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Advanced assessment/practice and managing complex patients

OR-CS-002
COST-EFFECTIVENESS OF NECK-SPECIFIC EXERCISE IN THE TREATMENT OF CHRONIC WHIPLASH ASSOCIATED DISORDERS
M. Landn Ludvigsson 1,*, A. Peolsson, G. Peterson 1 2, . Dedering 3, G. Johansson 4, L. Bernfort 5
1
Medical and Health Sciences, Physiotherapy, Linkping University, Linkping, 2Centre for Clinical Research Srmland, Uppsala University, Eskilstuna, 3Division of
Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, 4Institute of Environmental Medicine, Unit of Occupational Medicine,
Karolinska Insitutet, Stockholm, 5Medical and Health Sciences, Division of Health Care Analysis, Linkping University, Linkping, Sweden
Background: Whether neck-specific exercise is cost-effective in whiplash associated disorders (WAD) treatment has not been presented.
Purpose: The purpose of this study was to analyse cost-effectiveness following three exercise regimes in chronic WAD grade 2 or 3.
Methods: This is cost-effectiveness analysis of a multicenter prospective randomized clinical trial with assessor and group allocation blinding (n=170 aged 18-63
years). Participants were randomized to one of three exercise interventions for 12 weeks: physiotherapist-led neck-specific exercise (NSE), NSE with the addition of a
behavioral approach (NSEB) or prescription of physical activity (PPA). Quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs), including
direct (health care) and indirect (production loss) costs, were determined after 1 year and data are presented from both a health-care and societal perspective.
Results: There was trend for higher QALY gains in the NSEB group compared to the NSE group, but the costs were higher. The addition of a behavioural approach to
neck-specific exercise was not cost-effective from a societal perspective compared to neck-specific exercise alone, but from a health care perspective the ICER
comparing NSEB versus NSE could been seen as reasonable (< 42,200). The prescription of physical activity did not result in any QALY gain and was thus not costeffective regardless of costs. Furthermore, even though the intervention cost was lower for the PPA group, additional health care costs were instead significantly
higher.
Conclusion: The results of this study suggest that physiotherapist neck-specific exercise is cost-effective. Health-related quality of life improved following
physiotherapist-led neck-specific exercise both with or without a behavioural approach. However, the addition of a behavioural approach was not cost-effective from
a societal perspective. Prescription of physical activity did not result in any QALY gains, and was thus not cost-effective. Future studies need to also consider costeffectiveness of the treatments given.
Implications: Physiotherapist-led neck-specific exercise in primary care is a relatively cheap intervention from a health care perspective. It may improve general
health and can be cost-effective in the management of chronic WAD grade 2 and 3. It may therefore be an important option to consider.
Funding Acknowledgements: The study was supported by the Swedish Research Council, the Swedish government through the REHSAM foundation, the Medical
Research Council of Southeast Sweden, County Council of stergtland Centres for Clinical Research in stergtland and in Srmland at Uppsala University, and
Uppsala-rebro Regional Research Council, Sweden.
Ethics Approval: The study was approved by the Regional Ethics Committee of Linkping, Sweden.
Disclosure of Interest: None Declared
Keywords: whiplash injury, cost-effectiveness, exercise

Advanced assessment/practice and managing complex patients


OR-CS-004
ALTERED GREY MATTER MORPHOLOGY OF PAIN PROCESSING REGIONS IN TRAUMATIC AND NON-TRAUMATIC CHRONIC NECK PAIN PATIENTS: RELATIONS WITH
CLINICAL PAIN MEASURES?
I. Coppieters 1,*, M. Meeus 1 2, R. De Pauw 1, K. Caeyenberghs 3, L. Danneels 1, B. Cagnie 1
1
Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, Ghent University, Ghent, 2Rehabilitation Sciences and Physiotherapy, Faculty of
Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium, 3School of Psychology, Faculty of Health Sciences, Australian Catholic University, Melbourne,
Australia
Background: Accumulating evidence suggests that patients with chronic whiplash-associated disorders (CWAD) are characterized by impaired central pain
modulation, i.e. central sensitization. Previous imaging studies of patients with central sensitivity syndromes have revealed altered morphology in pain related brain
areas, such as the cingulate, insular and prefrontal cortex. Although it can be hypothesized that structural brain alterations play a role in the persistent complaints of
CWAD, these changes remain poorly investigated. Additionally, lack of evidence exists regarding the relations between brain morphology and clinical measures of
pain.
Purpose: To quantify alterations in grey matter (GM) morphology of brain regions involved in pain processing in patients with chronic traumatic (CWAD) and nontraumatic idiopathic neck pain (CINP) compared to healthy controls. To investigate the relationship between GM morphology and clinical pain measures in both
patient groups.
Methods: Ninety-nine women, 33 CWAD, 35 CINP and 31 healthy pain-free controls were enrolled. High-resolution T1-weighted magnetic resonance (MR) images
were acquired. Subcortical brain nuclei and cortical gyri, including the cingulate cortex, orbitofrontal, postcentral and parahippocampal gyrus, insula, amygdala and
nucleus accumbens were investigated to evaluate GM volume, surface area and cortical thickness. Morphometric analyses were carried out using FreeSurfer, a
surface-based automated labelling system.
Analysis of Covariance was performed to explore differences in GM morphology. Since it is known that age has a significant influence on GM morphology, age was
included as covariate. Post hoc Bonferroni correction was applied at the 5% significance level to correct for multiple comparisons. Relations between clinical pain
measures (neck pain duration and intensity, pain dysfunctions, self-perceived central sensitization symptoms) and GM morphology were evaluated by performing
Pearson correlation analyses at the 5% significance level.
Results: Age was comparable between all study groups. In addition, neck pain duration was comparable between both patient groups. Yet, CWAD patients reported
higher current neck pain intensity compared to CINP.
Regional surface area (left medial orbitofrontal gyrus) and GM volume (left medial and right lateral orbitofrontal gyrus, left posterior cingulate cortex, right nucleus
accumbens) was decreased in CWAD compared to healthy women.
Furthermore, significant negative weak to moderate correlations (ranging from -0.36 to -0.53) between regional GM morphology (orbitofrontal, parahippocampal and
postcentral gyrus, posterior and (rostral) anterior cingulate cortex, insula, amygdala) and clinical pain measures (neck pain duration and intensity, pain dysfunctions,
central sensitization symptoms) were found in both patient groups.
Conclusion: In conclusion, this innovative research has revealed that CWAD is associated with morphological GM alterations in brain regions involved in central pain
processing. In contrast, structural brain alterations were not established in CINP. Additionally, GM morphology was negatively related to clinical pain characteristics in
chronic traumatic and non-traumatic neck pain patients. The underlying mechanisms of the observed GM alterations are unclear. Further research is warranted to
unravel whether these morphologic brain alterations occur as a result of chronic pain or vice versa.
Implications: Negative relations between GM morphology of somatosensory, affective and cognitive pain processing regions, and clinical features of pain were
observed. Thereby, it can be recommended that the rehabilitation of patients with chronic neck pain has to be biopsychosocially-driven and that the central nervous
system, including the brain has to be addressed.
Funding Acknowledgements: Iris Coppieters, PhD student at University Ghent, is funded by the Special Research Fund of Ghent University (BOF-Ghent).
Ethics Approval: This research was approved by the Ethics committee of the University Hospital Ghent, Belgium.
Disclosure of Interest: None Declared
Keywords: clinical pain measures, grey matter morphology, Magnetic Resonance Imaging

Advanced assessment/practice and managing complex patients


OR-CS-006
TWO-YEAR FOLLOW UP OF A RANDOMIZED CLINICAL TRIAL OF PAIN AND DISABILITY FOLLOWING NECK-SPECIFIC EXERCISE IN CHRONIC WHIPLASH ASSOCIATED
DISORDERS.
M. Landn Ludvigsson 1 2,*, G. Peterson 3 4, . Dedering 5 6, A. Peolsson
1
County Council of stergtland, Rehab Vst, Motala, 2Medical and Health Sciences, Physiotherapy, Linkping University, Linkping, 3Centre for Clinical Research
Srmland, Uppsala University, Eskilstuna, 4Department of Physical Therapy, Linkping University, Linkping, 5Department of Physical Therapy, Karolinska University
Hospital, 64 Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
Background: Neck specific exercise (NSE) with or without additional behavioral approach (NSEB) has been shown to reduce short term pain and disability in
individuals with a chronic whiplash associated disorders (WAD). Whether these improvements remain over time has however as of yet not been presented.
Purpose:
To explore whether NSE with, or without NSEB, also has long term benefits after 1 and 2 years over prescription of PPA regarding pain and disability in chronic WAD
management.
Methods: This is a follow-up of a multicenter prospective randomized clinical trial with assessor and group allocation blinding of 216 individuals with chronic WAD
grade 2 or 3 (aged 18-63 years). Participants were randomized to one of three exercise interventions for 12 weeks: NSE, NSEB or PPA. Neck pain intensity was
measured after one and two years with a VAS scale, and disability was measured with the Neck Disability Index (NDI). Analyses were made both by intention-to-treat,
and with a sub analyses of clinically important improved in adherent participants.
Results: Both physiotherapist-led neck-specific exercise groups reported a larger reduction of neck disability than the PPA-group who reported no reduction
(p=0.001) compared to baseline at the one-year follow-up. At two years the NSEB group reported significant reduction in NDI compared with the PPA group (p0.02).
There was also a significantly larger proportion of patients in the two physiotherapist-led neck-specific groups at both one and two years with a remaining clinically
important improvement (p0.01) compared to the PPA group. There were no significant between-group differences (p 0.15) regarding reduction in neck pain at the
1-year or 2-year follow-up. However larger proportions of individuals in the two physiotherapist-led neck-specific groups reported clinically important improvements
of pain after 1 year. The difference was non-significant at 2 years (p0.11). There was no significant difference between the two physiotherapist-led neck-specific
exercise groups in either outcome.
Conclusion: The results of this study indicate that a substantial number of individuals with chronic WAD grade 2 or grade 3 can obtain long-lasting symptom
reduction, particularly following NSE compared to PPA.
Implications: Long-lasting symptom reduction for individuals with chronic WAD, grade 2 and 3, may be obtain particularly following NSE. The addition of a NSEB is
inconclusive. The PPA did not seem to improve disability on a group level, but it is important to consider individual factors when deciding which approach may be
useful in clinical practice.
Funding Acknowledgements: The study was supported by the Swedish Research Council, the Swedish government through the REHSAM foundation, the Medical
Research Council of Southeast Sweden, County Council of stergtland Centres for Clinical Research in stergtland and in Srmland at Uppsala University, and
Uppsala-rebro Regional Research Council, Sweden.
Ethics Approval: The study was approved by the Regional Ethics Committee of Linkping, Sweden.
Disclosure of Interest: None Declared
Keywords: whiplash injury, chronic, exercise

Advanced assessment/practice and managing complex patients


OR-ED-009
ITS HARD GAINING CONSENT - A QUALITATIVE INTERVIEW STUDY WITH OSTEOPATHS
S. Vogel 1,*, T. Mars 2, T. Barton
1
Research Centre, The British School of Osteopathy, 2National Council for Osteopathic Research, London, United Kingdom
Background: Safety events in manual therapy have caused some debate in the academic literature. The focus has been on treatment of the neck. Practitioners have
expressed concerns about how to manage this clinically in terms of safety, evaluation and what to say to patients as part of the process of receiving consent. Few
studies have explored practitioners views in this area. There is a need for practitioners' views to be taken account of when identifying appropriate guidance and
resources to support them in this area of practice.
Purpose: To explore osteopathic practitioners' views about the process of gaining consent in practice
Methods: Qualitative semis structured interview study drawing on nine consultations with practitioners to finalise the interview schedule. Participants were recruited
purposefully (experience, type of practice, working with other, use of HVT, experience of safety incidents) from a larger cross sectional survey study investigating risk
assessment, attitudes to consent and osteopathic practice. Seventy four osteopaths were invited by postal invitation. Interviews took part face to face or by
telephone. Audio files were transcribed verbatim and sent for member checking by participants. NVivo 9 was used to organise the data. Sorting and categorisation
using content analysis was performed during data collection and informed subsequent interviews. Recruitment stopped after 24 interviews when the team felt data
saturation had been reached. Categories were updated and restructured through retrospective analysis of transcripts between two of the team seperately and
consensus reached to determine initial themes. The framework was reviewed by the third member of the team and the thematic analysis finalised.
Results: Twenty four interviews took place and all transcripts were included in the final analysis. Five main themes were identified: 1. Uncertainty about risk and
patients understanding of information; 2. Information about the nature of treatment, diagnosis, risks, benefits and alternatives; 3. Communication and patient
partnership; 4. Negative perceptions of the consent process; 5. Use and value of information concerning consent in the Code of Practice.
Conclusion: Practitioners are uncertain about clinical risk from treatment particularly with respect to serious harm. Information about the benefits and nature of
treatment is seen as helpful in building confidence with patients and practitioners intergrate information about risks at times as part of partnership working. However
some practitioners are concerned about the potential harm from giving information about rare risks. There is a tension between the duty to do good - beneficence,
and the freedom for patients to decide for themselves what they would like - autonomy. Concerns about loss of scope of practice and regulatory restraints were
expressed. Future work should explore consent in action to observe how these tensions are, or are not resolved in real scenarios with patients.
Implications: This study suggests a need for CPD and learning resources to enable practitioners to feel confident understanding and communicating risk appropriately
as part of the process of consent. There are opportunities to capitalise by using consent as part of building parnership and patient centered care.
Funding Acknowledgements: General Osteopathic Council
Ethics Approval: University of Bedfordshire Research Ethics Committee
Disclosure of Interest: None Declared
Keywords: COMMUNICATION, CONSENT, REGULATION

Advanced assessment/practice and managing complex patients


OR-EX-043
REMOTE KINEMATIC E-TRAINING FOR PATIENTS WITH CHRONIC NECK PAIN, A RANDOMISED CONTROLLED TRIAL
H. Sarig Bahat 1,*, K. Croft 2, A. Hoddinott 2, C. Carter 2, J. Treleaven 2
1
Physical Therapy, University of Haifa, Haifa, Israel, 2Physiotherapy, University of Queensland, Brisbane, Australia
Background: Neck pain is a common health disorder in adults. An important function of the neck is to be able to quickly and accurately move the head to react to
external stimuli. Deficits in this ability, termed kinematic impairments, such as reduced velocity and smoothness of motion, were found in patients with chronic neck
pain as compared with control. The potential benefits kinematic training for neck pain using virtual reality (VR) are that it can be tailored to the individual, providing
real-time feedback, and thus can be delivered remotely. Ultimately this type of self-training could have important implications for future use in telemedicine and
remote e-health.
Purpose: This research aimed to evaluate the efficacy of kinematic home based training in patients with chronic neck pain as compared tp controls.
Methods: This study was designed as a 3-armed randomised controlled trial, with assessor blinding. Inclusion criteria to the 2 intervention groups included prolonged
neck pain>3 months; Neck Disability Index (NDI)>12%, and pain intensity (VAS)>30 mm. Exclusion criteria included existing vestibular pathology; cervical
fracture/dislocation; systemic diseases affecting physical performance; inability to provide informed consent; or pregnancy. Eligible participants were randomised
into either control, laser or virtual reality training using a concealed allocation procedure. Each participant in the intervention groups was provided with a training
plan directed towards increasing range, velocity and accuracy of neck motion. Patients were instructed to exercise 20 minutes a day, 5 times a week for 4 weeks. One
follow up meeting via phone was conducted each week with the physiotherapist to progress their training difficulty level, and help solving problems. The control
participants received no treatment during a waiting period of 4 weeks, while the intervention groups received training. Following their waiting period, control
participants were randomised to one of the two treatments. Outcome measures included global perceived effect, quality of life, neck disability, kinesiophobia and
pain intensity. Objective measures included range, velocity, smoothness and accuracy of neck motion. Statistical analysis explored the within and between group
differences of the post-pre change using 2-way ANOVA.
Results: Preliminary results include data from 49/90 participants: 17 in the VR group, 17 in laser, and 15 controls. To date 2 individuals dropped out preintervention due to simulator sickness and failure to complete the assessment. Current mid-trial results show significant within group change (Post-intervention
improvement) in kinematics and pain intensity (VAS) in both the VR and laser group. There was also a clinically significant improvement in NDI in the VR group. There
were no differences seen in the control group. There were no significant between group differences to date, likely due to sample size. Results from the full data set
will be presented at the conference.
Conclusion: Preliminary mid-trial results suggest that both types of remote kinematic training (VR and laser) can be effective in improving velocity and pain intensity,
with VR possibly more effective in improving neck pain and disability. . Further research should look into the value of combined individual physiotherapy with
kinematic self-training, which is what is commonly provided in practice.
Implications: Current results suggest that home VR kinematic training may help neck pain intensity and selected kinematics, but may not be sufficient in the total
management of chronic neck pain.
Funding Acknowledgements: This work was funded by the Physiotherapy Research Fellowships (HMR), provided by Queensland Health, Health and Medical
Research, Preventive Health Unit.
Ethics Approval: This study was approved by the Human Medical Research Ethics Committee, University of Queensland, and registered by the Australian New Zealand
Clinical Trials Registry- registration ID: ACTRN12615000231549.
Disclosure of Interest: None Declared
Keywords: Neck pain; virtual reality; training; physiotherapy; RCT; velocity; kinematics.

