Associate Professor Suzanne Snodgrass

OBJECTIVE: To examine the short- and longterm effectiveness of dry needling on disability, pain, and patient-perceived improvements in patients with mechanical neck pain when added to a multimodal treatment program that includes manual therapy and exercise. U DESIGN: Randomized controlled trial. U METHODS: Seventy-seven adults (mean ± SD age, 46.68 ± 14.18 years; 79% female) who were referred to physical therapy with acute, subacute, or chronic mechanical neck pain were randomly allocated to receive 7 multimodal treatment sessions over 4 weeks of (1) dry needling, manual therapy, and exercise (needling group); or (2) sham dry needling, manual therapy, and exercise (sham needling group). The primary outcome of disability (Neck Disability Index score) and secondary outcomes of pain (current and 24-hour average) and patient-perceived improvement were assessed at baseline and follow-ups of 4 weeks, 6 months, and 1 year by blinded assessors. Between-group differences were analyzed with a 2-way, repeated- measures analysis of variance. Global rating of change was analyzed with a Mann-Whitney U test. U RESULTS: There were no group-by-time interactions for disability (Neck Disability Index: F2.37,177.47 = 0.42, P = .69), current pain (visual analog scale: F2.84,213.16 = 1.04, P = .37), or average pain over 24 hours (F2.64,198.02 = 0.01, P = .10). There were no between- group differences for global rating of change at any time point (P=.65). Both groups improved over time for all variables (Neck Disability Index: F2.37,177.47 = 124.70, P<.001; current pain: F2.84,213.16 = 64.28, P<.001; and average pain over 24 hours: F2.64,198.02 = 76.69, P<.001). U CONCLUSION: There were no differences in outcomes between trigger point dry needling and sham dry needling when added to a multimodal treatment program for neck pain. Dry needling should not be part of a first-line approach to managing neck pain.

Introduction/objectives: Prior opioid use can influence outcomes for patients with musculoskeletal disorders. The purpose of this study was to compare downstream medical utilization-based outcomes (costs, visits, recurrent episodes) after an initial diagnosis of patellofemoral pain based on pre-injury utilization of opioids. Method: A total of 85,7880 consecutive patients were followed for a full 12¿months before and 24¿months after an initial diagnosis of patellofemoral pain (January 2009 to December 2013). Data were sourced from the Military Health System Data Repository, a single-payer closed government system. Opioid prescription fills were identified, and medical visits and costs were calculated for all knee-related medical care, to include recurrence rates in the 2-year surveillance period. Results: A relatively small number of individuals filled an opioid prescription in the year prior (n = 1746; 2.0%); however, these individuals had almost twice the mean costs of knee-related medical care ($1557 versus %802) and medical visits (8.4 versus 4.0). Patients with prior opioid use were more likely to have at least 1 recurrent episode of knee pain (relative risk 1.58, 95% CI 1.51, 1.65) with a higher mean number of episodes of knee pain (1.5 vs 1.8). The use of opioids with higher risk of misuse or dependency (Schedule II or III) resulted in greater medical costs (for any reason) and recurrent episodes of knee pain compared to the use of opioids in a lower risk category (Schedule IV). Conclusions: Prior opioid utilization was associated with a greater number of recurrent episodes of knee pain and higher downstream medical costs compared with individuals without prior opioid use. For individuals with prior opioid utilization, opioids with higher risk of misuse or dependency (Schedule II or III) resulted in greater medical costs (for any reason) and recurrent episodes compared to the use of lower-risk opioids (Schedule IV).Key Points¿ Patients with prior opioid use had much greater knee-related medical costs compared to patients without prior opioid use.¿ Patients with prior opioid use were more likely to have additional episodes of knee pain in the following 2¿years compared to patients without prior opioid use.¿ Prior opioid use has predicted higher costs and poor outcomes after surgery, but this is the first study to confirm similar findings in non-surgical patients.

Objective: The purpose of this study was to determine if there is a relationship between pain and movement kinematics during functional tasks, evaluated over time, in individuals with chronic idiopathic neck pain. Methods: Ten participants with chronic idiopathic neck pain performed 2 functional tasks (overhead reach to the right and putting on a seatbelt) while evaluated using 8 Oqus 300+ cameras. Kinematic variables included joint angles and range of motion (ROM) (°), head segment relative to neck segment (head-neck [HN]); and head/neck segment relative to upper thoracic segment (head/neck-trunk), velocity (m/s), and time (% of movement phase). Pain was quantified using a 100-mm visual analog scale. Linear mixed effects regression models were used to analyze associations between pain and kinematic variables adjusting for treatment group. Results: For overhead reach, higher pain was associated with less HN peak rotation at baseline (ß = ¿0.33; 95% CI -0.52 to ¿0.14, P = .003) and less HN total rotation ROM at 6 months (ß = ¿0.19; 95% CI ¿0.38 to ¿0.003, P = .048). For the seatbelt task, higher pain was associated with less HN peak rotation (ß = ¿0.52; 95% CI -0.74 to ¿0.30 to ¿0.74, P < .001) and less HN total rotation ROM at baseline (ß = ¿0.32; 95% CI ¿0.53 to ¿0.10, P = .006). No other movement variables demonstrated meaningful relationships with pain for the reach or seatbelt tasks. Conclusion: Higher pain is associated with less HN peak and total rotation during functional reaching tasks requiring head rotation. Recognizing altered functional kinematics in individuals with chronic neck pain may assist patient management.

Objectives: To describe the outcomes of 10 patients with chronic biceps tendinopathy treated by physical therapy with the novel approach of dry needling (DN), eccentric-concentric exercise (ECE), and stretching of the long head of the biceps tendon (LHBT). Methods: Ten individuals reporting chronic anterior shoulder symptoms (> 3¿months), pain with palpation of the LHBT, and positive results on a combination of tests including active shoulder flexion, Speed¿s, Hawkins Kennedy, Neer, and Yergason¿s tests participated in this case series. Validated self-reported outcome measures including the mean numeric pain rating scale (NPRS) and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) were taken at baseline. Participants were treated with two to eight sessions of DN to the LHBT and an ECE program and stretching of the biceps muscle. At discharge, patients completed the global rating of change (GROC), QuickDASH and NPRS. Results: Patients had an improved mean NPRS of 3.9 (SD, 1.3; p¿<¿0.001), QuickDASH of 19.01% (SD, 10.8; p¿<¿0.02) and GROC +5.4 (SD, 1.3). Conclusion: Findings from this case series suggest that DN and ECE may be beneficial for the management of patients with chronic LHBT tendinopathy. Further research on the efficacy of this novel treatment approach is warranted.

