individuals presenting with mild psychological symptoms. The preliminary findings suggest potential efficacy in improving mental health outcomes, warranting further investigation. Trial registration NCT05674071, registered 06/01/2023.

Clinical reasoning skills of German and Dutch manual therapists: a cross-sectional study

INTRODUCTION

Reflective clinical reasoning (CR) is believed to play a crucial role in achieving an efficient therapy process, supported by evidence-based approaches that improve patient outcomes. The aim of this study was to evaluate the CR process of German manual therapists (MTs) using the CR skills of Dutch MTs as a reference.

METHODS

This cross-sectional study evaluated the CR process and diagnostic ability of German MTs. Dutch MTs served as the reference standard due to their experience with direct access. The CR skills were assessed using the Diagnostic Thinking Inventory (DTI), a questionnaire measuring diagnostic competence. Descriptive and inferential statistics were conducted to compare the groups. Subgroup analyses were performed to analyze the influence of work experience (in years) and the level of education on CR.

RESULTS

396 manual therapists (229 German and 167 Dutch) completed the DTI. Dutch MTs revealed higher DTI sum-scores compared to German MTs (p < .001; Cohen´s d = .41). Subgroup analyses regarding professional education revealed no significant differences in DTI sum-scores within German MTs and between both groups. In the subgroup analyses regarding professional experience, differences of moderate effect size were reached between German and Dutch novice MTs (in favor of Dutch novice MTs; p = .001; Cohen´s d = .62), and between German novice MTs and experienced German MTs (in favor of experienced German MTs; p < .001; Cohen´s d = .6).

CONCLUSION

The results suggest that academically educated German and Dutch MTs as well as experienced German and Dutch MTs are similar in terms of their hypothetical-deductive CR skills. In turn, German novice MTs seem to use hypothetical-deductive processing to a lesser extent compared to Dutch novice MTs and experienced German MTs, which in turn may support the hypothesis that the level of professional experience and education has a significant impact on the development of hypothetical-deductive CR skills.

Associations of Treatment Outcome Expectations and Pain Sensitivity after Cervical Spine Manipulation in Patients with Chronic Non-Specific Neck Pain: A Cohort Study

(1) Background: This cohort study aimed to evaluate the effect of patients' treatment expectations on pain perception changes following manual therapy cervical manipulations in individuals with chronic mechanical neck pain. (2) Methods: Demographic data were collected by 56 subjects who were asked to fill out the Neck Disability Index (NDI) and the Expectations for Treatment Scale (ETS). All patients received one single cervical manipulation, and pressure pain thresholds (PPTs) were measured before and immediately after the manipulation with a digital algometer. (3) Results: A total of 56 patients participated. Most subjects (62.5%) had high treatment expectations according to the ETS scale. Statistically significant increases in PPTs were noted both locally and in remote areas (p < 0.05), with 37.5-48.2% of participants showing clinically significant changes in pain perception. However, no statistically significant correlation was found between high treatment expectations and increased PPTs (p > 0.05). (4) Conclusions: Although a significant reduction in pain perception was observed, it did not correlate with patients' treatment expectations. Future research for further investigation of this hypothesis by comparing real versus sham treatment and exploring additional mechanisms affecting changes in PPTs after cervical manipulations in this population will contribute to a better understanding of the research question.

Reflections on 50 years of IFOMPT

2024 marks the 50th anniversary of the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT). IFOMPT became the first subgroup of World Physiotherapy. IFOMPT aims and works for global promotion of excellence and unity in clinical and academic standards for manual/musculoskeletal physiotherapists. This dissertation reflects on some of IFOMPT's initiatives and achievements as an international organisation in its first 50 years as well as challenges for next 50 years. IFOMPT has achieved in several initiatives. These include the development of an international educational curriculum in manipulative/musculoskeletal physiotherapy which underpins education standards for membership. Educational standards for membership is a relatively unique requirement of a professional organisation. IFOMPT has achieved in developing several initiatives to disseminate knowledge for best standards of practice for its members and the wider community. The pinnacle is its four yearly international scientific conferences where the latest issues in both research and practice are presented and discussed. IFOMPT has also developed frameworks to guide clinical practice in key areas for safe practice - vascular pathologies of the neck, a clinical reasoning pathway to identify 'red flags', and the use of spinal manipulation in paediatrics. Other resources include on-line lectures, podcasts and research reviews. IFOMPT has challenges for the future. These include increasing the number of member countries and further establishing its profile and position of leadership in manual/musculoskeletal physiotherapy in the international context, particularly with decision makers in world health.