Advanced assessment/practice and managing complex patients


OR-EX-045
UNDERSTANDING THE DETERMINANTS INFLUENCING REHABILITATION ADHERENCE IN OUTPATIENT MUSCULOSKELETAL PHYSIOTHERAPY: A MIXED METHODS
PROJECT
D. Ahuja 1,*, N. Nasr 2, M. Whitfield, T. Rohra, S. McLean 1
1
Sheffield Hallam University, 2University of Sheffield, Sheffield, United Kingdom
Background: Within musculoskeletal physiotherapy (PT), the concept of rehabilitation adherence is multidimensional and could relate to attendance at appointments
(AA), in-clinic adherence (ICA) or home exercise adherence (HEA). Poor rehabilitation adherence can lead to sub-optimal treatment outcomes, reduced clinic
efficiency and increased cost of care.
Purpose: Current lack of successful interventions for enhancing rehabilitation adherence points to a poor understanding of determinants of adherence. This project
was undertaken to meet this challenge and explore the determinants of rehabilitation adherence.
Methods: A multi-phase mixed methods combination design with equal emphasis on qualitative and quantitative components was chosen. A concurrent approach
was used for the first phase where a quantitative systematic review of 43 studies (Phase Ia) and a qualitative meta-ethnography of 17 studies (Phase Ib) were
conducted in parallel. These were followed by a prospective cohort (236 participants) (Phase II) and a qualitative study involving in-depth interviews (9 patients and 7
reception staff) and focus groups (16 physiotherapists and 4 managers). Results from all three phases of study were integrated using a triangulation protocol (Phase
IV) to facilitate comparison between results and identification of levels of evidence for each determinant.
Results: The trianglation of findings from all phases resulted in three key outcomes. Firstly, it brought together the findings from the previous literature researching
the determinants of rehabilitation adherence and allowed an exploration of relationship between AA, ICA and HEA. A positive therapeutic relationship emerged as
the sole determinant which was related with all three rehabilitation adherence constructs. Secondly, it highlighted the close relationship between AA and HEA and
identified several common determinants. Finally, the consensus process resulted in three independent models of determinants of AA, ICA and HEA which provide an
up to date understanding of the factors influencing rehabilitation adherence.
Conclusion: The findings from this project indicate that rehabilitation adherence is an outcome of complex interactions between personal, social, therapeutic and
organisational factors. It is unlikely that any single intervention strategy will be effective in facilitating rehabilitation adherence across all conditions and settings and
therefore a systems approach to develop a complex intervention addressing barriers at each level (patient, physiotherapist, health environment and social
environment) needs to be implemented. Further research also needs to explore consensus on definition of adherence as well as development of validated and
relaible measures of adherence.
Implications: Four key areas which need to be addressed to facilitate rehabilitation adherence are therapeutic relationship, characteristics of treatment, support for
exercises and individual internal characteristics. Physiotherapists need to examine their own important role in contributing to non-adherence. Until our educational
practices, departmental policies, training habits and clinical practices change to support better bio-psychosocially orientated practice and enhanced therapeutic
relationships, poor rehabilitation adherence is likely to continue being a problem. The exercise programs developed for the patients need to be tailored around their
personal preferences, abilities and interests.
Entry level programs need greater focus on integration of biopsychosocial models within practice as well as greater focus on clinical and personal communication
skills, pain education and exercise prescription.
Funding Acknowledgements: PhD Studentship offered by Centre for Health and Social Care Research, Sheffield Hallam University, Sheffield.
Ethics Approval: Ethics approval for Phase II (prospective cohort) and III (qualitative) was obtained from Sheffield Hallam University Research Ethics Committee (SHU
REC) as well as NRES Committee - The Yorkshire and Humber (Ref: 13/YA/0096)
Disclosure of Interest: None Declared
Keywords: attendance, musculoskeletal physiotherapy, rehabilitation adherence

Advanced assessment/practice and managing complex patients


OR-EX-046
EXERCISE BELIEFS AND BEHAVIOURS AMONGST INDIVIDUALS WITH JOINT HYPERMOBILITY SYNDROME/ EHLERS DANLOS SYNDROME HYPERMOBILITY TYPE
J. Simmonds 1 2,*, A. Hakim 1, A. Herbland 3, N. Ninis 1 4, Q. Aziz 1 5, W. Lever 6, M. Cairns 3 7
1
Hypermobility Unit, Hospital of St John and St Elizabeth, 2Institute of Child Health, University College London, 3Health and Social Care, University of Hertfordshire,
London, 4Paediatrics, Imperial NHS Trust, nelly.ninis@imperial.nhs.uk, 5Neurogastrology, Barts NHS Hospital Trust, 6Dept of Pathology, University of Cambridge,
London, 7Physiotherapy, Physiocare, Twyford, United Kingdom
Background: Joint hypermobility syndrome is a complex multisystem hereditary disorder of connective tissue (HDCT). Many authorities now consider JHS to be
indistinguishable from Ehlers-Danlos Syndrome - Hypermobility Type (EDS-HT). The term JHS/EDS-HT is used here to describe these inseparable entities. The reported
prevalence of JHS/EDS-HT in musculoskeletal rheumatology and physiotherapy outpatient settings in the UK ranges between 30% and 60%. Physiotherapy plays a
central role. Exercise and pain management is considered the treatment of choice, however there is limited research evidence about optimal exercise prescription.
Greater understanding of individual preferences, perceptions of exercise and patients experience of physiotherapy is needed to optimise treatment approaches.
Purpose: To explore the beliefs and behaviours about exercise amongst individuals with JHS/ EDS-HT. A secondary objective was to explore experiences of
physiotherapy.
Methods: A survey design collected quantitative and qualitative data via a self administered questionnaire. Expert opinion was sought from physiotherapists,
rheumatology consultants and patients to ensure face validity of the questionnaire. The questionnaire was distributed to members of the Hypermobility Syndrome
Association (HMSA) and Ehlers Danlos Syndrome Support UK (EDSUK) aged 18 years and older. 948 questionnaires were returned. Data was scrutinised and 2
duplicate questionnaires were removed. Descriptive statistics and Chi squared tests using SPSS v23 were used to analyse the data. 12 incomplete questionnaires were
included in this data analysis. Qualitative data were analysed thematically.
Results: Nine hundred females and 46 males completed the questionnaire. 90% (897/946) of respondents suffered 'constant' or 'frequent' joint pain while 87%
(819/946) suffered 'constant' or 'frequent' fatigue. Spinal pain was the most commonly reported site of pain (668/946). Mental health disorders 44% (411/946),
cardiovascular dysautonomia 41% (385/946), gastrointestinal dysfunction 27% (251/946) were the most frequently reported comorbidities. 81% of respondents
(755/942) had received exercise advice from a physiotherapist. 90% (860/946) agreed or strongly agreed that exercise was important for fitness, while 78%
(741/946)/) agreed or strongly agreed that exercise was important for their well-being. These beliefs were also associated with the amount of weekly exercise
undertaken (P < 0.001). 41% (380/946) agreed or strongly believed exercise helped their pain, while 59% (566/946) were 'undecided' or 'disagreed'. Swimming
28%(261/946), walking 24% (233/946) and Pilates 22% (n=221/946) were reported as the most helpful modes of exercises. 87% of respondents (821/946) reported
pain to be a barrier to exercise, while fatigue 79% (745/946) and fear of injury 50% (468/938) were also reported. Three themes emerged regarding experience of
physiotherapy, physiotherapist as a partner, communication and knowledge and experience.
Conclusion: JHS/EDS-HT is a complex HDCT and comorbidities may coexist. The majority of individuals surveyed had been given exercise advice by a physiotherapist
and believed exercise to be important for fitness and wellbeing. Swimming, walking and Pilates were reported to be the most helpful modes of exercises. Pain, fatigue
and fear of injury were reported barriers to exercise. Physiotherapists working in partnership with individuals, who communicated clearly and who were
knowledgeable about JHS/ EDS-HT provided a positive patient experience.
Implications: Physiotherapists need to be mindful of the presence of possible complex comorbidities. Beliefs, barriers and fears regarding exercise may influence
adherence. Swimming, walking and Pilates may be helpful forms of exercise for individuals with JHS/ EDS-HT.
Funding Acknowledgements: Musculoskeletal Association of Chartered Physiotherapists, Ehlers Danlos Support UK, Hypermobility Syndrome Patient Association.
Ethics Approval: University of Hertfordshire, School of Health and Emergency Professions Ethics Committee.
Disclosure of Interest: None Declared
Keywords: Hypermobility Syndrome, Ehlers Danlos syndrome, Exercise

Advanced assessment/practice and managing complex patients


OR-LL-013
PROXIMAL LOWER LIMB KINEMATICS DIFFER IN PEOPLE WITH CHRONIC ANKLE INSTABILITY COMPARED TO CONTROLS DURING TREADMILL WALKING
H. Cook 1, K. Tucker 2, W. van den Hoorn 1, D. Button 1, M. Smith 1,*
1
School of Health and Rehabilitation Sciences, 2School of Biomedical Sciences, The University of Queensland, Brisbane, Australia
Background: Aberrant lower limb alignment during functional tasks is associated with increased risk of lower limb injuries and disease. Dysfunction in multiple areas
of the lower limb is often reported in people with musculoskeletal conditions. The majority of research into impairments following ankle sprains has focused on
changes local to the ankle; however, there is preliminary evidence of changes in proximal kinematics and muscle function in people with chronic ankle instability (CAI)
during some functional tasks. Changes in not been investigated during important daily activities, such as flat or downhill walking. It is important to understand the
influence of CAI on the entire lower kinetic chain as changes in proximal kinematics may influence efficiency of performance, distal limb function and risk of further
musculoskeletal injury.
Purpose: The aim of this study was to determine if pelvis, hip, knee and ankle kinematics are different in people with CAI compared to control participants during flat
and downhill treadmill walking.
Methods: Pelvic, hip, knee and ankle kinematics of 20 participants with CAI and 15 uninjured control participants (mean (standard deviation) age 24.8 (8.8) and 24.5
(7.7) years, p=0.89; BMI 23.7 (4.1) and 21.9 (2.0) kg/m2, p=0.13 respectively) were captured using a 10-camera 3D motion analysis system (Optitrack, Natural Point).
Data was collected when walking on a treadmill at 4.6 km/hr during both flat and downhill (with a decline of 4 degrees) walking conditions.
Results: During walking, participants with CAI demonstrated greater pelvic rotation (transverse plane) range of motion (ROM, p=0.038), greater peak anterior pelvic
tilt (sagittal plane, p=0.004), less peak posterior pelvic tilt (sagittal plane, p=0.033), and less peak hip extension ROM (p=0.028) than uninjured control participants. No
differences in knee or ankle kinematics were observed between CAI and control groups. Consistent with previous literature, all measured lower limb kinematics were
significantly different between flat and downhill walking (all p0.01, with the exception of peak knee extension and peak posterior pelvic tilt, both p=0.07), however
the changes in kinematics with altered slope, were consistently observed in both groups (all interactions p>0.08).
Conclusion: People with CAI have altered pelvic and hip kinematics during flat and downhill walking compared to uninjured controls. Interestingly, kinematics
differences between groups were present in the proximal joints of the lower limb (pelvis and hip), but not the more distal joints (ankle and knee).
Implications: This study highlights the need to consider the function of the proximal lower limb in the management of CAI. Alternations in pelvic and hip kinematics in
CAI may be related to the persistence of symptoms and repeated ankle sprains that are characteristic of this condition. It is not possible from this study to determine
if the kinematic differences were present prior to the development of CAI, or are the consequence of the chronic musculoskeletal condition. Further research is this
area is warranted.
Funding Acknowledgements: This project was funded by a grant from The University of Queensland.
Ethics Approval: This study received ethical approval from the Medical Research Ethics Committee at The University of Queensland.
Disclosure of Interest: H. Cook: None Declared, K. Tucker Conflict with: Supported by a grant from The University of Queensland, W. van den Hoorn: None Declared,
D. Button: None Declared, M. Smith Conflict with: Supported by a grant from The University of Queensland
Keywords: chronic ankle instability, gait, kinematics

Advanced assessment/practice and managing complex patients


OR-LL-016
WHAT IS THE ROLE OF GAIT ASSESSMENT IN PEOPLE WITH GLUTEAL TENDINOPATHY? A CASE CONTROLLED STUDY COMPARING GAIT CHARACTERISTICS OF THOSE
WITH GLUTEAL TENDINOPATHY VS HIP OA
A. Fearon*, J. Scarvell 1, T. Neeman 2, J. Cook 3, P. Smith 4
1
School of Physiotherapy, University of Canberra, 2Statistical Consulting Unit, Australian National University, Canberra, 3Latrobe Centre of Sport and Exercise Medicine
Research, Latrobe University, Melbourne, 4ANU Medical School, Australian National University, Canberra, Australia
Background: Crossing the road at an appropriate speed and to stand safely on one leg are measures of independence. People with severe hip OA are recognised as
having high levels of pain and disability (NAMSCAG 2004); however, the level of activity related disability associated with gluteal tendinopathy has not been
established.
Purpose: The purpose of the study was to evaluate gait disturbances in people with gluteal tendinopathy and compare them to a group of people known to have
significant disability - those with hip osteoarthritis.
Methods: Prospective observational study with blinded assessors. 36 participants with gluteal tendinopathy (GT) (mean (SD)) age: 52.6 (12.3) and 20 with hip
osteoarthritis (OA) (mean (SD)) age: 62.0 (12.0) were included; inclusion and exclusion criteria ensured the groups were mutually exclusive. Outcome measures:
Walking speed (s), cadance (steps/min), step length (m), wide of base of support (m) as measured by blinded assessors of 10mwt, and TUG. Standing was evaluated
by duration of single leg stance, walking quality was assess for Trendelenburg signs, and hip muscles strength (N) via wall mounted dynamometry.
Results: The GT group did not demonstrate superior speed (mean diff. (95%ci)) 0.15s (-0.02 to 0.32), cadence (mean diff. (95%ci)) 2.1 steps/minute (-7.6 to 11.7) or
width of base of support (mean diff. (95%ci)) 0.0 (-0.0 to 0.5) over 10m. The GT group was faster for the TUG (mean diff. (95%ci)) -2.0s (-3.8 to -0.2) and had a longer
step length (mean diff. (95%ci)) 0.09m (0.02 to 0.15). 35% fewer GT participants had an antalgic gait, 30% fewer had an ipsilateral lean, and 10% fewer had a positive
pelvic drop compared to the hip osteoarthritis group. On the affected leg, the GT group had greater hip abduction (mean diff. (95%ci)) 4.0N (0.71 to 7.3) and
adduction (mean diff. (95%ci)) 4.2N (0.18 to 6.7) strength. There was no group difference in affected leg single leg stance duration. The GT group had a longer, and
the hip osteoarthritis group had a shorter unaffected leg single leg stance duration.
Conclusion: Gait disturbances present with a loss of 40% strength of the legs. Participants in both groups demonstrated gait disturbances with trunk lean being
observed more frequently than pelvic drop.
Both groups have gait speeds that would make crossing a controlled intersection problematic. While the GT group is no faster than the OA group - the GT group has a
longer step length meaning that the GT group moved more slowly than the OA group.
The GT group was stronger in abduction than the OA group, (4N), and adduction (4N) on the symptomatic leg. This difference did not exist on the asymptomatic leg.
The hip OA group's limited single leg stance on the unaffected side was not due to limited strength.
Implications: People with gluteal tendinopathy have high levels of physical disability, affecting their ability to undertake activities of independence.
When assessing gait clinicians should look for trunk lean in addition to pelvic drop as it is more sensitive to gluteal weakness or pain related dysfunction than pelvic
drop.
Specific strengthening exercises along with pain management, neuromuscular rehabilitation, speed and agility should be incorporated in to a treatment program for
people with GT or hip OA.
Funding Acknowledgements: Angela Fearon was funded via the Australian National University
Prof. Cook was partially funded via The Australian Centre for Research into Sports Injury and its Prevention.
Ethics Approval: Approval was gained from ACTH-, ANU-, Deakin university-, and Calvary Health Care- human research ethics committees.
Disclosure of Interest: None Declared
Keywords: Gait analysis, gluteal tendinopathy, Hip Pain