Background: Cervical sensorimotor control (CSMC) outcomes have been suggested to be important in the assessment of individuals with neck pain, despite the lack of consistent supporting evidence that CSMC skills are related to neck pain. Objective: The aim of this study was to investigate whether CSMC changes over time in individuals with chronic idiopathic neck pain and whether neck pain characteristics are associated with CSMC. Design: A longitudinal observational study was performed. Methods: A total 50 participants with chronic idiopathic neck pain and 50 matched participants who were healthy (controls) completed 7 CSMC tests (including 14 test conditions): joint position error, postural balance, subjective visual vertical, head tilt response, The Fly, smooth pursuit neck torsion, and head steadiness. Neck pain characteristics included pain intensity (visual analog scale), pain duration, and neck disability (Neck Disability Index). Linear mixed models were used to investigate whether any factors were associated with changes in CSMC. Results: Neck pain intensity was associated with 1 of 14 CSMC test conditions (balance with torsion and eyes open), and neck disability was associated with balance with eyes open and high-load head steadiness. Other factors, including sex, age, body mass index, physical activity levels, and neck pain duration, showed no association with CSMC. Limitations: Although all other tests involved computerized data collection, the joint position error test was administered manually, introducing the risk of researcher bias. Conclusions: The few associations between test conditions and neck pain characteristics were at best weak; hence, these are likely to be chance findings. These results suggest that CSMC may not be associated with improvement/worsening of chronic idiopathic neck pain, spawning debate on the clinical usefulness of CSMC tests.

Objectives: Due to their potentially deleterious effects, minimizing the use of opioids for musculoskeletal pain is a priority for healthcare systems. The objective of this study was to examine the risk of future opioid prescription use based on prior opioid use within a non-surgical cohort with musculoskeletal knee pain. We also examined the risk of pre-existing comorbidities on future opioid use, and the risk of prior opioid use on future comorbidities (sleep, mental health, cardiometabolic disorders). Methods: Data came from the Military Health System Data Repository for 80 290 consecutive beneficiaries with an initial episode of care for patellofemoral pain from January 1, 2010 through December 31, 2011. Risk was calculated using 2 × 2 tables based on pre- and post-opioid utilization and comorbid diagnosis. Risk ratios, relative and absolute risk increases, and numbers needed to harm were calculated, all with 95% confidence intervals. Results: Prior opioid use resulted in a risk ratio of 18.0 (95 CI 17.1, 19.0) and an absolute risk increase of 61.6% for future opioid use (numbers needed to harm = 2). The presence of all comorbidities (except cardiometabolic syndrome) were associated with a significant relative risk for future opioid use (RR range 1.2-1.5), but the absolute risk increase was trivial (range 0.7%-2.2%). The relative risk for a chronic pain diagnosis, traumatic brain injury/concussion, insomnia, depression, and PTSD were all significantly higher in those with prior opioid use (1.3-1.6), but absolute risk increase was minimal (1.1%-6.5%). Discussion: Prior opioid use was a strong risk factor for future opioid use in non-surgical patients with knee pain. These findings show that history of prior opioid use is important when assessing the risk of future opioid use, whereas prior comorbidities may not be as important. Opioid history assessment should be standard practice for all patients with patellofemoral pain in whom an opioid prescription is considered.

Background: Clinically, a discrepancy of fibular position in relation to the tibia has been proposed as a factor in the persistence of chronic ankle instability (CAI). Previous studies have produced conflicting findings, perhaps due to varying radiological methods and measurement of participants in non-weight-bearing positions. Objectives: To compare normalized-fibular position in weight-bearing in individuals with CAI with healthy controls. Design: A weight-bearing lateral X-ray was taken of the affected ankle of 33 adults with CAI and 33 matched controls. The distance between the anterior edges of the distal fibula and tibia was recorded, and then normalized as a proportion of maximal tibial width. Normalized-fibular position was compared between groups using independent t-tests. Intra-class correlation coefficients (ICC ) were calculated to determine reliability of measurements. A receiver-operating characteristic (ROC) curve was used to determine sensitivity, specificity, and a cutoff score to differentiate individuals with CAI from controls using normalized-fibular position. Results: Normalized fibular position was significantly different (CAI, 29.7 (6.6)%; healthy, 26.7 (4.8)%) between the groups. Measurement of intra-rater (0.99, 95%CI¿=¿0.98 to 1.00) and inter-rater (0.98, 95%CI¿=¿0.96 to 0.99) reliability were both excellent. The threshold normalized-fibular position was 27%, with a score more than 27% indicating a greater chance of being in the CAI group. Sensitivity was 69.7% and specificity was 54.5% for this threshold. Conclusion: A slightly anteriorly positioned fibula in relation to the tibia was observed in people with CAI. Specificity/sensitivity scores for normalized-fibular position indicate that it has little ability to predict CAI alone. 2,1

Background: Sensorimotor control is commonly reported in neck pain research and rapidly gaining interest in clinical practice. Joint position error (conventional and torsion), postural balance, subjective visual vertical, head tilt response, The Fly®, smooth pursuit neck torsion and head steadiness are tests that have been reported to assess cervical sensorimotor control. However, it is unknown whether clinicians could use one test, or a test battery, to appropriately assess cervical sensorimotor control and improve efficiency. Our main research question is: Do seven cervical sensorimotor control tests measure unique or similar characteristics of sensorimotor control in individuals with chronic idiopathic neck pain? Methods: Principle components factor analysis. Data from seven cervical sensorimotor control tests of 50 participants with chronic idiopathic neck pain were included. Individual factors, potentially related to sensorimotor control, were determined by Eigen values >1.00 and inspection of a loading plot. Items with loadings =0.40 were considered satisfactory for inclusion in a factor. Results: All cervical sensorimotor control tests were found to measure unique skills. Four factors were isolated with two, postural balance and head steadiness, accounting for most of the variance across tests. The remaining two factors, continuous movement accuracy and perceived verticality, contributed less to the observed variance. Conclusion: Postural balance and head steadiness were the major underlying factors explaining cervical sensorimotor control in the current sample. However, our results imply that all seven tests are independent and measure different skills. It is not possible to recommend a test battery for clinical practice, as all tests measure unique skills which appear to be independent of each other.