Validation of the Cervical Torsion Test and Head-Neck Differentiation Test in Patients With Peripheral Vestibular Hypofunction

OBJECTIVE

This study compared adults with peripheral vestibular hypofunction (VH) to healthy controls and assessed the sensitivity and specificity of the Cervical Torsion Test (CTT) and the Head-Neck Differentiation Test (HNDT). This study aimed to determine whether neck problems affected primary outcomes.

METHODS

This cross-sectional study included adults from a specialist consultation for dizziness. VH had been diagnosed with the video Head Impulse Test. Exclusion criteria were conditions following head or neck trauma and diseases of the central nervous system. The sensitivity and specificity of the index tests were calculated, and regression analyses were performed to test for contributing factors.

RESULTS

A total of 19 patients with VH and a historical cohort of 19 matched healthy controls were included. Most patients with VH (84.2%) experienced symptoms in at least 1 test component, compared to 5.2% of the control group. Of patients with VH, 78.9% had symptoms during the HNDT "en bloc" (en bloc = head and trunk rotated together), whereas only 26.3% reported symptoms during the CTT en bloc. The best discriminatory validity was found for the HNDT en bloc, with a sensitivity of 0.79 (95% CI = 0.54-0.94), a specificity of 0.86 (95% CI = 0.65-0.97), and a positive likelihood ratio of 5.79 (95% CI = 1.97-17.00). The number of symptoms of CTT "in torsion" (in torsion = trunk rotated actively with fixed head) was increased by a factor of 1.13 (95% CI = 1.01-1.27) for every additional point on the Neck Disability Index.

CONCLUSION

The CTT and HNDT can serve as non-laboratory tests for patients with dizziness. The HNDT en bloc has the best discriminatory validity, finding those with and those without VH. Symptom reproduction during torsion may help to identify when neck problems may contribute to dizziness.

IMPACT

The HNDT en bloc may be useful for ruling VH in or out in patients with dizziness. Positive CTT and HNDT in torsion components may verify the likelihood of additional neck involvement.

Cervical manipulation versus thoracic or cervicothoracic manipulations for the management of neck pain. A systematic review and meta-analysis

BACKGROUND

Cervical and thoracic thrust or non-thrust manipulations have shown to be effective in patients with neck pain, but there is a lack of studies comparing both interventions in patients with neck pain.

OBJECTIVE

To investigate the effects of cervical thrust or non-thrust manipulations compared to thoracic or cervicothoracic manipulations for improving pain, disability, and range of motion in patients with neck pain.

DESIGN

Systematic review and meta-analysis.

METHOD

Searches were performed in PubMed, PEDro, Cochrane Library, CINHAL, and Web of Science databases from inception to May 22, 2023. Randomized clinical trials comparing cervical thrust or non-thrust manipulations to thoracic or cervicothoracic manipulations were included. Methodological quality was assessed with PEDro scale, and the certainty of evidence was evaluated using GRADE guidelines.

RESULTS

Six studies were included. Meta-analyses revealed no differences between cervical thrust or non-thrust manipulations and thoracic or cervicothoracic manipulations in pain intensity, disability, or cervical range of motion in any plane. The certainty of evidence was downgraded to very low for pain intensity, to moderate or very low for disability and to low or very low for cervical range of motion.

CONCLUSION

There is moderate to very low certainty evidence that there is no difference in effectiveness between cervical thrust or non-thrust manipulations and thoracic or cervicothoracic manipulations for improving pain, disability, and range of motion in patients with neck pain.