Advanced assessment/practice and managing complex patients


OR-LS-020
EFFECTIVENESS OF TRANSCRANIAL DIRECT CURRENT STIMULATION ALONE OR PRECEDING COGNITIVE-BEHAVIOURAL MANAGEMENT FOR CHRONIC LOW BACK
PAIN: A RANDOMISED CONTROLLED TRIAL
K. Luedtke*, A. Rushton 1, C. Wright 1, T. Juergens 2, A. Polzer 2, G. Mueller 3, A. May 2
1
School of Sport, Exercise and Rehabilitation Sciences College of Life and Environmental Sciences, University of Birmingham, Birmingham, United Kingdom, 2Institute
of Systems Neurosciences, University Medical Center Hamburg-Eppendorf, 3Backpain Clinic "Am Michel", Hamburg, Germany
Background: Non-specific chronic low back pain (NSCLBP) has serious personal and socio-economic consequences. Guidelines recommend multimodal cognitivebehavioral management (CBT). The effectiveness might be enhanced by targeting central nervous system pain processing. Transcranial direct current stimulation
(tDCS) is a novel approach aiming to influence pain by altering cortical excitability. Systematic reviews indicated pain reducing effects based on trials with moderate
to high risk of bias.
Purpose: To evaluate the effectiveness of transcranial direct current stimulation alone and in combination with cognitive-behavioral management in patients with
non-specific chronic low back pain.
Methods: Design: A double-blind, parallel group, randomised controlled trial with a 6 months follow-up was conducted between May 2011-March 2013. Participants,
physiotherapist, assessor and analyses were blinded to group allocation.
Setting: Interdisciplinary chronic pain centre.
Participants: N=135 participants with non-specific chronic low back pain >12 weeks were recruited from 225 patients assessed for eligibility.
Intervention: Participants were randomised to receive anodal (motor cortex, 2mA, 20 minutes) or sham transcranial direct current stimulation (identical electrode
position, stimulator switched off after 30 seconds) for 5 consecutive days immediately prior to cognitive-behavioral management (4 week multidisciplinary
programme of 80 hours).
Main outcomes and measures: Two primary outcome measures of pain intensity (0-100 visual analogue scale) and disability (Oswestry Disability Index), were
evaluated at 2 primary endpoints post stimulation and post cognitive-behavioral management.
Results: ANCOVA analyses with baseline values (pain or disability) as covariates demonstrated that transcranial direct current stimulation was ineffective for the
reduction of pain (p=0.68, 1mm between group difference, 99%CI -8.69 to 6.3) and disability (p=0.86, 0 points between group difference, 99%CI -1.73 to 1.98); and
did not influence the outcome of cognitive-behavioral management (visual analogue scale: p=0.58, 2mm between group difference, 99%CI -10.32 to 6.73; Oswestry
Disability Index: p=0.92, 1 point between group difference, 99%CI -2.45 to 2.62). The stimulation was well tolerated with minimal transitory side effects.
Conclusion: This was the first adequately powered and low risk of bias trial investigating the effectiveness of transcranial direct current stimulation for the reduction
of pain and disability. The results do not support the clinical use of transcranial direct current stimulation for managing non-specific chronic low back pain.
Implications: TDCS should not be used for the reduction of the pain intensity and disability associated with chronic low back pain.
Funding Acknowledgements: German Research Foundation (MA 1862/10-1) to AM.
Ethics Approval: German ethics authorities (PV 3297) and the University of Birmingham Research Ethics Committee (ERN_10-0863)
Disclosure of Interest: None Declared
Keywords: Chronic low back pain, non-invasive brain stimulation

Advanced assessment/practice and managing complex patients


OR-LS-021
THE PREDICTIVE ABILITY OF THE START BACK SCREENING TOOL WAS LIMITED IN A COHORT WITH CHRONIC LOW BACK PAIN
M. Kendell 1, D. Beales 1, A. Smith, P. O'Sullivan 1, M. Rabey 1,*
1
School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia
Background: Chronic low back pain is problematic with significant personal, social and economic impact. The need to screen for indicators of poor prognosis and/or
stratify patients with low back pain based on risk is highlighted in the literature. The STarT Back Screening Tool (SBST) is one tool that has been developed to meet
this need. There are a lack of studies evaluating the predictive ability and clinical utility of the SBST in a population with exclusively chronic low back pain.
Purpose: To determine the predictive ability and prognostic accuracy of the SBST for persistent pain, self-reported disability and self-perceived global rating of change
in an Australian population with exclusively chronic low back pain.
Methods: The SBST was completed at baseline by 290 participants with dominantly axial non-specific low back pain of at least three months duration. Follow-up data
was collected after one year (n=264) for pain severity (11-point numerical rating scale), disability (Roland Morris Disability Questionnaire) and global perceived
change (7-point global rating of change scale). The follow-up measures were dichotomised into recovered and not recovered for analyses. The proportion of
participants who were not recovered with respect to each follow-up measure was calculated at a cohort level and by baseline SBST risk sub-group. Risk ratios (RR)
(using the low risk group as the reference group) were calculated and ROC analyses performed.
Results: At baseline, the SBST characterised 82 participants (28.3%) as low risk, 116 (40.0%) as medium risk and 92 (31.7%) as high risk. Non-recovery rates at one
year were 31.4% (n=83) for disability, 76.1% (n=201) for pain and 44.5% (n=117) for global perceived change. The predictive ability of the SBST was strongest for
disability (RR medium risk group 2.30 (95% CI 1.28-4.10), p=0.003; RR high risk group 2.86 (95% CI 1.60-5.11), p0.001) and weaker for pain (RR medium risk group
1.25 (95% CI 1.04-1.51), p=0.013; RR high risk group 1.26 (95% CI 1.03-1.52, p=0.020). The AUC for disability was acceptable at 0.71 (95% CI 0.64-0.77) for the SBST
total score and 0.67 (95% CI 0.60-0.73) for the psychological sub-scale score. The AUC for pain was poor (0.63 (95% CI 0.55-0.71)) for both the total score and
psychological sub-scale score. The SBST risk sub-groups were unable to identify those who had rated themselves as improved or not improved at one year.
Conclusion: Baseline stratification with the SBST provided some indication of overall disability risk but its ability to predict future disability was attenuated compared
to that previously reported in UK primary care with variable duration low back pain. In this study the SBST was relatively poor in predicting future pain and was
unable to discriminate between those who perceived themselves as improved or not at one year.
Implications: The SBST should be applied with caution in patients presenting with chronic low back pain. Clinicians interested in predicting future pain or global
perceived change should consider using alternative screening measures in this population. It is recommended that the SBST be used in context with the clinical
examination and in conjunction with sound clinical reasoning, clinical intuition and expert judgement, not as a standalone tool.
Funding Acknowledgements: This work was not funded.
Ethics Approval: This study was approved by the Curtin University Human Research Ethics Committee (Approval Number 112/2012).
Disclosure of Interest: None Declared
Keywords: chronic low back pain, prediction, STarT Back Screening Tool

Advanced assessment/practice and managing complex patients


OR-LS-022
DIAGNOSIS OF NERVE ROOT INVOLVEMENT IN PRIMARY CARE CONSULTERS WITH LOW BACK-RELATED LEG PAIN
S. Stynes 1,*, K. Konstantinou 1, R. Ogollah 1, M. Lewis 1, E. Hay 1, K. Dunn 1
1
Arthritis Research UK Primary Care Sciences, Keele University, Keele, United Kingdom
Background: Up to 2/3 of patients with back pain also report leg pain. Low back-related leg pain (LBLP) is either radicular due to nerve root involvement (NRI) or
referred (non-specific) leg pain. The clinical task of differentiating NRI from referred leg pain is important, but can be challenging. There is currently no agreement on
which clinical criteria best identify NRI in clinical or research settings.
Purpose: The aim of this work was (i) to determine clinicians agreement on the diagnosis of LBLP and (ii) to develop a diagnostic tool to identify patients with leg pain
due to NRI.
Methods: Part (i) was a reliability study; 36 LBLP patients were assessed by one of six physiotherapists and the assessments were video-recorded. The
physiotherapists each viewed videos of six patients they had not assessed. The videos were also viewed by another six health professionals. All clinicians made an
independent diagnosis and rated their diagnostic confidence (range 50-100%). Data was summarised using percentage agreements and kappa (k) coefficients with
two sided 95% confidence intervals (CI).
Part (ii) used cross-sectional data on 394 LBLP primary care consulters to develop the diagnostic model. The reference standard was high confidence (80%) NRI
clinical diagnosis. Potential NRI indicators were seven clinical assessment items. A multivariable logistic regression model was constructed. Performance was
summarised using the Hosmer-Lemeshow statistic and area under the curve (AUC). Bootstrapping assessed internal validity.
Results: In the reliability study (part i), agreement among physiotherapists was 72% with fair inter-rater reliability (k=0.35, 95% CI 0.07, 0.63). Results were almost
identical among the other health professionals (k=0.34, 95% CI 0.02, 0.69). There was a clear trend of increased agreement and reliability indices with higher levels of
diagnostic confidence.
In part (ii), 295 (75%) of the 394 LBLP patients had NRI according to the high confidence clinical diagnosis reference standard. The diagnostic model retained five
items: subjective sensory changes, below knee pain, leg pain worse than back pain, positive neural tension, neurological deficit. The model was well calibrated
(p=0.17) and discrimination was almost perfect AUC 0.95 (95%CI: 0.93, 0.98). Bootstrapping revealed minimal overfitting. A simple scoring tool was devised showing
the probability of NRI in a LBLP patient based on results of five clinical assessment items.
Conclusion: Reliability was fair among clinicians diagnosing NRI in primary care LBLP consulters. When confidence in clinical diagnosis is high, agreement and
reliability indices improve substantially. Using this high confidence clinical diagnosis, a diagnostic model identified items from clinical assessment that clearly
differentiated patients with NRI.
Implications: This work showed that diagnosis of NRI in LBLP is challenging and subsequently developed a tool that could be potentially used in clinical and research
settings to improve identification of this subgroup of LBLP patients.
Funding Acknowledgements: S Stynes is supported by an NIHR/CNO Clinical Doctoral Research Fellowship. Dr Konstantinou is supported by a HEFCE/NIHR Senior
Clinical Lectureship. Professor Hay is an NIHR Senior Investigator.
Ethics Approval: This work is nested within a larger study. Ethical approval granted by South Birmingham REC (ref. 10/H1207/82).
Disclosure of Interest: None Declared
Keywords: diagnosis, low back-related leg pain, Reliability

Advanced assessment/practice and managing complex patients


OR-MS-028
COMPARATIVE EFFECTIVENESS OF CONSERVATIVE INTERVENTIONS FOR NON-SPECIFIC CHRONIC SPINAL PAIN: PHYSICAL, BEHAVIOURAL/PSYCHOLOGICAL OR
COMBINED? A SYSTEMATIC REVIEW AND META-ANALYSIS.
M. O'Keeffe 1,*, H. Purtill 2, N. Kennedy 1, M. Conneely 1, J. Hurley 1, P. O'Sullivan 3, W. Dankaerts 4, K. O'Sullivan 1
1
Clinical Therapies, 2Mathematics & Statistics, University of Limerick, Limerick, Ireland, 3School of Physiotherapy and Exercise Science, Curtin University, Perth,
Australia, 4Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven - University of Leuven, Leuven, Belgium
Background: Non-specific chronic spinal pain (NSCSP) is highly disabling. Current conservative rehabilitation includes physical and behavioural and/or psychologically
informed interventions, or a combination of these approaches. While these interventions yield moderately positive results when compared to minimalist
interventions, placebo or waiting list control groups, it remains unclear whether any of these approaches are superior to the other.
Purpose: This review aimed to assess the comparative effectiveness of physical, behavioural/psychological, and combined interventions on pain and disability in
patients with NSCSP.
Methods: The MEDLINE, CINAHL, SPORTDiscus, Biomedical Reference Collection, AMED, PsycINFO, PsycARTICLES, EMBASE and Web of Science databases were
searched. Randomised controlled trials (RCTs), published in English, with participants reporting NSCSP were included. Studies were required to have an active
conservative control group for comparison. Studies were not eligible if the interventions were from the same domain (e.g. if the study compared two physical
interventions/treatments). Study quality was assessed used the Cochrane Back Review Group risk of bias criteria. The treatment effects of physical,
behavioural/psychological and combined interventions were assessed using meta-analyses.
Results: 24 studies were included. While some comparisons reached statistical significance, there were no clinically relevant differences between physical,
behavioural/psychological and combined interventions for reducing pain and disability in patients with NSCSP.
Conclusion: There were no clinically relevant differences between physical, behavioural/psychological and combined interventions for reducing pain and disability in
patients with NSCSP. All interventions had modest effectiveness, suggesting the most cost-efficient, feasible rehabilitation choice should be considered. Further work
is needed to investigate whether tailoring rehabilitation to the needs of individual patients and their perceived risk of chronicity, which has been seen in recent RCTs
for low back pain (LBP), can enhance outcomes in NSCSP.
Implications: This review suggests the most cost-efficient and feasible rehabilitation should be used for spinal pain patients and that physiotherapists may need to
tailor treatment to the patient.
Funding Acknowledgements: Mary OKeeffe was funded by the Irish Research Council.
Ethics Approval: Not applicable.
Disclosure of Interest: None Declared
Keywords: conservative interventions, non-specific chronic spinal pain, systematic review

Advanced assessment/practice and managing complex patients


OR-MT-030
CHARACTERISING PAIN MODULATION MECHANISMS UNDERPINNING LATERAL ELBOW TENDINOPATHY: A CASE CONTROL STUDY
L. Bisset 1,*, C. Pinfildi 1 2, K. Evans 1, L. Laakso 1, S. Dhupelia 3
1
School of Allied Health Sciences, Griffith University, Gold Coast Campus, Australia, 2Departamento de Cincias do Movimento Humano , Federal University of Sao
Paulo, Sao Paulo, Brazil, 3Qld XRay, Gold Coast, Australia
Background: Lateral epicondylalgia (LE) is a debilitating musculoskeletal condition that is often resistant to treatment and causes long-term pain and disability. The
lack of treatment success may be due to the way people with LE process pain within their central nervous system. There is evidence of altered pain modulation (i.e.
descending facilitation and/or inhibition) in people with LE, yet specific impairments in pain modulation are currently unknown. Furthermore, interventions that
target local tissue pathology may not be effective when pain modulation processes are affected.
Purpose: A case control observational study design was used to examine pain modulation profiles in participants with LE compared to healthy controls. A secondary
aim is to determine the relationship between pain modulation profile, clinical characteristics and local tissue pathology in people with LE.
Methods: Twenty participants with a clinical diagnosis of LE and 10 age- and sex-matched healthy control participants underwent ultrasound and MRI investigations
of their affected (or matched) elbow. In addition, static and dynamic quantitative sensory testing was conducted, including pressure pain threshold, cold pain
threshold, conditioned pain modulation, and temporal summation. Demographic and other clinical characteristics (pain-free grip strength, PFG; Patient-Rated Tennis
Elbow Evaluation, PRTEE) were also collected.
Results: Participants with LE who exhibited a pro-nociceptive pain profile also exhibited higher levels of pain and disability (PRTEE 65.3 9.6, CPT 19.0 16.6C, PFG
affected/unaffected 19.7 10.2 N, PPT 137 27 kPa) compared to participants with LE who did not exhibit a pro-nociceptive pain profile (PRTEE 35.2 14.8, CPT 11.9
12C, PFG affected/unaffected 53.8 28.9 N, PPT 238 66 kPa). Demographic and clinical characteristics will be presented for each group. Between-group
comparisons and linear regression analyses will be used to identify the association between pain modulation characteristics, clinical characteristics and structural
pathology.
Conclusion: It is hypothesised that a sub-group of people with LE who exhibit a pro-nociceptive pain profile will also exhibit clinical and structural characteristics that
are recognised poor prognostic indicators. In addition, it is anticipated that people with LE will exhibit characteristics of altered pain modulation compared with
healthy controls. Future research should investigate whether pain modulation profile is associated with treatment effect in people with LE.
Implications: This is the first study to investigate dynamic pain modulation processes in people with LE. A better understanding of these pain modulation processes
will provide information to guide the development of treatment strategies which target pain modulation, thereby improving treatment outcomes for people with
chronic LE.
Funding Acknowledgements: School of Allied Health Sciences Project Grant; Griffith Health Institute Grant Scheme.
Ethics Approval: This study has been approved by the Griffith University Human Research Ethics Committee (AHS/55/14/HREC).
Disclosure of Interest: None Declared
Keywords: imaging, pain management, tennis elbow