Research is limited as to whether Functional Movement Screen scores relate to non-contact injury risk in rugby league players. This cohort study investigates whether the Functional Movement Screen score predicts non-contact injuries in elite adolescent rugby league players. Australian adolescent rugby league players (n = 52; mean age 16.0 ± 1.0 years) from one club participated in this study. Functional Movement Screen scores, height, and mass were collected at the beginning of the preseason. Training, match exposure, and injury incidence data (non-contact match and training injuries with three levels of severity) were recorded for each individual athlete throughout the season. Linear and logistic regression analyses were conducted to investigate the association between Functional Movement Screen score (continuous score, = 14 or > 14, and three subscores) and injury risk, whilst controlling for exposure time. The mean Functional Movement Screen score for the sample was 13.4 (95% CI: 11.0¿14.0). A total of 72 non-contact injuries were recorded (incidence rate: 18.7 per 1000 exposure hours; 95% CI: 11.6¿24.8). There were no statistically significant associations between non-contact injury and Functional Movement Screen score for any of the analyses conducted. Our results suggest that the Functional Movement Screen does not reflect non-contact injury risk in elite adolescent rugby league players. Further research should investigate whether a more sport-specific movement screen in the preseason can more effectively predict injury risk in this population.

Objectives: The main research aims were to investigate whether physical therapists are examining the hip(s) in individuals with a primary complaint of low back pain (LBP) and if so, the interventions being provided that target the hip(s). Methods: An anonymous electronic survey was distributed to the membership of the American Physical Therapy Association Orthopaedic and Sports Sections, as well as that of the American Academy of Orthopaedic Manual Physical Therapists. Participant demographics and survey responses were analyzed using descriptive statistics. Associations between variables were examined using chi-square analysis. Results: The estimated response rate was 18.4% (n = 1163, mean age 40.5 ± 11.4 years). The majority of respondents (91%, n = 1059) reported they always or most of the time examined the hip(s) in individuals with LBP. The most common examination items utilized were hip strength testing (94%, n = 948), passive range of motion (91%, n = 921) and muscle flexibility testing (90%, n = 906). The most common interventions included hip strengthening (94%, n = 866) and hip flexibility exercises (90%, n = 814). Respondents enrolled in or having completed a post-professional fellowship were more likely to utilize hip joint manual therapy techniques (x = 25.3, p = <0.001) and less likely to prescribe hip flexibility exercises (x = 7.9, p = 0.005) or use electrophysical modalities (x = 4.3, p = 0.039). Conclusions: Physical therapists commonly examine and provide interventions directed at the hip(s) for individuals with LBP. Post-professional fellowship training appears to influence the intervention selection of the physical therapist, with an increase in usage of hip joint manual therapy and a decrease in hip muscle flexibility and modality usage. 2 2 2

Objective: This study aimed to identify posture deviations in rugby league players, and to observe relationships between posture and the incidence of non-contact lower limb injury. Design: Prospective cohort. Setting: Laboratory and on-field. Participants: Junior representative, semi-professional and professional rugby league players (n = 207). Main outcome measures: Static posture scores from photographs (Watson and MacDonncha tool) in pre-season; non-contact lower limb injury surveillance and exposure data. Methods: Chi-square and logistic regression analyses were used to observe relationships between postural components and the incidence of non-contact lower limb injury. Results: 8.7% of players sustained a quadriceps injury; 7.2% sustained a calf injury. Semi-professional and professional players had the highest injury rates. The most common posture deviations were having a forward shoulder position (46.9%), a forward head position (33.3%), a varus knee interspace (32.9%) or a lumbar lordosis (30.9%). A moderate C-scoliosis deviation was associated with a decrease in injury risk (OR 1.57 95% CI 1.00-2.46 p = 0.052). Included in the model was player weight, which was associated with an increased risk of injury (OR 1.04 95% CI 1.01-1.07 p = 0.010). Conclusions: Although postural deviations are common in rugby league players, given the lack of association with injury, they may not warrant intervention.

Objective: To systematically review whether there is an association between hip range of motion (ROM) and nonspecific low back pain (NSLBP). Data sources: MEDLINE, EMBASE, Cochrane library, PsychINFO, CINAHL and AMED databases were searched from year of inception until October 31st, 2018, using a combination of LBP and hip joint search terms. Commonly cited journals were also hand searched within the previous two years. Study selection: Two reviewers independently screened identified articles, by title and abstract and then by full-text. After first round screening of 2908 identified records, 248 progressed to full-text screening. Due to the heterogeneity of studies identified, post hoc inclusion criteria of English language, studies comparing subjects with NSLBP and healthy controls, cross-sectional design, and clinical measures of hip ROM were applied. Twenty-four records were finally included. Data extraction: Extracted data included population characteristics, duration and severity of NSLBP, hip movement direction, testing position, measurement tool and between-group difference. The Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was used to assess for study bias. Data synthesis: Hip flexion ROM was measured in seven studies, extension in 13, internal rotation (IR) in 14, external rotation (ER) in 13, abduction in six, and adduction in only two studies. Among all directions tested, IR ROM was reported in more studies as significantly reduced in NSLBP subjects compared to healthy individuals. Overall the quality of evidence was very low. Common sources of study bias included lack of sample size justification, blinding of outcome assessors, adjusting for key confounders, and poor reporting. Conclusion: There is very low-quality evidence to support an association between limited hip ROM and NSLBP. Limited hip IR ROM was the only movement impairment found to be significantly associated with NSLBP, however this should be viewed with caution due to the low-quality supportive evidence. Further studies are needed.