PROSPERO REGISTRATION

CRD42023429933.

A modern way to teach and practice manual therapy

BACKGROUND

Musculoskeletal conditions are the leading contributor to global disability and health burden. Manual therapy (MT) interventions are commonly recommended in clinical guidelines and used in the management of musculoskeletal conditions. Traditional systems of manual therapy (TMT), including physiotherapy, osteopathy, chiropractic, and soft tissue therapy have been built on principles such as clinician-centred assessment, patho-anatomical reasoning, and technique specificity. These historical principles are not supported by current evidence. However, data from clinical trials support the clinical and cost effectiveness of manual therapy as an intervention for musculoskeletal conditions, when used as part of a package of care.

PURPOSE

The purpose of this paper is to propose a modern evidence-guided framework for the teaching and practice of MT which avoids reference to and reliance on the outdated principles of TMT. This framework is based on three fundamental humanistic dimensions common in all aspects of healthcare: safety, comfort, and efficiency. These practical elements are contextualised by positive communication, a collaborative context, and person-centred care. The framework facilitates best-practice, reasoning, and communication and is exemplified here with two case studies.

METHODS

A literature review stimulated by a new method of teaching manual therapy, reflecting contemporary evidence, being trialled at a United Kingdom education institute. A group of experienced, internationally-based academics, clinicians, and researchers from across the spectrum of manual therapy was convened. Perspectives were elicited through reviews of contemporary literature and discussions in an iterative process. Public presentations were made to multidisciplinary groups and feedback was incorporated. Consensus was achieved through repeated discussion of relevant elements.

CONCLUSIONS

Manual therapy interventions should include both passive and active, person-empowering interventions such as exercise, education, and lifestyle adaptations. These should be delivered in a contextualised healing environment with a well-developed person-practitioner therapeutic alliance. Teaching manual therapy should follow this model.

Use of the International IFOMPT Cervical Framework to inform clinical reasoning in postgraduate level physiotherapy students: a qualitative study using think aloud methodology

BACKGROUND

Vascular pathologies of the head and neck are rare but can present as musculoskeletal problems. The International Federation of Orthopedic Manipulative Physical Therapists (IFOMPT) Cervical Framework (Framework) aims to assist evidence-based clinical reasoning for safe assessment and management of the cervical spine considering potential for vascular pathology. Clinical reasoning is critical to physiotherapy, and developing high-level clinical reasoning is a priority for postgraduate (post-licensure) educational programs.

OBJECTIVE

To explore the influence of the Framework on clinical reasoning processes in postgraduate physiotherapy students.

METHODS

Qualitative case study design using think aloud methodology and interpretive description, informed by COnsolidated criteria for REporting Qualitative research. Participants were postgraduate musculoskeletal physiotherapy students who learned about the Framework through standardized delivery. Two cervical spine cases explored clinical reasoning processes. Coding and analysis of transcripts were guided by Elstein's diagnostic reasoning components and the Postgraduate Musculoskeletal Physiotherapy Practice model. Data were analyzed using thematic analysis (inductive and deductive) for individuals and then across participants, enabling analysis of key steps in clinical reasoning processes and use of the Framework. Trustworthiness was enhanced with multiple strategies (e.g., second researcher challenged codes).

RESULTS

For all participants (n = 8), the Framework supported clinical reasoning using primarily hypothetico-deductive processes. It informed vascular hypothesis generation in the patient history and testing the vascular hypothesis through patient history questions and selection of physical examination tests, to inform clarity and support for diagnosis and management. Most participant's clinical reasoning processes were characterized by high-level features (e.g., prioritization), however there was a continuum of proficiency. Clinical reasoning processes were informed by deep knowledge of the Framework integrated with a breadth of wider knowledge and supported by a range of personal characteristics (e.g., reflection).