Advanced assessment/practice and managing complex patients


OR-MT-033
DO MEASURES OF PAIN SENSITIVITY PREDICT PAIN AND DISABILITY AT 1-YEAR FOLLOW UP IN PEOPLE WITH CHRONIC NECK PAIN?
N. Moloney*, T. Rebeck, R. Azoory, M. Huebscher, R. Waller, D. Beales

Background: Neck pain is a global health burden. Data tracking the course of recovery for idiopathic neck pain and whiplash indicate that recovery is poor for many.
Besides patient characteristics and psychological factors, quantitative measures of pain sensitisation have been identified as predictive of poor recovery in some
categories of neck pain e.g. acute whiplash. Recent research has proposed clinical measures of pain sensitisation suitable for use in clinical practice; the predictive
ability of these methods has yet to be determined.
Purpose: The purpose of this study was to examine the unique contributions of quantitative and clinical measures of pain sensitisation to predict pain and disability at
long term follow up in people with chronic neck pain.
Methods: A prospective cohort study involving adults with chronic neck pain was conducted. Participants (n=64) completed self-reported measures of pain, disability,
psychological factors and co-morbidities, and underwent quantitative measures of cold and pressure pain thresholds. They also underwent assessment of sensitivity
to clinical measures of cold and pressure and provided pain ratings for brachial plexus provocation tests.
Univariate and multivariable hierarchical regression analyses were conducted to examine the relationship between these measures and pain intensity or neck
disability at 12-month follow-up.
Results: Univariate regression analyses revealed that depression, anxiety and stress, poor sleep, pain catastrophizing, higher baseline pain, higher manual pressure
pain sensitivity and higher pain ratings with brachial plexus provocation testing were associated with higher levels of disability at 12 months (r>0.3; p<0.05). Poorer
sleep, more co-morbidities, depression, anxiety and stress, as well as higher pain on manual pressure also demonstrated significant associations with pain at 12
months (r>0.3; p<0.05).
Multivariable regression analyses yielded models explaining 34.6% of the variance in disability and 44.4% of the variance in pain at 12 months. The resultant models
comprised self-reported measures (neuropathic symptoms, sleep, depression, co-morbidities). Neither QST nor clinical measures of pain sensitivity contributed to
either model.
Conclusion: The results of this study indicate that self-reported measures of pain and psychological factors were predictive of pain and disability at long-term follow
up. Measures of pain sensitivity did not predict long term pain and disability. These findings differ to those from acute whiplash populations, with the chronic nature
of pain in this cohort potentially explaining the difference.
Implications: Clinical and quantitative measures of pain sensitivity may be useful for profiling patients with chronic neck pain but have limited use in predicting
ongoing pain and disability in this population.
Funding Acknowledgements: TR and DB are supported by a NHMRC Research Fellowship. MH was supported by a postdoctoral fellowship from the German
Academic Exchange Service (DAAD).
Ethics Approval: Human ethics approval was obtained from University of Sydney (Protocol No. 14417) and Curtin University (Protocol No. PT0205) Human Research
Ethics Committees.
Disclosure of Interest: None Declared
Keywords: Chronic neck pain, clinical pain sensitivity, quantitative sensory testing

Advanced assessment/practice and managing complex patients


OR-MT-034
SENSORIMOTOR CONTROL IN INDIVIDUALS WITH IDIOPATHIC NECK PAIN AND HEALTHY INDIVIDUALS: A SYSTEMATIC REVIEW AND META-ANALYSIS
R. de Zoete 1,*, P. Osmotherly 1, D. Rivett 1, S. Farrell 1, S. Snodgrass 1
1
School of Health Sciences, The University of Newcastle, Callaghan, Australia
Background: Idiopathic neck pain is a common condition presenting in physiotherapy practice. However, treatment is often ineffective: 50-85% of individuals with
neck pain will experience recurrent neck pain within 1-5 years after the initial onset of neck pain. One aspect of assessment that may provide some insight into
possible reasons for neck pain recurrence is cervical sensorimotor control testing. Cervical sensorimotor control is defined as all the afferent and efferent information
streams, as well as the central integration components contributing to joint stability. However, consensus lacks on the measurement of sensorimotor control in
individuals with idiopathic neck pain.
Purpose: To systematically review and analyse reported outcomes of sensorimotor control in individuals with idiopathic neck pain, compared to healthy individuals.
Methods: Systematic review and meta-analysis of English and Dutch language observational and intervention studies, identified through searching the databases
AMED, CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, MEDLINE, PEDro, SCOPUS and SportDiscus. Studies were included if they
investigated individuals with idiopathic neck pain and/or healthy individuals, and reported outcomes of at least one sensorimotor control test. The aim of this
systematic review is to determine whether sensorimotor control tests can identify and quantify differences between individuals with idiopathic neck pain and healthy
individuals.
Results: Reported outcome measures for sensorimotor control tests were: joint position error (JPE), postural sway, subjective visual vertical (SVV), smooth pursuit
neck torsion (SPNT), The Fly and head steadiness. In included studies (n=43), sensorimotor control was most commonly assessed by JPE and postural sway. Pooled
means from 22 studies for JPE following cervical rotation in individuals with neck pain (range 2.2-9.8, median 3.14, IQR 2.79-3.33) differed significantly (p=0.04)
compared to healthy individuals (range 1.66-5.1, median 2.67, IQR 2.1-3.5). Clinical significance of this difference was not reported. Postural sway, eyes open
(EO), ranged from 3.0-10.5cm2 (median 7.68, IQR 4.85-10.5) for individuals with idiopathic neck pain and 2.7-6.6cm2 (median 4.36cm2, IQR 3.76cm2-5.65cm2) for
healthy individuals, and for eyes closed (EC), 2.5-16.6cm2 (median 8.84cm2, IQR 2.51cm2-16.6cm2) (neck pain) and 2.0-10.9cm2 (median 6.53cm2, IQR 4.19cm26.99cm2) (healthy). Individual studies, but not meta-analysis, demonstrated differences between neck pain and healthy groups for postural sway (EO: n=4, EC: n=6).
Other test conditions and other tests (15 studies) were not sufficiently investigated to enable pooling of data.
Conclusion: Six sensorimotor control tests were identified that have been used to investigate individuals with idiopathic neck pain. Meta-analysis demonstrated
differences between individuals with idiopathic neck pain and healthy individuals for JPE testing following rotation. Individual studies found significant differences
between idiopathic neck pain and healthy groups for postural sway, but not on meta-analysis. Although for some tests clinical usefulness of sensorimotor testing is
suggested by these results, further research is needed to investigate clinical meaningfulness of differences in outcomes for sensorimotor tests.
Implications: This systematic review and meta-analysis informs clinicians about the measurement methods of sensorimotor control in individuals with idiopathic neck
pain. Meta-analyses found a significant difference between individuals with idiopathic neck pain and healthy individuals in JPE testing, and this test may clinically be
useful in assessing sensorimotor control. Tests for postural sway, SPNT, SVV, head steadiness and The Fly test show some differences in individuals with idiopathic
neck pain compared to healthy individuals.
Funding Acknowledgements: This work was unfunded.
Ethics Approval: No ethics approval was required for this review.
Disclosure of Interest: None Declared
Keywords: cervical spine, idiopathic neck pain, Sensorimotor control

Advanced assessment/practice and managing complex patients


OR-PA-036
DOES IMPROVEMENT OF KNOWLEDGE ABOUT NEUROPHYSIOLOGY OF PAIN OCCUR AND PERSIST IN PATIENTS WITH CHRONIC LOW BACK PAIN AFTER A SINGLE
GROUP SESSION OF PAIN PHYSIOLOGY EDUCATION ?
C. Demoulin 1 2,*, P. Brasseur 2, N. Roussel 3 4, S. Grosdent 1 2, S. Wolfs 1 2, T. Osinski 5, S. Bornheim 1 2, J.-M. Crielaard 1 2, M. Vanderthommen 1 2, O. Bruyre 2 6
1
Department of Physical Medecine and Rehabilitation, Liege University Hospital Center, 2Department of Sport and Rehabilitation Sciences, University of Liege, Liege,
3
Pain in Motion Research Group, International, 4Department of Physiotherapy and Rehabilitation Sciences (REVAKI), Faculty of Medicine and Health Sciences,
University of Antwerp, Antwerp, Belgium, 5INSERM, U-987, Hpital Ambroise Par, Centre dEvaluation et de Traitement de la Douleur, F-92100, France, 6Department
of Public Health, Epidemiology and Health Economics, University of Liege, Liege, Belgium
Background: Pain neurophysiology education is now being considered as a key component in the management of patients with chronic pain. Several studies have
reported its effectiveness to reduce pain and disability but studies evaluating the effect on the patients knowledge are lacking. Yet, the Neurophysiology of Pain
Questionnaire (NPQ) has been developed by Moseley to assess knowledge about pain neurophysiology and has been translated and validated in several languages
(Dutch and French).
Purpose: The aims of the present study were the followings: 1) to investigate if a two-hour pain education group session is effective to improve the knowledge about
neurophysiology of pain in patients with chronic low back pain (CLBP); 2) to study whether these changes persist at a one-week follow-up.
Methods: 52 patients with non-specific CLBP attended a two-hour pain education session in groups of 4-6 patients. Prior to the session (pre-test), participants filled in
the French versions of the NPQ, which consists of 19 (True/False/I do not know) questions with good psychometric properties (valid, reliable, SEM one-week: 1.5), the
Roland-Morris Disability Questionnaire (RMDQ) and a 0-10 pain visual analogue scale (VAS). The NPQ was also filled in immediately after the session (post-test) as
well as one week later (follow-up). An ANOVA with post-hoc analysis were used to compare the changes in NPQ total scores (/19 and expressed in %) at the pre-test,
post-test and follow-up. The level of significance was set at 0.05.
Results: All patients filled in the questionnaires at the pre- and post-tests and all attended the follow-up session. Their mean standard deviation (SD) of baseline
pain intensity (VAS) and disability (RMDQ) scores were 4.3 2.5 and 9 5.1, respectively. The statistical analyses revealed a highly significant and clinically meaningful
improvement of the NPQ total score following the pain education (from 6.9 2.9 [min: 2, max: 14] at the pre-test to 14 2.6 [min: 7, max: 18] at the post-test,
p<0.001). Interestingly, the NPQ score at the follow-up (12.9 2.7 [min: 7, max: 18]) remained significantly higher than at baseline (p<0.001) and was not different
compared to the post-test (p=0.20).
Conclusion: Although the present study needs to be confirmed by a randomized controlled trial with a longer follow-up, it suggests that a single two-hour group
session on pain education is able to improve patients knowledge about neurophysiology of pain and that the improvements could last for one week after the
education session.
Implications: Despite the improvements in pain neurophysiology knowledge, the final NPQ scores suggest that several misunderstandings remain in some patients
and that an additional session might be necessary. Further studies comparing the effectiveness of this group session to an individual session, investigating the
relevance of an additional session and above all examining the relationships between the knowledge improvements and the improvements of patients health status
are necessary.
Funding Acknowledgements: The present work was unfunded.
Ethics Approval: Our study was accepted by the Ethical committee of the University of Liege, Belgium.
Disclosure of Interest: None Declared
Keywords: chronic pain, low back pain, pain education

Advanced assessment/practice and managing complex patients


OR-PA-037
UNDERSTANDING PAIN AMONG OLDER PERSONS: PART 2 - THE ASSOCIATION BETWEEN PAIN
PROFILES AND HEALTHCARE UTILISATION
K. O'Sullivan 1,*, N. Kennedy 1, H. Purtill 2, A. Hannigan 3
1
Clinical Therapies, 2Mathematics and Statistics, 3Graduate Entry Medical School, University of Limerick, Limerick, Ireland
Background: While polypharmacy and multimorbidity predict healthcare utilisation among older people, the influence of differing pain profiles on healthcare
utilisation is unclear.
Purpose: To compare healthcare utilisation between people with different pain profiles.
Methods: Baseline data from The Irish LongituDinal study on Ageing (TILDA), a population-representative prospective cohort study involving over 8,500 community
living people resident in Ireland aged 50 or over. Following the creation of four novel pain profiles, variables relating to healthcare utilisation were compared across
the different profiles using chi-square tests and logistic regression.
Results: Healthcare utilisation differed across the four pain profiles, with pain being an independent predictor of resource use. Profiles 3 and 4 had higher use of
general practitioner (GP) care and outpatient visits than people with no pain and pain that had less impact (profiles 1 and 2). The odds of being a frequent GP
attender increased across pain profiles, with those in profile 4 being almost three times as likely to be frequent attenders compared to those with no pain (adjusted
OR=2.79; 95% CI 2.74, 2.83). People in profile 4 were almost twice as likely to have a hospital outpatient visit compared to people with no pain (adjusted OR=1.75;
95% 1.73, 1.78).
Conclusion: Healthcare utilisation differed between the four pain profiles, with people in profiles 3 and 4 having greater usage of primary and secondary healthcare
resources. Pain profile membership was a significant independent predictor of the utilisation of GP care and hospital outpatient visits after adjusting for
multimorbidity and polypharmacy.
Implications: Healthcare utilisation among older adults is not uniform, and is linked to several characteristics which vary between profiles. Better targeting of those at
risk of high healthcare utilisation, incorporating greater self-management and consideration of comorbid health complaints, may enhance clinical outcomes and
healthcare utilisation.
Funding Acknowledgements: Not applicable.
Ethics Approval: Not applicable.
Disclosure of Interest: None Declared
Keywords: chronic pain, healthcare utilisation, older adults

Advanced assessment/practice and managing complex patients


OR-SH-047
INCREASED SUPRASPINATUS TENDON THICKNESS FOLLOWING FATIGUE LOADING IN ROTATOR CUFF TENDINOPATHY
K. Mccreesh*, A. Donnelly 1, J. Lewis 2 3 4
1
Dept of PE and Sports Sciences, 2Dept of Clinical Therapies, University of Limerick, Limerick, Ireland, 3Musculoskeletal Services, Central London Community
Healthcare NHS Trust, London, 4 Department of Allied Health Professions and Midwifery, University of Hertfordshire, Hatfield, United Kingdom
Background: Tendon loading leads to multiple changes in tendon properties, which can be different in healthy versus painful tendons. Studies of lower limb tendons
suggest that loading results in immediate reductions in tendon thickness in normal tendon, contrasting with increased thickening in painful tendons. However, no
such studies exist for the rotator cuff tendons.
Purpose: We examined the short-term effect of loading on thickness of the supraspinatus tendon and acromiohumeral distance (AHD) in people with and without
rotator cuff tendinopathy.
Methods: Controlled laboratory study. Participants were 20 healthy controls, and 22 people with rotator cuff tendinopathy, diagnosed using a combination of clinical
testing and ultrasound examination. Supraspinatus tendon thickness and AHD were measured using ultrasound scans before and at three time-points after a loading
protocol (one, six and 24 hours). Loading involved isokinetic eccentric and concentric external rotation and abduction to the point of fatigue (35% drop in overall
torque).
Results: There was a significant increase in supraspinatus tendon thickness in the RC tendinopathy group at one (7%, =0.4, 95% CI=-0.1, 0.7) and six hours (11%,
=0.6, 95%CI= -0.2, 0.9) after loading, although only the six hour difference exceeded minimal detectable difference (MDD). In contrast there was a small significant
reduction in supraspinatus tendon thickness (not exceeding MDD) in controls. The AHD reduced significantly in both groups at one hour (Controls: =0.7, 95%CI=0.3,
1.0; RC tendinopathy: =1.1, 95%CI=0.7, 1.4), with recovery to baseline by six hours in controls, but not until 24 hours in the pain group.
Conclusion: Painful rotator cuff tendons demonstrated an altered response to loading i.e. increased thickening and slower return to normal dimensions compared to
pain-free tendons. Reductions in the subacromial space were seen in both groups, but recovery to baseline was prolonged in the tendinopathy group.
Implications: This study adds to the understanding of potential mechanisms of rotator cuff tendinopathy. The response to fatigue loading in those with painful
rotator cuff tendinopathy was swelling of the supraspinatus tendon and reduction in the subacromial space. Physiotherapists should take into account the impact of
loading to fatigue when planning rotator cuff rehabilitation programmes.
Funding Acknowledgements: This work was supported by a Fellowship from the Health Research Board of Ireland
Ethics Approval: Ethical Approval was received from the University Hospital Limerick Ethics Committee.
Disclosure of Interest: None Declared
Keywords: EXERCISE, shoulder disorders, Tendinopathy