Background: There is a growing number of clinical prediction rules (CPRs) relevant to physiotherapy, particularly in the musculoskeletal area, but many students are not learning about them due to lack of awareness or understanding by clinical educators. An educational package specifically designed for physiotherapy clinical educators would aid their understanding of CPRs and ability to utilise them clinically, and also to be able to teach them to students. Objectives: To determine the desired content and preferred methods of delivery of an educational package for clinical educators on musculoskeletal CPRs. Design: A qualitative descriptive approach using semi-structured group and individual interviews with clinical educators. Method: Educators working in the clinical area of musculoskeletal physiotherapy who had an awareness of or interest in CPRs were recruited and interviewed on their views regarding the content and delivery of an educational package on musculoskeletal CPRs. Audio files were transcribed and analysed using framework analysis to explore and develop themes and subthemes. Findings: Content of an educational package should include general information on CPRs to improve familiarity and understanding, including a brief description, purpose, stages of development, application, limitations, and Information to dispel common myths and misunderstandings, as well as some specific examples of commonly-used CPRs. The package should be available in multiple formats to allow for different learning styles, both online via video, webinars, and podcasts, and face-to-face in practical sessions. Conclusions: Clinical educators would find an educational package useful in assisting them to learn about musculoskeletal CPRs and to teach them to students.

Objective: To assess the clinical benefits of joint mobilization for ankle sprains. Data Sources: MEDLINE, MEDLINE In-Process, Embase, AMED, PsycINFO, CINAHL, Cochrane Library, PEDro, Scopus, SPORTDiscus, and Dissertations and Theses were searched from inception to June 2017. Study Selection: Studies investigating humans with grade I or II lateral or medial sprains of the ankle in any pathologic state from acute to chronic, who had been treated with joint mobilization were considered for inclusion. Any conservative intervention was considered as a comparator. Commonly reported clinical outcomes were considered such as ankle range of movement, pain, and function. After screening of 1530 abstracts, 56 studies were selected for full-text screening, and 23 were eligible for inclusion. Eleven studies on chronic sprains reported sufficient data for meta-analysis. Data Extraction: Data were extracted using the participants, interventions, comparison, outcomes, and study design approach. Clinically relevant outcomes (dorsiflexion range, proprioception, balance, function, pain threshold, pain intensity) were assessed at immediate, short-term, and long-term follow-up points. Data Synthesis: Methodological quality was assessed independently by 2 reviewers, and most studies were found to be of moderate quality, with no studies rated as poor. Meta-analysis revealed significant immediate benefits of joint mobilization compared with comparators on improving posteromedial dynamic balance (P=.0004), but not for improving dorsiflexion range (P=.16), static balance (P=.96), or pain intensity (P=.45). Joint mobilization was beneficial in the short-term for improving weight-bearing dorsiflexion range (P=.003) compared with a control. Conclusions: Joint mobilization appears to be beneficial for improving dynamic balance immediately after application, and dorsiflexion range in the short-term. Long-term benefits have not been adequately investigated.

Background: neck pain and injury are common in rugby union. physical characteristics predisposing players to neck injury are largelyunknown. This study aimed to determine physical characteristics associated with neck pain and injury in rugby union players.MeThodS: Semi-professional rugby union players (n.=142) underwent pre-season measurements including cervical active range of motion(aroM), strength, sensorimotor proprioception (joint position error), and anthropometry. a structured interview established previous neckinjury history, current symptoms, playing position, competition level, age, and years playing rugby. Team physiotherapists and player telephoneinterviews identifed players sustaining a neck injury during the competitive season (defned as any reported neck pain or neck injury). T-tests orMann-Whitney u tests determined differences between neck injured and non-injured players. logistic regression determined factors associatedwith neck injury history and incidence.RESULTS: Sixty-fve (46%) players reported a previous neck injury; 11 (8%) sustained a neck injury during the competitive season. Player age(OR 1.14, 95% CI 1.03-1.25, P=0.009) was associated with neck injury history. Pre-season lateral flexion AROM was less in players sustaininga neck injury or reporting neck pain during the season (median left 23.6°, IQR 21.8-26.2°; right 27.9°, 23.6-32.5°) than in other players (left34.8°, 28.8-41.0°, P<0.01; right 39.1°, 28.9-48.1°, P=0.03). Lateral flexion AROM was associated with increased risk of neck pain or injury (OR0.82, 95%ci 0.71-0.94, p=0.005).CONCLUSIONS: Decreased cervical lateral flexion AROM may contribute to neck injury risk in rugby union players. However, few physicalcharacteristics predicted neck injury incidence, suggesting additional factors should be explored to determine injury risk.

Context: Scapular taping can offer clinical benefit to some patients with shoulder pain; however, the underlying mechanisms are unclear. Understanding these mechanisms may guide the development of treatment strategies for managing neuromusculoskeletal shoulder conditions. Objective: To examine the mechanisms underpinning the benefits of scapular taping. Design: Descriptive laboratory study. Setting: University laboratory. Patients or Other Participants: A total of 15 individuals (8 men, 7 women; age ¼ 31.0 6 12.4 years, height ¼ 170.9 6 7.6 cm, mass ¼ 73.8 6 14.4 kg) with no history of shoulder pain. Intervention(s): Scapular taping. Main Outcome Measure(s): Surface electromyography (EMG) was used to assess the (1) magnitude and onset of contraction of the upper trapezius (UT), lower trapezius (LT), and serratus anterior relative to the contraction of the middle deltoid during active shoulder flexion and abduction and (2) corticomotor excitability (amplitude of motor-evoked potentials from transcranial magnetic stimulation) of these muscles at rest and during isometric abduction. Active shoulder-flexion and shoulder-abduction range of motion were also evaluated. All outcomes were measured before taping, immediately after taping, 24 hours after taping with the original tape on, and 24 hours after taping with the tape removed. Results: Onset of contractions occurred earlier immediately after taping than before taping during abduction for the UT (34.18 6 118.91 milliseconds and 93.95 6 106.33 milliseconds, respectively, after middle deltoid contraction; P ¼ .02) and during flexion for the LT (110.02 6 109.83 milliseconds and 5.94 6 92.35 milliseconds, respectively, before middle deltoid contraction; P ¼ .06). These changes were not maintained 24 hours after taping. Mean motor-evoked potential onset of the middle deltoid was earlier at 24 hours after taping (tape on ¼ 7.20 6 4.33 milliseconds) than before taping (8.71 6 5.24 milliseconds, P ¼ .008). We observed no differences in peak root mean square EMG activity or corticomotor excitability of the scapular muscles among any time frames. Conclusions: Scapular taping was associated with the earlier onset of UT and LT contractions during shoulder abduction and flexion, respectively. Altered corticomotor excitability did not underpin earlier EMG onsets of activity after taping in this sample. Our findings suggested that the optimal time to engage in rehabilitative exercises to facilitate onset of trapezius contractions during shoulder movements may be immediately after tape application.