CONCLUSIONS

Findings support use of the Framework as an educational resource in postgraduate physiotherapy programs to inform clinical reasoning processes for safe and effective assessment and management of cervical spine presentations considering potential for vascular pathology. Individualized approaches may be required to support students, owing to a continuum of clinical reasoning proficiency. Future research is required to explore use of the Framework to inform clinical reasoning processes in learners at different levels.

Effectiveness and safety of manual therapy when compared with oral pain medications in patients with neck pain: a systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis seeks to investigate the effectiveness and safety of manual therapy (MT) interventions compared to oral pain medication in the management of neck pain.

METHODS

We searched from inception to March 2023, in Cochrane Central Register of Controller Trials (CENTRAL), MEDLINE, EMBASE, Allied and Complementary Medicine (AMED) and Cumulative Index to Nursing and Allied Health Literature (CINAHL; EBSCO) for randomized controlled trials that examined the effect of manual therapy interventions for neck pain when compared to medication in adults with self-reported neck pain, irrespective of radicular findings, specific cause, and associated cervicogenic headaches. We used the Cochrane Risk of Bias 2 tool to assess the potential risk of bias in the included studies, and the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach to grade the quality of the evidence.

RESULTS

Nine trials (779 participants) were included in the meta-analysis. We found low certainty of evidence that MT interventions may be more effective than oral pain medication in pain reduction in the short-term (Standardized Mean Difference: -0.39; 95% CI -0.66 to -0.11; 8 trials, 676 participants), and moderate certainty of evidence that MT interventions may be more effective than oral pain medication in pain reduction in the long-term (Standardized Mean Difference: - 0.36; 95% CI - 0.55 to - 0.17; 6 trials, 567 participants). We found low certainty evidence that the risk of adverse events may be lower for patients that received MT compared to the ones that received oral pain medication (Risk Ratio: 0.59; 95% CI 0.43 to 0.79; 5 trials, 426 participants).

CONCLUSIONS

MT may be more effective for people with neck pain in both short and long-term with a better safety profile regarding adverse events when compared to patients receiving oral pain medications. However, we advise caution when interpreting our safety results due to the different level of reporting strategies in place for MT and medication-induced adverse events. Future MT trials should create and adhere to strict reporting strategies with regards to adverse events to help gain a better understanding on the nature of potential MT-induced adverse events and to ensure patient safety.

TRIAL REGISTRATION

PROSPERO registration number: CRD42023421147.

Development of a diagnostic support tool for predicting cervical arterial dissection in primary care

OBJECTIVES

Cervical arterial dissection (CAD) is an important cause of stroke in young people which may be missed because early features may mimic migraine or a musculoskeletal presentation. The study aimed to develop a diagnostic support tool for early identification of CAD.

DESIGN

Retrospective observational study.

SETTING

Tertiary hospital.

PARTICIPANTS

Radiologically confirmed CAD cases (n = 37), non-CAD stroke cases (n = 20), and healthy controls (n = 100).

MAIN OUTCOME MEASURES

The presence of CAD is confirmed with imaging. Predictive variables included risk factors and clinical characteristics of CAD. Variables with a p-value <0.2 included in a multivariable model. Predictive utility of the model is assessed by calculating area underthe ROC curve (AUC).

RESULTS

The model including four variables: age 40-55 years (vs < 40), trauma, recent onset headache, and > 2 neurological features, demonstrated excellent discrimination: AUC of 0.953 (95% CI: 0.916, 0.987). A predictive scoring system (total score/7) identified an optimal threshold of ≥ 3 points, with a sensitivity of 87% and specificity of 79%.

CONCLUSIONS

The study identified a diagnostic support tool with four variables to predict increased risk of CAD. Validation in a clinical sample is needed to confirm variables and refine descriptors to enable clinicians to efficiently apply the tool.Optimum cutoff scores of ≥ 3/7 points will help identify those in whom CAD should be considered and further investigation instigated. The potential impact of the tool is to improve early recognition of CAD in those with acute headache or neck pain, thereby facilitating more timely medical intervention, preventing inappropriate treatment, and improving patient outcomes.Wordcount: 3195.