Changing roles and scope of practice


OR-EX-044
TELEREHABILITATION AS AN ADDITIONAL SERVICE DELIVERY OPTION WITHIN AN AUSTRALIAN ORTHOPAEDIC PHYSIOTHERAPY SCREENING SERVICE: A NEEDS
ASSESSMENT
M. Cottrell*, A. Hill, S. O'Leary, M. Raymer, T. Russell

Background: Chronic musculoskeletal conditions are a leading cause of pain and disability within Australia, resulting in unprecedented economic burden being placed
on the public healthcare system. The Orthopaedic Physiotherapy Screening Clinic and Multidisciplinary Service (OPSC & MDS) was initiated in response to this
demand as an alternative, non-surgical pathway for patients currently on specialist consultation waiting lists. Whilst this cost-effective service has been able to
successfully remove over 70% of referred patients from specialist waitlists, there is still a large proportion of patients being discharged from the OPSC & MDS due to
non-attendance. This is now a critical time to identify those individuals who are unable to attend this service due to issues with accessibility, and redirect potentially
lost resources in order to optimise the healthcare outcomes for both patients and providers alike.
Purpose: The aim of this study is to identify the current barriers to accessing appropriate and timely healthcare for the management of chronic musculoskeletal
conditions, and to evaluate the potential need for the implementation of telerehabilitation as an additional method of service delivery within the OPSC & MDS.
Methods: Using selective and purposive sampling, a mixed methods needs assessment was undertaken involving six OPSC & MD services situated throughout
Queensland, Australia. Healthcare providers (n = 30) participated in qualitative interviews, whilst patients (n = 120) completed surveys.
Results: Preliminary thematic analysis of completed interviews suggest the following major themes: (1) barriers to accessing current care is complex and
multifaceted; (2) telerehabilitation could improve access to appropriate healthcare, however (3) would not be better than standard face-to-face care; and (4) that the
delivery of telerehabilitation should be flexible and dependent on individual patient circumstances. Patient surveys are currently in data collection phase.
Conclusion: Based on preliminary analysis, healthcare providers are cautious, but overall supportive, with respects to the implementation of telerehabilitation within
the OPSC & MDS, acknowledging that it could improve access to healthcare, which would allow for more positive outcomes for those individuals receiving no care
and remaining on a specialist waitlist.
Implications: The results of this study will provide valuable information on the current barriers and opportunities surrounding access to appropriate multidisciplinary
care in the management of chronic musculoskeletal conditions, which will assist in the introduction of a telerehabilitation service delivery option within the OPSC &
MDS.
Funding Acknowledgements: There was no funding in relation to this study.
Ethics Approval: Ethical approval was granted by the Human Research Ethics Committee (HREC), Royal Brisbane & Womens Hospital, Queensland, Australia
(HREC/15/QRBW/130).
Disclosure of Interest: None Declared
Keywords: MUSCULOSKELETAL, screening clinic, telerehabilitation

Changing roles and scope of practice


OR-LS-023
A SPINAL PATHWAY OF CARE: DEVELOPING AND IMPLEMENTING AN EQUITABLE AND EVIDENCE BASED PATHWAY FOR ALL METROPOLITAN AND RURAL PATIENTS
REFERRED TO A TERTIARY HOSPITAL
P. Swete Kelly 1 2,*, M. Cruickshank 2, P. Judd 2
1
Physiotherapy, Performance Rehab, Annerley, 2Physiotherapy, Royal Brisbane and Women's Hospitals, Brisbane, Australia
Background: Advanced scope roles in physiotherapy have been successfully introduced into the Queensland public health sector in Neuro- and Orthopaedic Surgery
Specialist Outpatient departments for patients who reside local to a facility. Geographical distance limits rural patients access to equitable health care (compared to
metropolitan counterparts). One major metropolitan Queensland tertiary hospital receives Neuro- and Orthopaedic surgery spinal referrals from over 1000km away
and had 5000 patients on specialist outpatient waiting lists with some patients waiting 10 years for an appointment. An equitable and efficacious pathway of care was
required for all spinal pain patients.
Purpose: The project purpose was to undertake a major health service re-design and provide a safe, equitable and evidence based model of care addressing the
clinical needs of all spinal pain patients and the organisational needs of the health service. A secondary aim was to facilitate change in the perception, of patients and
referring practitioners, which is patients with spinal pain all require a surgical opinion.
Methods: A qualitative review of the existing service was undertaken. Key clinical and organisational criteria were identified by panels of and individual experts.
Existing and alternative service models and patient stratification strategies were reviewed to establish a spinal pathway that met the service and patient needs.
Quantitative analysis of clinical and organisational outcomes has been undertaken.
Results: The existing pathway was unsustainable, not evidence based and inequitable for rural patients. No existing pathways were identified that provided a suitable
model of care. A new pathway, integrating best evidence, for all spinal pain patients (non-surgical and surgical) was implemented and included strategies to address
patient urgency, location of care, appropriate profession and professional expertise. Annual funding for non-surgical management increased AUS$1.3 million and
Musculoskeletal Physiotherapists in advanced practice roles were identified as integral to the pathway. Clinical outcomes for rural patients are approaching those of
metropolitan patients. Organisational outcomes are being met: 12 months after implementation patients waiting outside recommended times have reduced (33% in
Orthopaedic & 46% in Neurosurgical Outpatient Departments). Some unexpected barriers within other health services are being addressed.
Conclusion: An integrated spinal pathway has been developed and implemented at a major Queensland public health facility providing all spinal pain patients an
equitable, efficacious and evidence based model of care. Stratification strategies identified Musculoskeletal Physiotherapists as an integral profession in the pathway.
Unexpected barriers are being addressed.
Implications: Although designed and adopted within one health service significant aspects of this spinal pain pathway are applicable to other health services.
Musculoskeletal Physiotherapists are one key profession in providing an integrated and stratified spinal pathway of care.
Funding Acknowledgements: Funding for this project was provided through the Metro North Hospital and Health Service Improving Outpatient Access program.
Ethics Approval: No ethics approval was required. The project was undertaken within normal clinic service redesign.
Disclosure of Interest: None Declared
Keywords: physiotherapy, spinal pathway

Changing roles and scope of practice


OR-SH-048
AGREEMENT BETWEEN A PHYSIOTHERAPIST AND ORTHOPAEDIC SURGEON REGARDING MANAGEMENT OF SHOULDER PAIN AND PRESCRIPTION OF
SUBACROMIAL CORTICOSTEROID INJECTION
D. Marks 1 2,*, T. Comans 1, M. Thomas 2, S. K. Ng 1, S. O'Leary 3, P. G. Conaghan 4, P. Scuffham 1, L. Bisset 1
1
Menzies Health Institute Griffith University, Gold Coast, 2Gold Coast University Hospital, Southport, 3University of Queensland, Brisbane, Australia, 4Leeds Institute of
Rheumatic & Musculoskeletal Medicine, Chapel Allerton Hospital, Leeds, United Kingdom
Background: Shoulder pain is commonly referred to orthopaedics, and managed by physiotherapists instead of orthopaedic doctors. Understanding differences in
decision-making between these two professions, for representative orthopaedic populations, will inform the safety, quality and cost of this model. Previous studies
comparing inter-professional musculoskeletal care decisions, have excluded patients with medical complexities and detailed comparison of corticosteroid injection
decisions has not previously been reported.
Purpose: To assess the level of agreement between a physiotherapist and consultant orthopaedic surgeon regarding management, and use of corticosteroid injection
for adult shoulder pain.
Methods: An inter-rater reliability study was undertaken on the Gold Coast in Australia in which 274 adults with an orthopaedic shoulder pain referral were
independently assessed by a physiotherapist and a consultant orthopaedic surgeon. Participants were blind to the professional identity of assessors, and were not
excluded on the basis of medical complexity. Assessors were blind to each-others decisions. Primary outcomes were inter-professional agreement regarding
management and subacromial corticosteroid injection. Secondary outcomes were diagnostic and investigation decisions.
Results: Agreement between the physiotherapist and the orthopaedic surgeon was near perfect for surgical versus non-surgical management (Gwets agreement
coefficient AC1=.93, 95%CI: .90-.93), and whether it was safe to inject (AC1=.85 CI: .79-.91); substantial for the presence of subacromial pain (AC1=.74 CI .66-.81); and
moderate for immediate subacromial injection delivery (AC1=.48 CI .33-.53). Disagreement about immediate injection was mainly due to the physiotherapist
recommending physiotherapy before injection (17 cases), injection-safety concerns (15 cases) or further imaging prior to injection (13 cases). Physiotherapist and
orthopaedic surgeon referral rates to physiotherapy were highly similar (86% and 91% respectively), as were investigation requests (MRI 15% and 10% respectively).
Conclusion: A physiotherapist and consultant orthopaedic surgeon reach near perfect agreement regarding the management of unfiltered orthopaedic shoulder
referrals, including whether it is safe to administer corticosteroid injection, and moderate agreement on the priority of injection as a first line treatment.
Implications: Unfiltered orthopaedic shoulder referrals can be initially managed by an appropriately trained physiotherapist.
Jurisdictions that do not already permit physiotherapists to prescribe corticosteroid injection for shoulder pain should consider implementing this model of care.
Funding Acknowledgements: This study was not funded by any external sources. We received support from within Queensland Health (Queensland Government)
through a Models Of Care Project administered by the Queensland Health Allied Health Professions Office, and in-kind support from the Gold Coast Hospital and
Health Service Orthopaedic and Allied Health departments.
Ethics Approval: Gold Coast Hospital and Health Service Human Research Ethics Committee, NHMRC code EC00160 (HREC/12/QGC/30; SSA/12/QGC/97), and Griffith
University Human Research Ethics Committee (MED/23/13/HREC).
Disclosure of Interest: None Declared
Keywords: corticosteroid injection, physiotherapy, Shoulder pain

Changing roles and scope of practice


OR-SH-052
THE ECONOMIC BURDEN OF SHOULDER PAIN AWAITING PUBLIC ORTHOPAEDIC CARE
D. Marks 1 2,*, T. Comans 1, L. Bisset 1, P. Scuffham 1
1
Menzies Health Institute Griffith University, Gold Coast, 2Gold Coast University Hospital, Southport, Australia
Background: Shoulder pain is the second to third most prevalent musculoskeletal disorder and is frequently referred to public orthopaedic services, where patients
often face long waiting lists. An understanding of the societal economic burden of shoulder pain in patients awaiting orthopaedic care is needed to inform public
health expenditure and the economic impact of new services. Little is presently known of the indirect costs of shoulder pain, such as personal support costs and work
related productivity loss. Furthermore the economic burden of shoulder pain awaiting orthopaedic care has not previously been reported.
Purpose: To estimate the economic burden of shoulder pain from a societal perspective, in patients on a waiting list for public hospital orthopaedic care.
Methods: Information relating to the cost of shoulder pain was gathered from 277 patients on an Australian public hospital orthopaedic waiting list. Demographic
and clinical information was recorded and a variety of direct and indirect cost information obtained via patient-reported questionnaire using a three-month recall
period. Work-related absenteeism and productivity loss at work was collected with two tools; the Work Productivity and Activity Index (WPAI), and the Work
Limitations Questionnaire. Indirect costs were assigned through the human capital approach using wage rates for employed patients, and the Australian minimum
wage for personal and domestic support items. All costs were converted to per day figures to obtain a daily societal economic burden of shoulder pain.
Results: For shoulder patients on an orthopaedic waiting list we estimate average per day direct healthcare costs (appointments, investigations, care, medicines) at
AUD$5.82 (SD 4.05), with patient costs for related time and travel at AUD$0.65 (SD 0.98). Average per day indirect cost estimates were AUD$9.61 (SD19.93) for
personal and domestic support, and AUD$40.84 (SD 36.08) for WPAI reported overall work productivity loss due to absenteeism and presenteeism. This equates to an
overall societal cost of AUD$16.08 per patient per day, increasing to AUD$56.92 for employed patients.
Conclusion: We estimate the cost to society per case of shoulder pain on an orthopaedic waiting list to be AUD$16.08 per day, increasing to AUD$56.92 per day for
employed patients when the additional burden of work productivity loss is considered.
Implications: Considering the volume of shoulder pain patients on public orthopaedic waiting lists, the national economic burden of shoulder pain in patients
awaiting orthopaedic care is likely to be hundreds of millions of dollars annually. This highlights the importance of new models of care that improve access for
patients.
Funding Acknowledgements: In kind support was provided by Gold Coast Hospital and Health Service.
Ethics Approval: Gold Coast Hospital and Health Service Human Research Ethics Committee, NHMRC code EC00160 (HREC/12/QGC/30; SSA/12/QGC/97), and Griffith
University Human Research Ethics Committee (MED/23/13/HREC).
Disclosure of Interest: None Declared
Keywords: Cost, Shoulder pain, Waiting list

Health promotion/Public health


OR-LL-015
EVIDENCE OF EARLY POST-TRAUMATIC OSTEOARTHRITIS 3-10 YEARS FOLLOWING KNEE JOINT INJURY IN YOUTH SPORT
J. Whittaker 1,*, C. Toomey 2, A. Nettel-Aguirre 3, J. Jaremko 4, L. Woodhouse 1, C. Emery 2
1
Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, 2Faculty of Kinesiology, University of Calgary, 3Alberta Childrens Hospital Research Institute for
Child and Maternal Health, University of Clagary, Calgary, 4Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
Background: Osteoarthritis (OA) is the fastest growing health condition based on Years Lived with Disability. Knee OA contributes 80% of this burden. Currently there
are no disease modifying treatments and the prevailing convention for managing OA is to passively await final joint death necessitating joint replacement. Metaanalyses indicate a 3.9 fold (95%CI 2.7,5.6) increased risk of radiographic ( 2 Kellgren Lawrence grade) post-traumatic OA (PTOA) after significant knee joint injury.
There is a paucity of research examining outcomes associated with PTOA early in the period between joint injury and disease onset (<10 years post-injury). Improved
understanding of this interval is critical to developing prevention strategies aimed at reducing the growing burden of knee OA.
Purpose: This investigation examines the association between a knee joint injury sustained in youth sport (<18 years) and outcomes associated with early onset PTOA
and other long-term health outcomes in the 3-10 years post-injury. This information will inform the development, evaluation and implementation of early diagnostics
and prevention interventions aimed at delaying/prevention progression to PTOA after knee joint injury.
Methods: This cohort study involves 100 individuals (15-26yrs) who sustained a sport-related intra-articular knee injury 3-10 years previously when they were under
the age of 18 years and 100 age-sex-sport-matched controls. Outcomes measures included; Knee Injury and OA Outcome Score (KOOS), weekly physical activity
(Godin Questionnaire), normalized knee flexor/extensor strength (dynamometry), body mass index (BMI) and MRI-defined OA. Descriptive statistics (mean withinpair difference, 95%CI) and unadjusted conditional logistic regression (OR, 95%CI) were used to compare injured an uninjured study groups.
Results: Injured participants had poorer KOOS scores; symptoms -8.1(-11.2,-5.0), pain -4.9(-7.0,-2.7), daily-function -2.8(-4.2,-1.4), sport-participation -5.8(-7.8,-3.7),
quality-of-life -8.3(-10.2,-6.3)] than controls. No between group differences existed for quadriceps strength [-0.2Nm/kg (-0.02,0)] however, injured participants had
weaker hamstrings [-0.02Nm/kg (-0.03,-0.01)] were 3.75 times (95%CI;1.2,11.3) more likely to be overweight/obese (BMI) and 2.1 (95%CI;1.1,4.0) times more likely to
be in the lowest physical activity quartile. Based on a subset (n=100), injured participants were 8.5 (95%CI; 1.96,36.79) times more likely to demonstrate MRI-defined
OA compared to controls.
Conclusion: This study provides preliminary evidence that young adults (15-26 years) with a history of sport-related knee injury demonstrate greater
symptomatology, poorer function, lower physical activity levels, greater BMI and more structural joint changes consistent with future PTOA 3-10 years post-injury
compared to uninjured controls.
Implications: The findings of this research will be used to inform screening programs aimed at identifying those at increased risk for PTOA as well as physical therapy
led prevention interventions aimed at delaying/preventing the onset of the disease.
Funding Acknowledgements: This research is funded by the Canadian Institutes of Health Research, the Alberta Team Osteoarthritis Team supported by Alberta
Innovates Health Solutions and the Alberta Childrens Hospital Research Institute for Child and Maternal Health Professorship in Pediatric Rehabilitation. The Sport
Injury Prevention Research Centre at the University of Calgary is supported by an International Olympic Committee Research Centre Award.
Ethics Approval: Ethics approval was granted from the Conjoint Health Research Ethics Board at the University of Calgary, Canada.