STUDY DESIGN: Systematic review. BACKGROUND: Therapeutic exercise is commonly used to treat individuals with knee disorders, but dosing parameters for optimal outcomes are unclear. Large variations exist in exercise prescription, and research related to specific dosing variables for knee osteoarthritis, patellar tendinopathy, and patellofemoral pain is sparse. OBJECTIVES: To identify specific doses of exercise related to improved outcomes of pain and function in individuals with common knee disorders, categorized by effect size. METHODS: Five electronic databases were searched for studies related to exercise and the 3 diagnoses. Means and standard deviations were used to calculate effect sizes for the exercise groups. The overall quality of evidence was assessed using the Physiotherapy Evidence Database scale. RESULTS: Five hundred eighty-three studies were found after the initial search, and 45 were included for analysis after screening. Physiotherapy Evidence Database scale scores were "fair" quality and ranged from 3 to 8. For knee osteoarthritis, 24 total therapeutic exercise sessions and 8- and 12-week durations of exercise were parameters most often associated with large effects. An exercise frequency of once per week was associated with no effect. No trends were seen with exercise dosing for patellar tendinopathy and patellofemoral pain. CONCLUSION: This review suggests that there are clinically relevant exercise dosing variables that result in improved pain and function for patients with knee osteoarthritis, but optimal dosing is still unclear for patellar tendinopathy and patellofemoral pain. Prospective studies investigating dosing parameters are needed to confirm the results from this systematic review.

BACKGROUND: Limited literature exists investigating biomechanical changes during a Functional Capacity Evaluation (FCE). OBJECTIVE: To determine change in joint angle measurement between minimum load to safe maximum load in the bench to shoulder lift of the WorkHab FCE. METHODS: Dartfish ProSuite was used to analyse bench to shoulder lift video from 28 subjects. Measurements of joint angle at lumbar spine, thoracic spine, elbow and shoulder at four points in the ascending and descending lift phases (0/3, 1/3, 2/3, 3/3) in the minimum load and safe maximum lift were collected. Paired t-tests were used to analyse differences in joint angles between lifts. RESULTS: Significant differences in joint angles were identified in the thoracic spine, elbow and shoulder at maximal weight. Increased extension occurred: Thoracic spine at 3/3 ascending [2.922, 95% CI 0.8, 3.8, p=0.004]. Increased flexion occurred: elbow ascending [1/3:6.405, 95% CI -11.8, 1.8, p=0.008],[3/3:15.575, 95% CI 4.2, 27.0, p=0.009]; elbow descending [0/3:18.446, 95% CI 9.5, 27.4, p=0.000]; shoulder ascending [3/3:16.785, 95% CI 11.8, 21.8, p<0.001]; shoulder descending [0/3:16.647, 95% CI 10.6, 22.7, p<0.001]. CONCLUSIONS: This study provides insight into the biomechanical changes during a bench to shoulder lift and support observations and clinical reasoning used in determining the safe maximal lift.

Objective: The purpose of this review was to identify doses of exercise therapy associated with greater treatment effect sizes in individuals with common musculoskeletal disorders of the foot and ankle, namely, achilles tendinopathy, ankle sprains and plantar heel pain. Methods: AMED, EMBASE and MEDLINE were searched from 2005 to August 2017 for randomized controlled trials related to exercise for these three diagnoses. The Physiotherapy Evidence Database scale was used for methodological quality assessment. Exercise dosing variables and outcome measures related to pain and function were extracted from the studies, and standardized mean differences were calculated for the exercise groups. Results: Fourteen studies met the final inclusion. A majority of the studies showed large effects and two small trends were identified. Patients with plantar heel pain may benefit more from a daily home exercise program than two supervised visits per week (SMD = 3.82), but this recommendation is based on weak evidence. In achilles tendinopathy, a relationship was also seen when sets and repetitions of eccentric exercise were performed as tolerated (SMD = 1.08 for function, -1.29 for pain). Conclusions: Session duration, frequency, total number of visits, and overall length of care may all be dosing variables with limited value for determining effective exercise prescription. However, the limited number of studies prevents any definitive conclusions. Further investigation is warranted to improve our understanding of the influence exercise dosing has on treatment effect sizes. Future randomized controlled trials comparing specific exercise dose variables should be conducted to clarify the impact of these variables.

STUDY DESIGN: Systematic review and metaanalysis. BACKGROUND: An increasing number of physical therapists in the United States and throughout the world are using dry needling to treat musculoskeletal pain. OBJECTIVE: To examine the short- and longterm effectiveness of dry needling delivered by a physical therapist for any musculoskeletal pain condition. METHODS: Electronic databases were searched. Eligible randomized controlled trials included those with human subjects who had musculoskeletal conditions that were treated with dry needling performed by a physical therapist, compared with a control or other intervention. The overall quality of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation. RESULTS: The initial search returned 218 articles. After screening, 13 were included. Physiotherapy Evidence Database quality scale scores ranged from 4 to 9 (out of a maximum score of 10), with a median score of 7. Eight meta-analyses were performed. In the immediate to 12-week follow-up period, studies provided evidence that dry needling may decrease pain and increase pressure pain threshold when compared to control/sham or other treatment. At 6 to 12 months, dry needling was favored for decreasing pain, but the treatment effect was not statistically significant. Dry needling, when compared to control/sham treatment, provides a statistically significant effect on functional outcomes, but not when compared to other treatments. CONCLUSION: Very low-quality to moderatequality evidence suggests that dry needling performed by physical therapists is more effective than no treatment, sham dry needling, and other treatments for reducing pain and improving pressure pain threshold in patients presenting with musculoskeletal pain in the immediate to 12-week follow-up period. Low-quality evidence suggests superior outcomes with dry needling for functional outcomes when compared to no treatment or sham needling. However, no difference in functional outcomes exists when compared to other physical therapy treatments. Evidence of long-term benefit of dry needling is currently lacking.