Plausible Mechanisms of Causation of Immediate Stroke by Cervical Spine Manipulation: A Narrative Review

It has been proposed that cervical spine manipulation (CSM) can cause dissection in healthy cervical arteries, with resultant immediate stroke. However, research does not support a causal association between CSM and cervical artery dissection (CAD) in healthy cervical arteries. The objective of this study was to review the literature to identify plausible mechanisms of causation of immediate stroke by CSM. Immediate stroke is defined as a stroke occurring within seconds or minutes of CSM. Our review found plausible thromboembolic and thrombotic mechanisms of causation of immediate stroke by CSM in the literature. The common premise of these mechanisms is CAD being present before CSM, not occurring as a result of CSM. These mechanisms of causation have clinical and medicolegal implications for physicians performing CSM.

Red flags for potential serious pathologies in people with neck pain: a systematic review of clinical practice guidelines

Introduction

We conducted a systematic review of clinical practice guidelines to identify red flags for serious pathologies in neck pain mentioned in clinical practice guidelines, to evaluate agreement in red flag recommendations across guidelines, and to investigate the level of evidence including what study type the recommendations are based on.

Methods

We searched for guidelines focusing on specific and nonspecific neck pain in MEDLINE, EMBASE, and PEDro up to June 9, 2023. Additionally, we searched for guidelines through citation tracking strategies, by consulting experts in the field, and by checking guideline organization databases.

Results

We included 29 guidelines, 12 of which provided a total of 114 red flags for fracture (n = 17), cancer (n = 21), spinal infection (n = 14), myelopathy (n = 15), injury to the spinal cord (n = 1), artery dissection (n = 7), intracranial pathology (n = 3), inflammatory arthritis (n = 2), other systemic disease (n = 6), or unrelated to a specific condition (n = 19). Overall, there is very little agreement (median Fleiss' kappa of 0) between guidelines on the red flags to screen for serious pathologies.

Conclusion

Red flags were mainly supported by expert opinions. We also observed a general lack of consensus among guidelines regarding which red flags to endorse. Considering the current limitations of the evidence, specific recommendations on which red flags to use cannot be provided, except for using the Canadian C-Spine rule for screening posttraumatic fractures.

Risk assessment of vascular complications following manual therapy and exercise for the cervical region: diagnostic accuracy of the International Federation of Orthopaedic Manipulative Physical Therapists framework (The Go4Safe project)

QUESTION

What is the diagnostic accuracy of the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) framework to assess the risk of vascular complications in patients seeking physiotherapy care for neck pain and/or headache?

DESIGN

Cross-sectional diagnostic accuracy study.

PARTICIPANTS

One hundred and fifty patients seeking physiotherapy for neck pain and/or headache in primary care.

METHODS

Nineteen physiotherapists performed the index test according to the IFOMPT framework. Patients were classified as having a high, intermediate or low risk of vascular complications, following manual therapy and/or exercise, derived from the estimated risk of the presence of vascular pathology. The reference test was a consensus medical decision reached by a vascular neurologist and an interventional neurologist, with input from a neuroradiologist. The neurologists had access to clinical data and magnetic resonance imaging of the cervical spine, including an angiogram of the cervical arteries.

OUTCOME MEASURES

Diagnostic accuracy measures were calculated for 'no contraindication' (ie, the low-risk category) and 'contraindication' (ie, the high-risk and intermediate-risk categories) for manual therapy and/or exercise. Sensitivity, specificity, predictive values, likelihood ratios and the area under the curve were calculated.

RESULTS

Manual therapy and/or exercise were contraindicated in 54.7% of the patients. The sensitivity of the IFOMPT framework was low (0.50, 95% CI 0.39 to 0.61) and its specificity was moderate (0.63, 95% CI 0.51 to 0.75). The positive and negative likelihood ratios were weak at 1.36 (95% CI 0.93 to 1.99) and 0.79 (95% CI 0.60 to 1.05), respectively. The area under the curve was poor (0.57, 95% CI 0.49 to 0.65).