Disclosure of Interest: None Declared


Keywords: Knee Injury, Post-traumatic Osteoarthritis, Prevention

Health promotion/Public health


OR-PA-038
THE ROLE OF CONTEXTUAL FACTORS IN THE MANAGEMENT OF CHRONIC MUSCULOSKELETAL PAIN IN PRIMARY HEALTH CARE SETTINGS
D. Ernstzen 1,*, Q. Louw 1, S. Hillier 2
1
Physiotherapy, Stellenbosch University, Cape Town, South Africa, 2School of Health Sciences, University of South Australia, Adelaide, Australia
Background: Chronic Musculoskeletal (CMSK) pain is a global healthcare concern and a major cause of disability in sub-Saharan Africa. It negatively impacts physical
and psychosocial health, life roles and health care utilisation. Patients contextual circumstances may influence treatment effectiveness and adherence to the
treatment regime. It is thus important that the clinician consider contextual circumstances, to optimise management strategies for CMSK pain.
Purpose: The purpose was to discover patient and healthcare provider perspectives on the contextual factors that could act as barriers and facilitators for optimum
management of CMSK pain in community health centres (CHC) in the Western Cape, South Africa (SA).
Methods: A descriptive, qualitative study, with an interpretive research paradigm was performed. Three CHCs were strategically selected to represent urban and
rural settings with diversity in language and cultural groups. Patients with CMSK pain and their respective clinicians were invited to participate. Patients with chronic
pain from non-musculoskeletal origin were excluded (neuropathic pain, cancer pain and pain from sickle cell anaemia). In-depth individual interviews were
conducted, recorded and transcribed. Data were analysed using inductive, thematic content analysis. Data were triangulated by inter-case comparison and
stakeholder (patient and clinician) comparison.
Results: Twenty patients and 21 clinicians (doctors, nurses, physiotherapists, occupational therapists, social workers and psychologists) participated. The patients
conditions included: general joint pain, low back pain, neck/shoulder pain and body pain. Participants identified several factors that impact the quality and continuity
of care and treatment adherence. The strongest emerging themes included:
Patient specific factors, e.g. understanding of pain, impact of pain, resilience
Management factors, e.g. adequate pain medication, the value of physical and cognitive rehabilitation
Health care system factors, e.g. volume of patients, staff turnover and the importance of interdisciplinary care
- Socio-economic factors that impact the development of chronicity, including: occupational influences, trauma, poverty and disability insurance.
Conclusion: Several contextual factors, which were intricately related, were found to influence the care of patients with CMSK pain. The identified barriers and
facilitators to care highlighted CMSK pain as a multidimensional phenomenon. Care should thus include physical, psychological, social and environmental
domains. Further research to explore the feasibility of such a care model in primary health care is advisable.
Implications: It is important for clinicians to consider the contextual circumstances that influence patients values and beliefs about CMSK pain and its
management. Interdisciplinary care and patient empowerment through contextually relevant education plays a vital role in quality care of patients with CMSK
pain. These management options may positively impact treatment effectiveness and adherence.
Funding Acknowledgements: This work is based on the research supported in part by the National Research Foundation of South Africa for the grant 85086; and the
Stellenbosch University Rural Medical Education Partnership Initiative. Any opinion, finding and conclusion or recommendation expressed in this material are that of
the author and the National Research Foundation does not accept any liability in this regard.
Ethics Approval: Ethical approval for this study was provided by the Human Research Ethics Committee, Faculty of Medicine and Health Sciences, Stellenbosch
University, South Africa
Disclosure of Interest: None Declared
Keywords: Chronic pain, Contextual factors, Primary health care

Intergrating Research into practice


OR-CS-001
CERVICAL SPINE MENISCOID MORPHOLOGY IN WHIPLASH ASSOCIATED DISORDER: A CASE-CONTROL RADIOLOGICAL STUDY
S. Farrell*, P. Osmotherly 1, J. Cornwall 2, P. Lau 3, D. Rivett 1
1
Discipline of Physiotherapy, The University of Newcastle, Callaghan, Australia, 2Graduate School of Nursing, Midwifery and Health, Victoria University of Wellington,
Wellington, New Zealand, 3Hunter New England Imaging, Hunter New England Local Health District, Newcastle, Australia
Background: Cervical spine meniscoids are folds of synovial membrane that extend into the joint cavity of cervical zygapophyseal, lateral atlantoaxial and atlantooccipital joints. It is hypothesised that these structures are potential contributors to pain and hypomobility in chronic whiplash associated disorder (WAD). However,
their morphology has not been studied in vivo in the WAD population, and their potential contribution to ongoing pain and pathology is unclear.
Purpose: To examine the morphology of cervical spine meniscoids in chronic WAD.
Methods: Twenty subjects with WAD lasting greater than three months duration (mean [SD] age 39.3 [11.0] years, ten female) and 20 age and gender-matched painfree controls (39.1 [10.6] years) underwent magnetic resonance imaging (MRI) of the cervical spine. Each lateral atlantoaxial and zygapophyseal joint (C2/3-C6/7) was
examined for presence of meniscoids. Meniscoid protrusion length was measured in the sagittal plane and histological composition (adipose/fibrous/fibroadipose)
was assessed by comparing signal intensities on T1- and T2-weighted scans. Wilcoxon signed-rank tests, linear and logistic regression were employed for data analysis
(p < 0.05).
Results: Cervical spine meniscoids were observed in both the WAD (n = 317) and control (n = 296) groups. Median meniscoid protrusion length was greater in the
control group (ventral 6.1 mm; dorsal 7.2 mm) than WAD group (ventral 5.0 mm, p = 0.06; dorsal 6.5 mm, p < 0.01) at the lateral atlantoaxial joints. Meniscoids were
more frequently fibrous in composition in the WAD group at the dorsal aspect of zygapophyseal joints compared to the control group (odds ratio 2.4, p < 0.01;
Likelihood ratio test [LRT] Chi-square [2] = 9.0, LRT p = 0.01).
Conclusion: In chronic WAD, the size of lateral atlantoaxial joint meniscoids is decreased. Further, there is an increase in frequency of fibrous meniscoid composition
at the dorsal aspect of zygapophyseal joints in this group. These differences may plausibly exist due to altered joint kinematics secondary to pain and hypomobility,
such as the proliferation of fibrous tissue in a relatively immobile joint.
Implications: Results indicate that meniscoids in the lateral atlantoaxial joint and cervical zygapophyseal joints show morphological characteristics that differentiate
this patient group from those with normal cervical spine morphology. This supports the notion that these structures may be pathoanatomical contributors to
chronic WAD. Such data inform our current understanding of the processes underpinning the clinical management of WAD and could be extrapolated to infer support
for current treatment guidelines of encouraging range of motion exercises, advice to act as usual, and avoiding immobilisation.
Funding Acknowledgements: Project supported by graduate student and internal research funding from The University of Newcastle.
Ethics Approval: Approval granted by Hunter New England Local Health District Human Research Ethics Committee (Ref. 13/09/18/4.09).
Disclosure of Interest: None Declared
Keywords: chronic pain, morphology, imaging

Intergrating Research into practice


OR-CS-003
SEASONAL VARIATION IN SPONTANEOUS CERVICAL ARTERY DISSECTION: A COMPARISON BETWEEN UK AND AUSTRALIAN SITES
L. Thomas 1,*, L. A. Hall, J. Attia, C. Levi 2, H. Markus 3
1
School of Health and Rehabilitation Sciences, University of Queensland, St Lucia, 2Faculty of Health and Medicine, University of Newcastle, Callaghan, Australia,
3
Stroke Research Group, University of Cambridge, Cambridge, United Kingdom
Background: Spontaneous cervical artery dissection (sCAD) is a leading cause of ischemic stroke among middle aged adults, yet the aetiology remains poorly
understood. There are varying reports of a seasonal variation in incidence of sCAD in northern hemisphere countries which suggests there may be a transient
underlying arterial susceptibility. It is unknown whether this also exists in temperate climates. Better understanding of the pathophysiology and risk factors for sCAD
may improve recognition and reduce the significance of the contribution of neck manipulation to sCAD aetiology.
Purpose: This study aimed to assess whether counts of cervical artery dissection (CAD) varied with season despite different geographical and climatic conditions.
A secondary objective was to compare the incidence of clinical variables between seasonal groups and between carotid and vertebral artery dissection cases.
Methods: This was a retrospective observational study of patients aged over 18 years with a radiological diagnosis of internal carotid or vertebral or basilar arterial
dissection from sites in Australia and the UK. Demographic details, date of dissection, risk factors including exposure to minor neck trauma or infection, clinical
variables including blood pressure and full blood count were collected from digital case records. Clinical variables were compared between autumn-winter and
spring-summer and site of dissection.
Results: 133 CAD cases were documented in Australia and 242 in the UK. There appeared to be a seasonal pattern to the onset of CAD in both the Northern and
Southern hemisphere sites, with a trend for dissection to occur more commonly in autumn, winter and spring than summer. Exposure to minor trauma was more
common in vertebral artery dissection (p=0.023) and white blood count was also elevated (0.041) in comparison to internal carotid arterial dissection. Exposure to
minor trauma was more common in the autumn-winter group but was not significant (p=0.128). Neither systolic blood pressure nor pulse pressure were significantly
associated with CAD counts.
Conclusion: Cervical arterial dissection appears to occur more commonly in autumn and winter and suggests differing trigger mechanisms between dissection sites.
This study did not support blood pressure as a risk factor for CAD incidence at least in this group.
Implications:
- Seasonal variation suggests different trigger mechanisms between internal carotid and vertebral arterial dissection perhaps reducing the
importance of the contribution from manipulation as a causative factor for CAD.
- Consider the greater possibility of CAD in autumn and winter months
- Ask patients presenting with neck pain and headache about recent exposure to minor trauma or recent infection
Funding Acknowledgements: The project was supported by a grant from the National Stroke Foundation in Australia
Ethics Approval: Ethics approval was granted by the Hunter New England Human Research Ethics Committee
Disclosure of Interest: None Declared
Keywords: Cervical Artery Dissection, Carotid, Vertebral, Spontaneous, Risk Factors, Seasonal Variation

Intergrating Research into practice


OR-CS-005
DEEP CERVICAL EXTENSOR MUSCLE THICKNESS INCREASES UNDER CONTRACTION AND CAN BE MEASURED RELIABLY IN THE CLINIC USING VIDEO REAL TIME
ULTRASOUND.
T. Rebbeck*, V. Desa 1, D. Shirley 1, J. Clarke 2, A. Leaver 1
1
Discipline of Physiotherapy , 2Discipline of Medical Radiation Sciences, University of Sydney, Sydney, Australia
Background: The Deep Cervical Extensors (DCE) have a stabilising role and this function is hypothesised to be impaired in cervical spine states. To date, impairment
of DCE control has been unable to be measured easily in the clinic in real time. Rather, methods of evaluating DCE function to date have been clinically inaccessible
(mfMRI) or invasive (eg EMG) or evaluated using static imaging under RTUS.
Purpose: 1) To evaluate the change in muscle dimensions of the DCEs under low load contraction in real time using a newly developed clinically accessible protocol
and 2) to evaluate the reliability of this protocol.
Methods: : Twenty two asymptomatic individuals were recruited. Their DCEs were imaged using video RTUS at the C4 level at rest and under low-load contraction.
Thickness and width of the DCEs were measured by four independent raters. All raters paused the video clip when relaxed and then again when the DCEs were
viewed to be contracted. Mean differences and precent change between relaxed and contracted states were calculated. Reliability was determined using Intraclass
correlation coefficients (ICC).
Results: DCE thickness increased between rest and contraction by up to 7% (Mean (SD) % change 6.62 (7.58) p=.001) in these asymptomatic patients. The width of
the DCEs however did not change (Mean (SD) % change 2.02(4.24). Thickness measurements of the DCEs displayed excellent intra-rater reliability when measured in
the relaxed (eg ICC 0.92; 95%CI 0.81-0.97) and contracted (eg ICC 0.91; 95%CI 0.78-0.96) states. Similarly inter-rater reliability was excellent for the relaxed state ( ICC
0.94; 95%CI 0.87-0.98) and contracted states (0.95 (0.89-0.98). Width measurements of the DCEs displayed poorer intra-rater (e.g. ICC 0.58; 95%CI -0.04-0.83) and
inter- rater (eg ICC 0.76; 95%CI 0.51-0.90) reliability in both states.
Conclusion: The thickness of the DCEs appears to increase under low load contraction in asymptomatic individuals. The width measurements appeared not to
change. Measurement of the change in thickness was reliable when used within and between users. The width measurement was less reliable, suggesting this is less
useful clinically.
Implications: Clinicians now have clinically accessible and easy way to measure the contraction of the DCEs using video RTUS. The entire protocol takes less than a
few minutes to perform, requiring up to 4-6 hours or training to become competent. Further work will use the protocol to evaluate the changes in these dimension
in cervical spine states. In the meantime, clinicians can use this protocol to observe changes in DCE thickness and note the difference between their patients and
that now published for asymptomatic individuals. The protocol then allows clinicians to measure if change has occurred after rehabilitation.
Funding Acknowledgements: Trudy Rebbeck is funded by the National Health and Medical Research Council (NHMRC) of Australia.
Ethics Approval: Ethics approval was given by The University of Sydney Human Research Ethics Committee (2012/727).
Disclosure of Interest: None Declared
Keywords: Cervical multifidus, semispinalis cervicis, real time ultrasound, deep neck extensors.

Intergrating Research into practice


OR-EX-041
STRATIFIED CARE IN CHRONIC PAIN REHABILITATION DOES IT WORK IN THE CLINICAL SETTING?
K. Barker*, L. Heelas 1, F. Toye 1
1
Physiotherapy Department, Nuffield Orthopaedic CEntre, Oxford University Hospitals NHS FT, Oxford, United Kingdom
Background: The use of stratified care is well established for management of back pain in the primary care setting, but as yet is not commonly used in the chronic
pain rehabilitation population. Only 14% of the 7.8 million people with chronic pain in the United Kingdom, will have access to a pain clinic and many pain clinics do
not have the capacity to meet demand, suggesting a need for more responsive service models. We have previously described how we developed model of
stratification to be used in specialist secondary care chronic setting [Barker et al 2014]
Purpose: To evaluate the use of a stratified care algorithm in clinical practice for clinical utility and effectiveness
Methods: We collected standardised outcome data on 212 consecutive patients attending an NHS pain rehabilitation service. Patients were stratified to either a
physiotherapist led rehabilitation programme [PLP] of 45 hours duration or a multidisciplinary programme [PMP] of 35 hours duration. Data was collected using the
Brief Pain Inventory, Physical Health Questionnaire (PHQ-9), Generalised Anxiety Scale GAD-7 and chronic pain acceptance questionnaire (CPAQ) together with timed
walk test and sit to stand tests at baseline and 3 months after completion of the programmes. Effect sizes and the number of patients achieving a clinically meaningful
improvement in score were calculated.
Results: Effect sizes were small for GAD 7 (anxiety) 0.33 and .26 for the PMP and PLP respectively, moderate for PHQ-9 (depression) 0.48 and 0.63 for the PMP and
PLP respectively, moderate for the walk tests 0.48 and large for sit to stand 0 .85 (PMP), 0.93 (PLP) and BPI 0.76 (PMP) and 0.84 (PLP).
33% of the PMP patients and 40% of the PLP patients obtained a clinically reliable improvement in depression. The baseline data demonstrated that patients
attending the PMP were more highly disabled, more depressed and had higher levels of pain interference.
Conclusion: The results suggest that patients were appropriately stratified, with only the more severe patients accessing the PMP. This stratification is in keeping with
the Stepped Care Model advocated by IASP (2012). Most of the effect sizes were moderate or large suggesting that both programmes were effective up to three
months post treatment.
Implications: These findings suggest that experienced physiotherapists working in pain rehabilitation can provide efficacious treatment to patients using a stratified
care model.
Funding Acknowledgements: Supported by Oxfordshire Health Services Research Committee grant 8110
Ethics Approval: All patients assented to their outcome data being used for service evaluation. The Joint Research & Development Committee confirmed LREC not
required.
Disclosure of Interest: None Declared
Keywords: Pain rehabilitation, stratified care.