Objectives Clinical reasoning can be difficult to teach to pre-professional physiotherapy students due to their lack of clinical experience. It may be that tools such as clinical prediction rules (CPRs) could aid the process, but there has been little investigation into their use in physiotherapy clinical education. This study aimed to determine the perceptions and experiences of physiotherapy students regarding CPRs, and whether they are learning about CPRs on clinical placement. Design Cross-sectional survey using a paper-based questionnaire. Participants Final year pre-professional physiotherapy students (n¿=¿371, response rate 77%) from five universities across five states of Australia. Results Sixty percent of respondents had not heard of CPRs, and a further 19% had not clinically used CPRs. Only 21% reported using CPRs, and of these nearly three-quarters were rarely, if ever, learning about CPRs in the clinical setting. However most of those who used CPRs (78%) believed CPRs assisted in the development of clinical reasoning skills and none (0%) was opposed to the teaching of CPRs to students. The CPRs most commonly recognised and used by students were those for determining the need for an X-ray following injuries to the ankle and foot (67%), and for identifying deep venous thrombosis (63%). Conclusions The large majority of students in this sample knew little, if anything, about CPRs and few had learned about, experienced or practiced them on clinical placement. However, students who were aware of CPRs found them helpful for their clinical reasoning and were in favour of learning more about them.

Objective: To determine whether nonmodifiable and modifiable risk factors [ankle dorsiflexion range of motion (ROM), lower limb power output, and balance], as identified in preseason screening, predict the risk of sustaining a noncontact ankle injury in amateur male soccer players during the training and competitive season. Design: Prospective cohort study. Setting: Amateur soccer competition (club and area representative teams). Participants: Amateur soccer players (n = 210) aged =15 years. Assessment of Risk Factors (Independent Variables): Height, weight, ankle dorsiflexion ROM, power (vertical jump) and balance (time of double-leg balanced stance on an electronic wobble board, maximum 20 seconds) measured in preseason screening. Main Outcome Measures (Dependent Variable): Incidence of noncontact ankle injury and exposure to both training and games, monitored during the competitive season following baseline measurement. Noncontact ankle injury was defined as any ankle injury not caused by a collision (with another player or object) resulting in a participant missing at least 1 game or training session. Results: Fourteen of the 210 participants (6.7%) sustained a noncontact ankle injury yielding an injury rate of 0.484 injuries per 1000 player hours. Lower limb power output scores <30 W/kg [odds ratio (OR), 9.20, 95% confidence interval (CI), 1.13-75.09, P = 0.038] and poorer balance scores (OR, 0.43, 95% CI, 0.21-0.89, P = 0.024) were associated with higher odds of injury. Conclusions: Poorer lower limb power output and balance are risk factors for noncontact ankle injury among amateur soccer players. These deficits can potentially be identified by screening, providing opportunities to investigate prevention strategies.

© 2016 John Wiley & Sons Australia, Ltd The development of student-practitioners' practical clinical skills is essential in health professional education. Objective Structured Clinical Examinations are central to the assessment of students performing clinical procedures on simulated patients (actors). While feedback is considered core to learning providing timely, individualised student OSCE feedback is difficult. This study explored the perceptions of students about the multiple factors which shape the utility of e-feedback following an electronic Objective Structured Clinical Examinations, which utilized iPad and specialised software. The e-feedback was trialled in four courses within occupational therapy and physiotherapy pre-professional programs with a cohort of 204 students. Evaluation of student perceptions about feedback was collected using two surveys and eight focus groups. This data showed three factors shaped perceptions of the utility of e- Objective Structured Clinical Examinations feedback: 1) timely accessibility within one day of the assessment, 2) feedback demonstrating examiners' academic literacy and 3) feedback orientated to ways of improving future performance of clinical skills. The study found training in the provision of feedback using IPads and software is needed for examiners to ensure e-feedback meets students' needs for specific, future-oriented e-feedback and institutional requirements for justification of grades.

Background. The ulnar nerve upper limb neurodynamic test (ULNT3) uses upper limb positioning to investigate symptoms arising from the ulnar nerve. It is proposed to selectively increase tension of the nerve; however, this property of the test is not well established. Objective. The aim of this study was to determine the upper limb position that results in: (1) the greatest tension of the ulnar nerve and (2) the greatest difference in tension between the ulnar nerve and the other 2 major nerves of the upper limb: median and radial. Design. This was an observational cadaver study. Methods. Tension (in newtons) of the ulnar, median, and radial nerves was measured simultaneously using 3 buckle force transducers in 5 upper limb positions in 10 embalmed human cadavers (N=20 limbs). Repeated-measures analysis of variance (ANOVA) with Bonferroni post hoc tests determined differences in tension among nerves and among limb positions. Results. The addition of shoulder horizontal abduction (H.Abd; 12.62 N; 95% confidence interval [95% CI]=10.76, 14.47) and combined shoulder abduction and internal rotation (H.Abd+IR; 11.86 N; 95% CI=9.96, 13.77) to ULNT3 (scapular depression, shoulder abduction and external rotation, elbow flexion, forearm pronation, and wrist and finger extension) produced significantly greater ulnar nerve tension compared with the ULNT3 alone (8.71 N; 95% CI=7.25, 10.17). The ULNT3+H.Abd test demonstrated the greatest difference in tension among nerves (mean difference between ulnar and median nerves=11.87 N; 95% CI=9.80, 13.92; mean difference between ulnar and radial nerves=8.47 N; 95% CI=6.41, 10.53). Limitations. These results pertain only to the biomechanical plausibility of the ulnar nerve neurodynamic test and do not account for other factors that may affect the clinical application of this test. Conclusions. The ULNT3+H.Abd is a biomechanically plausible test for detecting peripheral neuropathic pain related to the ulnar nerve. In situations where the shoulder complex will not tolerate the combination of shoulder external rotation in abduction, performing upper limb neurodynamic tests with internal rotation instead of external rotation is a biomechanically plausible alternative.