CONCLUSION

The IFOMPT framework has poor diagnostic accuracy when compared with a reference standard consisting of a consensus medical decision.

Applying an osteopathic intervention to improve mild to moderate mental health symptoms: a mixed-methods feasibility study protocol

INTRODUCTION

Mental health services are stretched in the UK and are in need of support. One approach that could improve mental health symptoms is osteopathy. Research suggests that osteopathy influences psychophysiological factors, which could lead to improvements in mental health. The first objective of this protocol is to investigate the feasibility and acceptability of four osteopathic interventions. A secondary aim is to evaluate the interventions' effectiveness for improving psychophysiological and mental health outcomes.

METHODS AND ANALYSIS

This study will be an explanatory mixed-methods design. Participants will be 30 adults who have mild to moderate mental health symptoms and not experiencing any issues with pain. The feasibility and acceptability of the interventions will be the primary outcomes. Secondary outcomes will be physiological measures including heart rate variability, interoceptive accuracy and blood pressure. Psychological outcomes, collected preintervention and postintervention, will also be measured by five standardised questionnaires, which include: (1) the Depression, Anxiety and Stress Scale (DASS); (2) the International Positive and Negative Affect Schedule-Short-Form; (3) Acceptance and Action Questionnaire-II; (4) the Self as Context Scale and (5) and the Multidimensional Assessment of Interoceptive Awareness Version 2. Participants will be randomised to one of four intervention groups and receive a single intervention treatment session. These intervention groups are: (1) high-velocity and articulation techniques, (2) soft-tissue massage, (3) craniosacral techniques, and (4) a combination of these three approaches. Mixed design two (preintervention and postintervention) by the four interventions analysis of covariance models will be used to analyse the quantitative data for each quantitative measure. Participants will also be interviewed about their experiences of the study and interventions and a thematic analysis will be used to analyse this qualitative data. This will aid the assessment of the feasibility and acceptability of the study design.

ETHICS AND DISSEMINATION

The protocol for this feasibility study has received ethical approval from the Department of Psychology Ethics Committee at Swansea University, ethical review reference number: 2022-5603-4810. Feasibility results from this protocol will be published in a peer review journal and presented at both national and international conferences.

DISCUSSION

This study will assess the feasibility and acceptability of conducting osteopathic interventions for improving mental health outcomes. The results from this will help to inform the development of a future randomised controlled trial. The study will also produce original data which could provide preliminary evidence of whether osteopathic approaches are of benefit to individual's mental health in the form of effect sizes, even if they are pain-free.

TRIAL REGISTRATION NUMBER

NCT05674071.

Response to the Letter to the Editor-in-Chief

Author response to the JOSPT Letter to the Editor-in-Chief "A Second Look at the Risks of Serious Adverse Events with Orthopaedic Manual Therapy, Paracetamol, and NSAID Treatment of Neck Pain" J Orthop Sports Phys Ther 2023;53(6):1-2. doi:10.2519/jospt.2023.0202-R.

A Second Look at the Risks of Serious Adverse Events with Orthopaedic Manual Therapy, Paracetamol, and NSAID Treatment of Neck Pain

Letter to the Editor-in-Chief in response to JOSPT article "International Framework for Examination of the Cervical Region for Potential of Vascular Pathologies of the Neck Prior to Musculoskeletal Intervention: International IFOMPT Cervical Framework" by Rushton A, Carlesso LC, Flynn T, et al. J Orthop Sports Phys Ther 2023;53(6):1-2. doi:10.2519/jospt.2023.0202.

Modernizing patient-centered manual therapy: Findings from a Delphi study on orthopaedic manual therapy application

BACKGROUND

Recent literature challenges the process by which orthopaedic manual therapy (OMT) has traditionally been applied. Progressive understanding of the complexities surrounding OMT analgesia and the decreased reliance on technique specific characteristics in determining treatment effectiveness promotes an update to training paradigms related to OMT.