Intergrating Research into practice


OR-EX-042
ARE GENETICS RESPONSIBLE FOR THE BENEFICIAL EFFECTS OF PHYSICAL ACTIVITY? A SYSTEMATIC REVIEW AND META-ANALYSIS OF TWIN STUDIES
J. Zadro, D. Shirley 1,*, P. Ferreira 1, T. Andrade 1
1
Faculty of Health Sciences, The University of Sydney, Lidcombe, Australia
Background: Engagement in regular physical activity is one of the most important aspects to maintaining optimal health and is strongly recommended in the
prevention and management of various conditions (e.g. cardiovascular disease, mental-health disorders and low back pain). However, there is strong evidence for
considerable heterogeneity in a persons response to physical activity, with research suggesting genetics play a substantial role in this variation.
Purpose: To quantify the role genetics plays in the response to physical activity for measures of body composition and cardiorespiratory fitness.
Methods: We conducted this systematic review in accordance with the PRISMA statement and performed electronic database searches in MEDLINE, CINAHL,
EMBASE, SPORTS Discuss, AMED, PsycINFO, WEB OF SCIENCE and SCOPUS from the earliest records to May 2015. A comprehensive search strategy was used
combining key words relating to physical activity AND genetics. Studies were included if they investigated measures of body composition or cardiorespiratory
fitness following an identical physical activity intervention in a sample of twins. Since the design of these studies is unique, methodological quality was assessed but
did not form part of the inclusion criteria. There was no restriction on the type of physical activity investigated, although observational studies were excluded. Data
on the within twin-pair correlation (r) and heritability were extracted from included studies.
Results: After screening 136 full texts, 9 twin studies were included in this systematic review. We pooled results for the within monozygotic (MZ) twin-pair
correlation, giving us quantitative estimates for the upper bound of heritability. We were unable to pool estimates for heritability, since the outcomes investigated in
twin studies reporting heritability estimates were heterogeneous. Pooled results for body composition measures (five studies) demonstrated a significant within MZ
twin-pair correlation in response to physical activity for BMI (r=0.79, p<0.001) and body fat percentage (r=0.63, p<0.001). There was also a significant within MZ twinpair correlation in response to physical activity for VO2max (L.min-1) (r=0.70, p=0.001) (four studies).
Conclusion: Genetics play a considerable role in the response of body composition and cardiorespiratory fitness following a physical activity intervention. Future twin
studies investigating the response to physical activity should utilize dizygotic (DZ) twins in their design to allow the calculation of heritability, a more direct estimate
of the role of genetic factors.
Implications: These results have implications for the prevention or management of conditions which advocate increased levels of physical activity (e.g. cardiovascular
disease), since genetic factors might serve as an explanation for why some people respond better than others.
Funding Acknowledgements: None.
Ethics Approval: Ethics approval is not required.
Disclosure of Interest: None Declared
Keywords: physical activity, response , twins

Intergrating Research into practice


OR-LL-014
LOWER LIMB KINEMATICS, MUSCLE ACTIVITY AND STRENGTH IN PARTICIPANTS WITH PATELLOFEMORAL PAIN SYNDROME
L. Kedroff 1,*, A. Amis 2, D. Newham 3
1
Division of Health and Social Care, King's College London, 2Biomechanics Group, Department of Mechanical Engineering, Imperial College London, 3Centre for Human
and Aerospace Physiological Sciences, King's College London, London, United Kingdom
Background: Patellofemoral Pain Syndrome (PFPS) is one of the most prevalent knee disorders and can lead to persistent symptoms and restriction of activities. The
aetiology is largely unproven but factors such as hip and knee muscle weakness, altered muscle activity and changes in kinematics have been implicated.
Physiotherapy management focuses on exercises to address modifiable physical factors and research to identify the relevant factors will help inform clinical trials and
rehabilitation programmes.
Purpose: Four studies of healthy and PFPS participants were undertaken to compare; (i) hip and knee muscle activity and strength and (ii) foot and lower limb
kinematics during stair negotiation, walking and squatting.
Methods: For the 4 studies, convenience samples of male and female healthy controls (n ranged from 11-23) and participants with PFPS (n = 11 - 25) were recruited.
The participants with PFPS had symptoms for at least 6 weeks and no coexistent pathology. Other inclusion criteria were knee pain on at least 2 of the following
activities: prolonged sitting, squatting, kneeling, ascending/descending stairs, or running. Light-emitting diodes were placed on the lower limb and foot and data were
acquired using a 3-D movement analysis system (CODA mpx30). Measurements of joint motion were taken while the participants performed trials of walking, stair
ascent and descent and single- and double-leg squats. Surface EMG from the vastus medialis obliquus, vastus lateralis, rectus femoris, hamstrings, gluteus maximus,
and gluteus medius was recorded simultaneously, using pairs of active electrodes (Biopac). Hip and knee isometric strength was measured using an isokinetic
(KinCom) or hand-held dynamometer (Nicholas Manual Muscle Tester).
Using Mathcad software, the data were analysed and group differences in joint or body segment range and normalized EMG signal were assessed with either
independent t or Mann-Whitney tests using SPSS software.
Results: Weaker hip abductors, external rotators and extensors and knee extensors (p0.04) were found in PFPS participants. Greater gluteus maximus and less
hamstring EMG activity (p0.01) were found during single leg squat descent in PFPS participants. No other group differences were noted in leg muscle activity and in
hip and knee joint range during squatting and stair negotiation. Increased shank and rearfoot segment internal rotation and adduction of the mid- and forefoot
segments (p0.04) was found in PFPS participants during walking.
Conclusion: PFPS participants have weak hip and knee muscles and demonstrate some kinematic changes, typically distal increases in limb internal rotation. Gluteus
maximus and hamstrings muscle activity were altered during one task. However kinematic and muscle activity changes were variable and it is likely that for subgroups
of participants, these changes are implicated in PFPS aetiology. Future work should explore whether kinematic variables are more important for subgroups and
investigate the clinical relevance of these findings in rehabilitation trials.
Implications: Physiotherapy management currently focuses on hip and knee muscle strengthening and some kinematic retraining. The studies undertaken provide
evidence to support targeting strength deficits rather than kinematic retraining.
Funding Acknowledgements: Doctoral award (1000) from the MACP
Kingston NHS Hospital PhD funding (12,000)
Ethics Approval: Ethical approval was obtained from Kings College London University Ethics Committee and Guys Research Ethics Committees.

Disclosure of Interest: None Declared


Keywords: Cross sectional study, Patella

Intergrating Research into practice


OR-LL-017
CLINICAL PREDICTORS OF RESPONSE TO EXERCISE & MANUAL THERAPY INTERVENTIONS FOR PATIENTS WITH HIP OSTEOARTHRITIS: A INDEPENDENT VALIDATION
STUDY
J. H. Abbott 1,*, G. Puts 2, Y. Pua 3, A. Wright 4, K. Bennell 5
1
Centre for Musculoskeletal Outcomes Research, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand, 2Radboud University, Nijmegen,
Netherlands, 3Singapore General Hospital, Singapore, Singapore, 4Highpoint University, Highpoint, United States, 5University of Melbourne, Melbourne, Australia
Background: Exercise therapy is the recommended first-line intervention for patients with hip osteoarthritis (OA), and emerging evidence also recommends manual
therapy. Previous authors have developed clinical prediction rules (CPRs) to predict the outcome from exercise and manual therapy interventions in patients with hip
OA, however, the predictors identified in these models were different and have not been independently validated.
Purpose: To assess the external validity of published preliminary CPR models, and to update those models, using data from the intervention and control arms from
two randomized controlled trials (RCTs) of exercise and manual therapy in patients with hip OA.
Methods: This was a parallel groups prognostic validity study. Data were obtained from 2 RCTs (#1: n=102, active intervention 49, sham control 53; and #2: n=93,
active interventions 70, usual care control 23). Participants were classified as responders or non-responders using the OMERACT/OARSI criteria at 9-12 month followup. Logistic regression modelling was conducted. Log likelihood, pseudo-R2, area under-the-curve (AUC), Pearson goodness-of-fit test and the Hosmer and Lemeshow
test were used to assess the performance of the models.
Results: The external validity of the previously published models could not be confirmed. The updated models contained different predictors, namely: WOMAC
overall 51; PCS overall 64; and the internal rotation range-of-motion 18.5. The final updated model had good fit with the intervention group data from RCT #1,
resulting in an AUC of 0.92. All models showed poor fit with the sham group data from RCT #1. The updated model could not be shown to be valid in the independent
data from RCT #2.
Conclusion: Previously published preliminary models could not be validated on an independent dataset. Despite the promising results of the newly developed
updated model, it too could not be validated on an independent dataset. Limitations include risk of overfitting of the prediction models due to a large number of
potential predictor variables and relatively small number of responders per variable, and use of baseline WOMAC as a potential predictor, as it is correlated with the
outcome of the OMERACT/OARSI criteria. Removal of baseline WOMAC from the model did not change the conclusions or interpretation. These analyses and results
are consistent with concerns raised in the CPR literature that many preliminary models are not valid, but rather are chance findings that are not replicable in
independent samples.
Implications: Existing published preliminary models for prediction of response to exercise and manual therapy in patients with hip OA are not valid and should not be
used in clinical practice.
Funding Acknowledgements: This study was a secondary analysis of data from trials funded by the Health Research Council of New Zealand (HRC), and the Australian
Government National Health and Medical Research Council (NHMRC). During the conduct of this study Dr Abbott was supported by a Sir Charles Hercus Health
Research Fellowship from the Health Research Council of New Zealand.
Ethics Approval: Study #1 was approved by the University of Melbourne Human Research Ethics Committee. Study #2 was approved by the Lower South Regional
Ethics Committee of the New Zealand Ministry of Health.
Disclosure of Interest: J. H. Abbott Conflict with: Health Research Council of New Zealand, Conflict with: District Health Boards of the New Zealand Ministry of Health,
G. Puts: None Declared, Y. Pua: None Declared, A. Wright: None Declared, K. Bennell Conflict with: NHMRC Principal Research Fellow
Keywords: clinical decision-making, osteoarthritis, Prediction

Intergrating Research into practice


OR-LL-018
VALIDITY OF THE THESSALY TEST IN EVALUATING MENISCAL TEARS COMPARED WITH ARTHROSCOPY: A DIAGNOSTIC ACCURACY STUDY
W. Scholten-Peeters 1,*, E. Keijsers 2, P. Goossens 3, A. Verhagen 4
1
Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, 2University of Applied
Sciences, 3Department of Physiotherapy, Amphia Hospital, Breda, 4Department of General Practice, Erasmus MC-University Medical Center, Rotterdam, Netherlands
Background: The Thessaly test was introduced to improve the diagnostic accuracy of the clinical examination in detecting meniscal tears. This test appears to be a
valuable alternative to other meniscal clinical tests usually performed, but additional diagnostic accuracy data are required.
Purpose: To evaluate the diagnostic accuracy of the Thessaly test compared with an arthroscopic examination in patients with suspected meniscal tears in a hospital
care setting.
Methods: Patients with suspected meniscal tears, referred to a hospital for arthroscopic surgery, were eligible. The Thessaly test alone, and the combination of the
Thessaly and McMurray tests, were considered as index tests and arthroscopy was used as the reference test. Experienced physiotherapists performed the Thessaly
test at 20 flexion and the McMurray test for both knees. The physiotherapist was blinded to patient information, affected knee, and the results from possible earlier
diagnostic imaging. An orthopedic surgeon, blinded to the clinical test results from the physiotherapist, performed the arthroscopic examination.
Results: A total of 593 patients were included, of which 493 (83%) had a meniscal tear according to the arthroscopic examination. The Thessaly test had a sensitivity
of 64% (95% CI 60-68), specificity of 53% (95% CI 43-63), positive predictive value (PPV) of 87% (95% CI 83-90), negative predictive value (NPV) of 23% (95% CI 18-29),
and a positive and negative likelihood ratios (LR+ and LR-) of 1.37 (95% CI 1.10-1.70) and 0.68 (95% CI 0.59-0.78), respectively. The combination of a positive Thessaly
and McMurray tests showed somewhat lower sensitivity (53%) and higher specificity (62%). Combining negative Thessaly and McMurray tests results resulted in
sensitivity of 82% and specificity of 36%, respectively.
Conclusion: The results of the Thessaly test alone, or combined with the McMurray test, do not seem useful to confirm meniscal tears.
Implications:
The Thessaly test yielded only marginal diagnostic benefits compared with the pretest probability of a meniscal tear in a hospital care setting. Therefore, these tests
should not be recommended for use in a hospital care setting to determine the presence of meniscal tears.
Funding Acknowledgements: This study was funded by the Scientific College of Physiotherapy of the Royal Dutch Society for Physical Therapy.
Ethics Approval: The local medical ethical committee of the Elisabeth Hospitalin Tilburg approved the protocol of the study.

Disclosure of Interest: None Declared


Keywords: McMurraytest, Thessalytest, validity

Intergrating Research into practice


OR-LS-019
THE NATURAL COURSE OF PAIN AND DISABILITY FOLLOWING PRIMARY LUMBAR DISCECTOMY: PROTOCOL FOR A SYSTEMATIC REVIEW AND META-ANALYSIS
A. Rushton 1,*, N. Heneghan 1, M. Heymans 2, J. B. Staal 3, P. Goodwin 4
1
School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom, 2Department of Epidemiology and Biostatistics and
the Department of Methodology and Applied Biostatistics of the Faculty of Earth and Life Sciences, VU University Medical Center, Amsterdam, 3Scientific Institute for
Quality of Healthcare (IQ healthcare) , Nijmegen, Netherlands, 4Health Professions Department (Physiotherapy), Manchester Metropolitan University, Manchester,
United Kingdom
Background: Although lumbar discectomy success rates are reported as high (46-75% at 6-8 weeks, and 78-95% at 1-2 years post surgery), ongoing problems are an
issue for a substantial number of patients. The evidence suggests 30% to 70% of patients continue to experience pain and that 3% to 12% require further surgery.
Knowledge about natural clinical course is needed to improve understanding of recovery post surgery, as outcome is poor for some patients.
Purpose: To provide the first evidence synthesis investigating the natural clinical course of disability and pain in patients aged >16 years post primary lumbar
discectomy.
Methods: A systematic review and data synthesis was conducted according to a pre-defined protocol registered with PROSPERO (CRD42015020806). Prospective
cohorts that included a well-defined inception cohort (point of surgery) of adult participants who have undergone primary lumbar discectomy / microdiscectomy
were included. Outcomes included measurements reported on one or more outcomes of disability and pain (leg and back pain), with a baseline pre surgery. Two
reviewers independently searched information sources, assessed identified studies for inclusion, extracted data and assessed risk of bias for included studies. A third
reviewer mediated any disagreement at each stage. The search employed sensitive topic-based strategies designed for each database from inception to 31 May 2015.
There were no language or geographical restrictions. Risk of bias was assessed using a modified QUIPs tool (Quality in Prognostic Studies). Data synthesis was
conducted on data extracted for time points where follow up was at least 80%. Medians and range were reported for each outcome. In a data synthesis, means and
95% Confidence Intervals were plotted over time for leg pain, back pain and disability.
Results: 45 prospective cohorts (n>50,000) across a range of countries were included. Although a further 15 cohorts were eligible, no data were available. Few
authors responded to requests for raw data. All results were reported in the context of overall study quality. 18 studies were at high risk of bias. Few cohorts
evaluated the initial 3 month period post surgery. 16 cohorts evaluated 6 month outcomes and 26 cohorts evaluated long term outcomes (12 months). The median
leg pain (VAS 0-10) was 7 (range 3 to 8.7) before the operation, and 2.6 (range 0.6 to 3.1) and 2.0 (range 0.3 to 3.3) at 6 and 12 months follow-up respectively. The
median back pain (VAS 0-10) was 5.1 (range 3.6 to 7.6) before the operation, and 2.2 (range 0.7 to 3.1) and 2.2 (range 0.1 to 3.7) at 6 and 12 months follow-up
respectively. Other outcomes and meta-analyses will be discussed.
Conclusion: These data demonstrate the initial improvement in outcomes following lumbar discectomy surgery, illustrating the initial success of surgery. However the
data highlight a subsequent plateau in improvement, demonstrated here for leg and back pain between 6 and 12 months follow-up.
Implications: This review has provided the first rigorous summary of the course of pain and disability across all published prospective cohorts for adult patients
following primary lumbar discectomy. The findings will inform our understanding of when to offer and how to optimise rehabilitation following surgery.
Funding Acknowledgements: None.
Ethics Approval: Not applicable.
Disclosure of Interest: None Declared
Keywords: lumbar spine rehabilitation, natural history, systematic review