Manual therapy is effective for reducing cervicogenic dizziness, a disabling and persistent problem, in the short term. This study investigated the effects of sustained natural apophyseal glides (SNAGs) and passive joint mobilisations (PJMs) on cervicogenic dizziness compared to a placebo at 12 months post-treatment. Eighty-six participants (mean age 62 years, standard deviation (SD) 12.7) with chronic cervicogenic dizziness were randomised to receive SNAGs with self-SNAGs (n=29), PJMs with range-of-motion (ROM) exercises (n=29), or a placebo (n=28) for 2-6 sessions over 6 weeks. Outcome measures were dizziness intensity, dizziness frequency (rated between 0 [none] and 5 [>once/day]), the Dizziness Handicap Inventory (DHI), pain intensity, head repositioning accuracy (HRA), cervical spine ROM, balance, and global perceived effect (GPE). At 12 months both manual therapy groups had less dizziness frequency (mean difference SNAGs vs placebo-0.7, 95% confidence interval (CI)-1.3,-0.2, p=0.01; PJMs vs placebo-0.7,-1.2,-0.1, p=0.02), lower DHI scores (mean difference SNAGs vs placebo-8.9, 95% CI-16.3,-1.6, p=0.02; PJMs vs placebo-13.6,-20.8,-6.4, p<0.001) and higher GPE compared to placebo, whereas there were no between-group differences in dizziness intensity, pain intensity or HRA. There was greater ROM in all six directions for the SNAG group and in four directions for the PJM group compared to placebo, and small improvements in balance for the SNAG group compared to placebo. There were no adverse effects. These results provide evidence that both forms of manual therapy have long-term beneficial effects in the treatment of chronic cervicogenic dizziness.

Aim: The aim of this analysis is to establish if dietitians have the knowledge, skills and attitude to provide support to other health professional (HP) groups in the provision of weight management advice to overweight/obese patients. Methods: A secondary data analysis of a cross-sectional survey of HPs was undertaken to perform a gap analysis with regard to practices, knowledge, confidence and attitudes in the provision of weight management advice. Survey responses and additional measures (practice, knowledge, confidence and attitude scores) were compared between dietitians and other HPs. Descriptive statistics were undertaken, and differences between group ¿² tests were performed for nominal data and the Wilcoxon rank sum test for ordinal and non-parametric data. Results: About 100% of dietitians had received initial weight management training and 85% had participated in professional development training, compared with 18 and 19% of HPs, respectively, although 70% believed it was within their scope of practice to provide evidence-based advice. Dietitian respondents achieved a higher median score (maximum 10) in the following areas (practice = 6.5, knowledge = 8.0, confidence = 8.3) when compared with HP respondents (practice = 4.2, knowledge = 7.0, confidence = 5.4). The median attitude score for both groups was 6.0. Conclusions: HPs are receptive to providing evidence-based weight loss messages to overweight/obese clients in their current practice. However, weight management training is required to enhance HPs' knowledge and skills in order to increase confidence and improve practice skills. Dietitians can assist HPs to ensure that clear, consistent, evidence-based messages are delivered to overweight clients throughout the health-care system.

A cross-sectional survey was conducted in a regional area in Australia to measure nurses' perceptions, practices, and knowledge in regard to providing healthy lifestyle advice to people who are overweight or obese. Responses were compared between geographic regions. Participation was voluntary and anonymous. Of the 79 nurse participants, 68% considered that provision of healthy lifestyle advice was within their scope of practice. Only 28% reported frequently estimating body mass index in the practice setting. Nurses often recommended increasing activity levels (44%), but recommended reducing daily caloric intake less often (25%). Nurses' knowledge about weight management was variable and the proportion of correct answers to knowledge items ranged from 33-99%. Nurses have many opportunities to deliver healthy lifestyle advice in a range of practice settings. The variation in practices and knowledge of nurses indicates a need for improved healthy lifestyle education for undergraduate and practicing nurses.

Objectives: Clinical prediction rules (CPRs) are widely used in medicine, but their application to physiotherapy practice is more recent and less widespread, and their implementation in physiotherapy clinical education has not been investigated. This study aimed to determine the experiences and perceptions of physiotherapy clinical educators regarding CPRs, and whether they are teaching CPRs to students on clinical placement. Design: Cross-sectional observational survey using a modified Dillman method. Participants: Clinical educators (n = 211, response rate 81%) supervising physiotherapy students from 10 universities across 5 states and territories in Australia. Results: Half (48%) of respondents had never heard of CPRs, and a further 25% had never used CPRs. Only 27% reported using CPRs, and of these half (51%) were rarely if ever teaching CPRs to students in the clinical setting. However most respondents (81%) believed CPRs assisted in the development of clinical reasoning skills and few (9%) were opposed to teaching CPRs to students. Users of CPRs were more likely to be male (p <. 0.001), have post-professional qualifications (p = 0.020), work in private practice (p <. 0.001), and work in the area of musculoskeletal physiotherapy (p <. 0.001) compared with non-users. The CPRs most commonly known, used and taught were the Ottawa Ankle Rule, the Ottawa Knee Rule, and Wells' Rule for Deep Vein Thrombosis. Conclusions: Students are unlikely to be learning about CPRs on clinical placement, as few clinical educators use them. Clinical educators will require training in CPRs and assistance in teaching them if students are to better learn about implementing CPRs in physiotherapy clinical practice.

BACKGROUND: The reproducibility of the HUMAC-NORM isokinetic dynamometer has not yet been established for the muscles around the knee. Previous research suggests practice-based improvement (PBI) may impact upon the reproducibility of isokinetic testing. OBJECTIVE: To investigate test-retest reproducibility of knee flexion and extension isokinetic findings at different velocities, including the influence of familiarisation. METHODS: Seventy physically active, healthy participants with no experience in isokinetic dynamometry performed five repetitions of continuous concentric knee flexion and extension at 60, 120, 180 and 240°/s on four occasions. Peak moment, angle of peak moment, total work and average power were recorded. Reproducibility was determined using percentage change in the mean, typical error and intraclass correlation coefficients (ICC). RESULTS: For knee flexion and extension, group data met desirable reproducibility criteria for most outcomes and velocities after Trial 2. Within-subject reproducibility generally met acceptable reliabilty criteria after Trial 2 for knee extension, but was predominantly unacceptable for knee flexion. ICC's were acceptable from Trial 2, except for angle of peak moment which did not achieve an acceptable level of reliabilty across any trials, outcomes or velocities. CONCLUSIONS: The HUMAC-NORM demonstrates excellent reproducibility for peak moment, average power and total work parameters for the major knee muscles after one trial. One familiarisation session is recommended prior to testing to minimise the impact of PBI. Additional familiarisation is beneficial when testing individuals, higher velocities and knee flexion.