OBJECTIVES

The purpose of this Delphi study was to establish consensus on what trainees should be focusing on when demonstrating OMT techniques and how candidates for OMT should be identified.

DESIGN

An international three-round Delphi study following recommended guidelines for conducting and reporting of Delphi studies (CREDES) was performed.

METHODS

One-hundred sixty-four expert manual therapy educators were identified for participation across four countries. Participants were asked to provide what concepts trainees should be focusing on when demonstrating OMT techniques and how candidates for OMT should be identified. Twenty-one themes were identified for each question.

RESULTS

Twenty-eight participants completed all three rounds of the Delphi. Consensus was reached on nineteen themes and eighteen themes respectively. Results from this Delphi stress patient-centered care within a biopsychosocial pain management model. Representation across all pillars of evidence-based practice were represented. Themes reaching consensus within this study favored the importance of neurophysiological, psychological, and biomechanical principles.

CONCLUSION

This Delphi presents consensus-based recommendations for what manual therapy trainees should focus on when demonstrating OMT techniques and on how candidates for OMT should be identified. These findings in collaboration with previous consensus recommendations on concepts to focus on within OMT education promote restructuring of OMT curriculum to evidence-based patient-centered care models.

Recognition of Prodromal Hypoglossal Nerve Palsy Presenting with Neck Pain as Primary Complaint: Findings from a Rare Case Report in Direct Access Physiotherapy during the COVID-19 Pandemic

Neck pain (NP) is the second most common musculoskeletal disorder. Spinal cysts (SCs) are cystic dilatations of the synovial sheaths in joints and tendons. SCs are extremely rare in the cervical spine. Typically, patients are unaware of having an SC due to its asymptomatic nature; however, when cervical SC extends, its volume could compress the surrounding structures, such as the hypoglossal nerve. Isolated hypoglossal nerve palsy (HNP) is very rare and typically presents with unilateral atrophy of the musculature of the tongue and contralateral tongue deviation. Often, patients with HNP also report occipital/neck pain. A 75-year-old man with occipital/neck pain as a primary complaint. Although difficult to observe because of the filtering facepiece two mask, difficulties in articulation and sialorrhea during the interview were noticed. These latter were cues to consider CN examination that revealed CN XII palsy. This prompted a referral for further examination that revealed an SC compressing the right hypoglossal canal. The patient was not considered a surgical candidate and was managed conservatively. This case report outlines the relevant findings relating to the triage of a rare isolated hypoglossal nerve palsy from the physiotherapist's perspective within a complex setting because of the COVID-19 pandemic. Although referred with a diagnosis of cervical radiculopathy, our case highlights that skilled physiotherapists may play a fundamental role in both the recognition and, when applicable, subsequent novel management of a non-musculoskeletal presentation.

Physiotherapy Screening for Referral of a Patient with Patent Foramen Ovale Presenting with Neck Pain as Primary Complaint: A Case Report

Neck pain is a common musculoskeletal disorder encountered by physiotherapists. However, it may be the early manifestation of more alarming conditions, such as cardiovascular diseases mimicking musculoskeletal pain. Patent foramen ovale (PFO) is a congenital heart defect consisting of a small opening between the right and the left atrium. A 56-year-old male presented with neck pain and head heaviness as primary complaints. The cardiovascular profile and the behavioral symptoms led the physiotherapist to find an exaggerated blood pressure response during exercise; in addition to subtle neurological signs, this prompted the physiotherapist to make an urgent referral. At the emergency department a PFO was diagnosed. To the best of the authors' knowledge, this is the first case to describe a rare clinical presentation of a PFO presenting neck pain as primary complaint. This case report emphasizes the importance for physiotherapists to be able to triage patients for conditions outside their scope suggestive of further medical investigation.