Background: Clinicians commonly assess cervical range of motion (ROM), but it has rarely been critically evaluated for its ability to contribute to patient diagnosis or prognosis, or whether it is affected by mobilisation/manipulation. Objectives: This review summarises the methods used to measure cervical ROM in research involving patients with cervical spine disorders, reviews the evidence for using cervical ROM in patient diagnosis, prognosis, and evaluation of the effects of mobilisation/manipulation on cervical ROM. Data sources and study selection: A systematic search of MEDLINE, EMBASE, CINAHL, AMED and ICL databases was conducted, addressing one of four constructs related to cervical ROM: measurement, diagnosis, prognosis, and the effects of mobilisation/manipulation on cervical ROM. Study appraisal and synthesis: Two independent raters appraised methodological quality using the QUADAS-2 tool for diagnostic studies, the QUIPS tool for prognostic studies and the PEDro scale for interventional studies. Heterogeneity of studies prevented meta-analysis. Results: Thirty-six studies met the criteria and findings showed there is limited evidence for the diagnostic value of cervical ROM in cervicogenic headache, cervical radiculopathy and cervical spine injury. There is conflicting evidence for the prognostic value of cervical ROM, though restricted ROM appears associated with negative outcomes while greater ROM is associated with positive outcomes. There is conflicting evidence as to whether cervical ROM increases or decreases following mobilisation/manipulation. Conclusion and implications of key findings: Cervical ROM has value as one component of assessment, but clinicians should be cautious about making clinical judgments primarily on the basis of cervical ROM. Funding: This collaboration was supported by an internal grant from the Faculty of Health, The University of Newcastle.

Evidence is emerging for central nervous system (CNS) changes in the presence of musculoskeletal dysfunction and pain. Motor control exercises, and potentially manual therapy, can induce changes in the CNS, yet the focus in musculoskeletal physiotherapy practice is conventionally on movement impairments with less consideration of intervention-induced neuroplastic changes. Studies in healthy individuals and those with neurological dysfunction provide examples of strategies that may also be used to enhance neuroplasticity during the rehabilitation of individuals with musculoskeletal dysfunction, improving the effectiveness of interventions. In this paper, the evidence for neuroplastic changes in patients with musculoskeletal conditions is discussed. The authors compare and contrast neurological and musculoskeletal physiotherapy clinical paradigms in the context of the motor learning principles of experience-dependent plasticity: part and whole practice, repetition, task-specificity and feedback that induces an external focus of attention in the learner. It is proposed that increased collaboration between neurological and musculoskeletal physiotherapists and researchers will facilitate new discoveries on the neurophysiological mechanisms underpinning sensorimotor changes in patients with musculoskeletal dysfunction. This may lead to greater integration of strategies to enhance neuroplasticity in patients treated in musculoskeletal physiotherapy practice.

© 2015 Elsevier Ltd. The radial nerve neurodynamic test (ULNT2b), used to implicate symptoms arising from the radial nerve, is proposed to selectively increase strain of the nerve without increasing strain of adjacent tissue, though this has not been established. This study aimed to determine the upper limb position that results in: (1) the greatest tension of the radial nerve and (2) the greatest difference in tension between the radial nerve and the other two major nerves of the upper limb: median and ulnar. Tension (N) of the radial, median and ulnar nerves was measured simultaneously using three buckle force transducers during seven upper limb positions in the axilla of ten embalmed whole body human cadavers (n=20 limbs). Repeated measures analysis of variance (ANOVA) with Bonferroni post-hoc tests determined differences in tension between nerves and between limb positions. A Composite position consisting of ULNT2b (scapular depression, shoulder internal rotation, elbow extension, forearm pronation, wrist flexion) with the addition of shoulder abduction 40° and extension 25°, wrist ulnar deviation and thumb flexion demonstrated significantly greater tension of the radial nerve than any other tested position (mean tension 11.32N; 95% CI 10.25, 12.29, p<0.01), including ULNT2b (2.20N; 1.84, 2.57; p<0.01). Additionally, the Composite position demonstrated the greatest difference in tension between the radial and median (mean difference 4.88N; 95% CI 3.16, 6.61; p<0.01) and radial and ulnar nerves (9.26N, 7.54, 10.99; p<0.01). This position constitutes a biomechanically plausible test to detect neuropathic pain related to the radial nerve.

Background/aim: Obesity affects more than half the Australian population and has become epidemic throughout the world. Little is known regarding occupational therapy interventions with clients who are overweight or obese. This study aimed to identify occupational therapy practice in relation to the provision of weight management. This was part of a larger study investigating health professional practice. Methods: A cross-sectional study design using a self-administered, purpose-designed survey was employed to identify the current practices of occupational therapists working in a regional area of New South Wales, Australia. Participants were recruited via email or mail as publically available. Results: Fifty-one occupational therapists anonymously completed the survey. Results revealed that 53% (n = 26) of respondents did not consider weight management to be within their scope of practice or their workplace role description. The most common intervention was the provision of physical activity advice (65.2%; n = 30). Dietary advice was provided by 20.8% (n = 10), while 77% (n = 32) referred onto dietitian services. During entry-level occupational therapy education, only 7.8% (n = 4) had received weight management advice education. Completion of postgraduate professional development training in this area was reported by 14% (n = 7) of respondents. Conclusion: This study provides insight into the current practices of Australian occupational therapists in relation to the provision of weight management advice. This research displays a need to acknowledge both a generic and a discipline-specific role for the provision of healthy lifestyle interventions. This may be achieved through better access to education during entry-level programmes and in the workplace. © 2013 Occupational Therapy Australia.