A guide to identify cervical autonomic dysfunctions (and associated conditions) in patients with musculoskeletal disorders in physical therapy practice

BACKGROUND

Differential diagnosis is a hot topic in physical therapy, especially for those working in a direct access setting dealing with neck pain and its associated disorders. All international guidelines agree in recommending to first rule out non-musculoskeletal pathologies as the cause of signs and symptoms in the patient. Although the autonomic nervous system (ANS) has a crucial role and is also involved in pain conditions, coverage of it in neuroscience textbooks and educational programmes is limited and most healthcare professionals are unfamiliar with it. Although autonomic conditions are benign in nature, they are clinically of great importance as they may be a 'red flag' warning of an injury along the sympathetic pathway. Therefore, sound knowledge of the ANS system is essential for clinicians.

OBJECTIVE

To develop physical therapists' knowledge of and confidence in understanding cervical ANS function and dysfunction, thus enhancing clinical reasoning skills and the pattern recognition process, and performing and interpreting objective examinations.

METHODS

This master class provides an introductory guide and essential knowledge to facilitate clinicians to understand cervical autonomic dysfunctions and their clinical evaluation. The optimal referral method is also handled.

CONCLUSIONS

Gaining knowledge and understanding of the ANS, its function, its dysfunction, and the related clinical manifestations is likely to lead to a decision-making process driven by 'science and conscience'. This will empower physical therapists to be aware of subtle clues that may be offered by patients during the interview and history intake leading to the appropriate physical examination and triage.

A Novel Device for Assessment and Treatment of Upper Cervical Spine: Test-Retest Reliability Study

INTRODUCTION

Neck pain is one of the most frequent reasons for consultation in primary care. Clinicians evaluate different variables, including movement and cervical strength, to determine the prognosis of patients. Usually, the tools employed for this purpose are expensive and bulky, or more than one is needed. This study aims to describe a novel device designed to assess the cervical spine and describe its test-retest reliability.

METHODS

The Spinetrack device was designed to measure the strength of deep cervical flexor muscles and the chin-in and chin-out movement of the upper cervical spine. A test-retest reliability study was developed. The flexion, extension and strength needed to move the Spinetrack device were registered. Two measurements were developed, with one week between each assessment.

RESULTS

Twenty healthy subjects were evaluated. The strength of the deep cervical flexor muscles in the first measurement was 21.18 ± 3.15 Newtons, the displacement movement during chin-in movement was 12.79 mm ± 3.46 and the displacement during chin-out movement was 35.99 mm ± 4.44. The test-retest reliability of strength was ICC 0.97 (95% CI (0.91-0.99)).

CONCLUSION

The Spinetrack device has shown excellent test-retest reliability values for the measurement of the strength of the cervical flexor muscles and for the chin-in and chin-out movements.

The Addition of Diacutaneous Fibrolysis to a Pharmacological Intervention in Patients with Tension-Type Headache: A Randomized Controlled Trial

Background: Tension-type headache (TTH) is the most common headache worldwide. Pharmacological interventions are the most investigated therapies in patients with TTH. The addition of physical therapy treatments such as diacutaneous fibrolysis (DF) may have promising results. The aim of this study was to investigate the addition of three sessions of DF to a pharmacological intervention in patients with TTH. Methods: A single-blinded randomized controlled trial was carried out. Participants were randomly assigned to the standard care group or to the DF group. Both groups received a pharmacological intervention. Three sessions of DF in the thoracic and cervicocranial region were added in the DF group. The impact caused by headache (HIT-6), headache intensity, and cervical range of motion were measured by blinded assessors at baseline, after the intervention, and at 1 month follow-up. Results: Eighty-two patients with TTH were included (41 standard care group; 41 DF group). Statistically significant differences were found between both groups in all the variables after the intervention and at 1 month follow-up (p < 0.001). No adverse effects or side-effects were reported during the study. Conclusions: The addition of three sessions of DF to a pharmacological therapy provided improvements in the impact caused by headache, headache intensity, and cervical range of motion after the intervention and at 1 month follow-up compared to a pharmacological therapy in isolation. Further research is needed to investigate long-term effects.