Intergrating Research into practice


OR-LS-024
RELATIONSHIP OF STRAIGHT LEG RAISE AND SLUMP TESTS TO NERVE PALPATION IN INDIVIDUALS WITH SPINALLY REFERRED LEG PAIN
C. Ridehalgh*, A. Moore 1, A. Hough 2
1
School of Health Sciences, University of Brighton, Eastbourne, 2School of Health Professions, University of Plymouth, Plymouth, United Kingdom
Background: Neurodynamic testing (NDT) is performed to ascertain the presence of nerve as source of the individuals symptoms. It has been proposed that nerve
palpation can aid the clinical decision making, but limited literature supports this. In addition, it is not known if there is a difference in the presence of tenderness to
nerve palpation (NP) between individuals with radicular pain and radiculopathy.
Purpose: To assess the relationship between nerve palpation and straight leg raise (SLR) and slump tests in individuals with spinally referred leg pain, and to ascertain
if NP on individuals with radicular pain and radiculopathy produces similar mechanical responses.
Methods: Sixty five participants with spinally referred leg pain were sub-grouped into somatic, radicular pain or radiculopathy. As part of this examination, clinicians
were asked to assess SLR, slump test or both and perform NP of the sciatic and tibial or common peroneal nerves. Clinicians were blinded to the purpose of the
current study. Phi correlation was used to assess relationship between the NDT and NP. Validity of NP was assessed against a positive NDT, and sensitivity, specificity,
positive predictive value (PPV), negative predictive value(NPV), positive and negative likelihood ratios (LR) were calculated. Differences in the presence of positive NP
between the radicular and radiculopathy group was analysed using chi squared test.
Results: Eleven participants were sub-grouped as somatic, 32 as radicular pain and 22 as radiculopathy. Correlations between SLR test and NP were not significant
(p=0.08, r=0.47), slump and NP were significant (p=0.009, r= 0.72) and for both SLR and slump and NP were significant (p=0.000, r=0.64). Validity of NP for SLR alone
revealed a sensitivity =0.43, specificity =1, PPV=1, NPV= 0.46, and ve LR = 0.57. As specificity was 1, it was not possible to calculate +ve LR. NP for both SLR and
slump tests revealed a sensitivity =0.76, specificity =1, PPV=1, NPV= 0.54,ve LR = 0.24. There was no significant difference in NP findings between the radicular and
radiculopathy groups (p=0.7).
Conclusion: Whilst slump test alone had the best correlation, this was undertaken in only 11 participants. The best r value and validity occurred when both slump and
SLR were tested. There was no significant difference in positive NP findings between radicular and radiculopathy groups.
Implications: Better relationship occurs between a NDT and NP when both slump and SLR are tested. It is not clear why this occurs, but could be because of a greater
mechanical impact on neural tissue since NP was always performed after the NDT. Individuals with radicular leg pain and radiculopathy do not behave differently to
NP.
Funding Acknowledgements: Doctoral award from the MACP
Ethics Approval: London Chelsea Ethics committee (12/LO/0397)
Disclosure of Interest: None Declared
Keywords: Nerve palpation, Neurodynamics

Intergrating Research into practice


OR-MS-025
HOW DO PA MOVEMENTS RELATE TO LOCALISED STIFFNESS IN THE UNDERLYING MOTION SEGMENT, THERAPISTS PERCEIVED STIFFNESS, AND PATIENT
SYMPTOMS?
N. Tuttle 1 2,*, K. Evans 1 3
1
School of Allied Health Sciences, Griffith University, Gold Coast, QLD, 2Menzies Health Institute Queensland, Gold Coast, 3Menzies Health Institute Queensland, Gold
Coast, QLD, Australia
Background: Manually applied forces to individual vertebrae in a posterio-anterior direction (PA) are one of the most common assessment techniques used in manual
therapy for all regions of the spine. Whether these techniques are able to achieve one of their stated objectives of detecting alterations in mobility of underlying
motion segments is unclear. Early studies of PA movements mostly focussed on the segmental motion in the lumbar spine and have largely failed to establish links
between characteristics of PA movements and either segmental mobility or patient symptoms.
Purpose: The series of studies described in this presentation consider what aspects of the measurable, physical characteristics of PAs relate to 1) altered mobility in
the underlying motion segments, 2) alterations in therapist perception and/or 3) patient symptoms.
Methods: In vitro methods included determining the impact of decreased mobility of an underlying motion segment on the force/displacement (FD) curves of PA
movements using computer-based modelling of the lumbar and cervical spines and using a biomechanically accurate physical model of the lumbar spine. In vivo
methods included measuring PA movements in tender and less tender locations of the cervical spine, determining how characteristics of PA movements changed
when patient symptoms improved in the cervical spine and measuring PA movements in locations that were perceived as having different levels of stiffness in the
thoracic spine.
Results: When linear approximations of stiffness from the FD curves were used in modelling segmental movements or in characterising FD curves, no significant
differences were detected when an underlying segment was stiffened. When the entire non-linear FD curves were considered including regions at low force levels,
statistically significant differences in the FD curves were apparent. The pattern of differences in the curves were consistent 1) in vitro when there was reduced
mobility in the underlying motion segments, 2) in vivo when the therapist perceived decreased mobility, and 3) with the presence of, or change in, patient
symptoms. The differences were most marked in a shortening of the so-called toe region at forces often well below 20 N.
Conclusion: Although the toe region of the FD curves of PA movements has often been considered to represent soft tissue compression rather than joint motion, our
modelling demonstrated that a reduction in the size of the segmental neutral zone had a significant impact on the toe region of PA movements. Similarly, therapist
perception of reduced mobility was related to a reduction in the size of the toe region of PA movements. Our clinical studies found that the differences in PA
movements that were related to tenderness or changes in patient symptoms were also most apparent in the toe region of the FD curves.
Implications: Armed with this knowledge therapists have been trained to detect relevant differences in PA movements reliably and with levels of force that are up to
an order of magnitude less than those that have been reported in the literature. Potential benefits include not only increased repeatability, but also reduced wear
and tear on the therapist and patient discomfort.
Funding Acknowledgements: Some aspects of the work were assisted by funding from the Australian Government
Ethics Approval: Ethics approval was received from Griffith University Ethics review board for all aspects of this research that involved human participants.
Disclosure of Interest: None Declared
Keywords: Assessment, cervical spine, Palpation

Intergrating Research into practice


OR-MS-026
PELVIC FLOOR DYSFUNCTION IN WOMEN WITH CHRONIC OR RECURRENT LUMBO-PELVIC PAIN
A. McNamara, K. Briffa 1,*, J. Thompson 1, A. Andrews 1, A. Jacques 1
1
Curtin University, Perth, Australia
Background: Lumbo-pelvic pain (LPP) is a common complaint with many people developing chronic or recurrent symptoms. Altered muscle recruitment strategies of
the deep trunk stabilisers, including the pelvic floor muscles, has been hypothesised as a possible cause for ongoing symptoms. A link has been suggested between
symptoms of pelvic floor dysfunction (PFD) and LPP, however prevalence data is lacking.
Purpose: The purpose of this study was to describe the prevalence of urinary incontinence (UI) in women with chronic or recurrent LPP and to compare this to
women without LPP. A secondary aim was to explore other forms of PFD in these women and compare this to women without LPP.
Methods: Women presenting to physiotherapy in Regional Australia were invited to participate in this cross sectional study by completing a questionnaire. The
questionnaire collected data regarding subject demographics. Urinary incontinence and PFD were assessed by using the Australian Pelvic Floor Questionnaire (APFQ).
Women who reported chronic or recurrent episodes of LPP were allocated to the study group, while women without a history of LPP made up the reference
group.Mann-Whitney U tests were used to compare continous data between groups and Pearsons chi-square tests were used to compare categorical data between
groups. Covariate effects were summarized using odds ratios (ORs) and their 95% confidence intervals. Factors that were significantly different between groups were
entered into a multivariable logistic regression model to determine which factors were significantly independently associated with LPP.
Results: Seventy-nine percent of women with LPP reported UI compared 59.3% of the reference group (p =0.02). Total APFQ scores also yielded a significant
difference between groups (p =0.02), as did the specific bladder function (p <0.0001) and bowel function (p =0.03) subsections of the APFQ. In multiple regression
analysis, urinary frequency (OR 2.32; 95% CI 1.01-5.33: p =0.048, stress urinary incontinence (OR 3.54; 95% CI 1.51-8.31: p =0.004) and incomplete bowel emptying
(OR 4.45; 95% CI 1.89-10.45; p =0.001) were significant independent risk factors for LPP.
Conclusion: Women with chronic or recurrent LPP have significantly higher UI and PFDs which provides further evidence of a link between PFD and LPP. Precise
mechanisms into cause and effect require further investigation.
Implications: Women presenting to physiotherapy with chronic or recurrent LPP should be screened for potential co-morbid UI and PFD. The APFQ may be a useful
tool to identify women with these disorders which will allow clinicians to either provide a detailed assessment and treatment, or provide an appropriate referral.
Funding Acknowledgements: Unfunded. This project was completed as part of a Master of Clinical Physiotherapy degree.
Ethics Approval: Ethics approval was obtained from the Human Research Ethics Committee, Curtin University, Australia.
Disclosure of Interest: None Declared
Keywords: lumbo-pelvic pain, pelvic floor dysfuncion, urinary incontinence

Intergrating Research into practice


OR-MS-027
WELL CHARACTERISED NECK POSTURE IS NOT RELATED TO NECK PAIN IN ADOLESCENTS IN A LARGE COMMUNITY-BASED SAMPLE
K. Richards*, D. Beales, A. Smith, P. O'Sullivan, L. Straker

Background: There is conflicting evidence on the relationship between sagittal neck posture and neck pain. Most evidence is cross sectional in nature, and based on
weakly characterised posture and a lack of consideration of biopsychosocial factors known to be related to both neck pain and posture.
Purpose: To determine the existence of neck posture clusters in adolescents and establish whether identified clusters were associated with biopsychosocial factors
and neck pain.
Methods: 1108 17-year-olds enrolled in the Western Australian Pregnancy Cohort (Raine) Study underwent photographic postural assessment in sitting. One distance
and four angular measures of the head, neck and thorax were calculated from photo-reflective markers placed on bony landmarks. Subgroups of sagittal sitting neck
posture were determined by cluster analysis. Height and weight were measured and lifestyle and psychological factors, as well as neck pain and headache, were
assessed by questionnaire. The associations between posture clusters, neck pain and other factors at 17 years were evaluated using logistic regression.
Results: Four distinct clusters of sitting neck posture were identified and characterised as upright, intermediate, slumped thorax/forward head and erect
thorax/forward head postures. Significant associations between cluster and sex, weight and height, were found. Adolescents classified as having slumped thorax
forward/head posture were at higher odds of mild, moderate or severe depression. Adolescents classified as upright posture exercised more frequently. There was no
significant difference in the odds of persistent neck pain, neck pain made worse by sitting or headache across the clusters. Female sex was strongly associated with
neck pain.
Conclusion: Sagittal sitting neck posture clusters were identified in 17-year-olds that align with common clinical perceptions. Clusters differed on biopsychosocial
profiles. The finding of no association between cluster membership and neck pain in this cross sectional analysis challenges widely held beliefs about the role of
posture in adolescent neck pain.
Implications: The premise for the clinical assessment of posture should be reconsidered and take into account other biopsychosocial factors.
Funding Acknowledgements: NHMRC program grant 353514 and NHMRC project grant 323200 and additional funding for core management from The University of
Western Australia (UWA), Raine Medical Research Foundation, Telethon Kids Institute, UWA Faculty of Medicine, Dentistry and Health Sciences, Women and Infants
Research Foundation, Curtin University and Edith Cowan University.
Ethics Approval: Ethical approval was from Curtin University Human Research Ethics Committee (Reference HR 84/2005), Princess Margaret Hospital Human
Research Ethics Committee (Reference 1214EP) and The University of Western Australia (reference RA/4/1/502).
Disclosure of Interest: None Declared
Keywords: Classification system, Neck pain, Sagittal alignment

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OR-MS-029
EXAMINATION OF A CLINICAL PREDICTION RULE TO IDENTIFY PATIENTS WITH SHOULDER PAIN LIKELY TO BENEFIT FROM CERVICOTHORACIC MANIPULATION: A
MULTI-CENTER RANDOMIZED CLINICAL TRIAL
P. Mintken 1,*, A. McDevitt 1, L. Michener 2, S. Burns 3, R. Boyles 4, J. Cleland 5
1
Physical Therapy, University of Colorado Anschutz Medical Campus, Aurora, 2Division of Biokinesiology and Physical Therapy, University of Southern California, Los
Angeles, CA, 3Physical Therapy, Temple University, Philadelphia, PA, 4Physical Therapy, University of Puget Sound, Tacoma, WA, 5Physical Therapy, Franklin Pierce
University, Concord, NH, United States
Background: Research is emerging that manual therapy of the cervical and thoracic spine may be beneficial in patients with shoulder pain. Prognostic variables
identifying patients with shoulder pain who are likely to respond to cervicothoracic manipulation have been reported, however they have yet to be validated in a
separate cohort
Purpose: The purpose of this study was to examine the validity of previously reported prognostic variables and to determine if the addition of cervicothoracic
manipulation to an exercise program produces superior outcomes compared to exercise alone.
Methods: Multi-center randomized controlled trial in which 140 participants with a primary report of shoulder pain were randomly assigned to receive either 2
sessions of range of motion (ROM) exercises plus 6 sessions of stretching and strengthening exercises (Ex group) or 2 sessions of cervicothoracic manipulation and
ROM exercises followed by 6 sessions of stretching and strengthening exercise (MT+Ex group). The Shoulder Pain and Disability Index (SPADI) and Numerical Pain
Rating Scale (NPRS) were collected at baseline, 1-week, 4-weeks and 6-months. A generalized linear mixed-effects model with repeated measures was used to
examine the primary outcomes on the SPADI and the NPRS. Time, treatment group and status of predictor variables, as well as all possible 2-way and 3-way
interactions were modeled as fixed effects with disability and pain as the dependent variable. We then analyzed the percentage of participants in each treatment
group experiencing a successful outcome using the Global Rating of Change (GROC), and the Patient Acceptable Symptom Scale (PASS) using 2 tests of independence
at all follow-up periods.
Results: Repeated measures analyses did not show a significant 3-way interaction for either disability (p=0.27) or pain scores (p=0.70). Additionally, there was no
significant 2-way interaction between group and time for both disability (p=0.62) and pain (p=0.87). At 4-weeks, the percentage of participants experiencing success
defined by GROC and acceptable symptom state defined by the PASS was greater in the MT+Ex group (p=0.027, 0.009 respectively). Additionally, there was a
significant difference (p=0.04) between groups at the 6- month follow-up period with 66% in the MT+Ex as compared to 48% in the Ex group reporting GROC-success.
Conclusion: The results of the current study did not validate the previously identified prognostic variables. However, the results demonstrated that participants with
mechanical shoulder pain who received cervicothoracic MT+Ex were more likely to experience treatment success and an acceptable symptom state as compared to
participants who received exercise alone.
Implications: It has been suggested that patients with shoulder pain would benefit from cervicothoracic manipulation, but this recommendation has not been
investigated in a randomized clinical trial. Our results suggest that adding cervicothoracic manipulation may improve patient reported success compared to exercise
alone.
Funding Acknowledgements: Funding was provided by the Orthopaedic Section of the American Physical Therapy Association.
Ethics Approval: This study was approved by the Colorado Multiple Institutional Review Board (COMIRB), Aurora, Colorado, USA.
Disclosure of Interest: None Declared
Keywords: None

Intergrating Research into practice


OR-MT-031
THE HYPOALGESIC EFFECT OF HIGH AND LOW FORCE MOBILISATION OF THE KNEE. DOES FORCE OF MOBILISATION TREATMENT MATTER?
C. Hebron*, J. Andrews 1, P. Kenny 1
1
School of Health Sciences, University of Brighton, Eastbourne, United Kingdom
Background: Mobilisations are commonly used in the treatment of musculoskeletal disorders. Current thinking is that the effect of mobilisation treatments is
predominantly neurophysiological, resulting in a decrease in pain. A number of studies have reported that mobilisations have a hypoalgesic effect (as measured by
pressure pain threshold (PPT) in both symptomatic and asymptomatic populations. This hypoalgesic effect of mobilisation treatment is thought to occur via both
spinal and supraspinal neurophysiological mechanisms. However the research in this area is inconclusive with some studies reporting an immediate increase in PPT
following mobilisations local to the site of intervention and other studies reporting both local and distal effects, thereby suggesting a systemic analgesic mechanism.
A number of studies have explored the influence of treatment dose and suggest that changing dose parameters may affect the treatment outcome. For example a
study exploring the analgesic effect of lumbar mobilisations in chronic low back pain patients found that higher forces were associated with a greater analgesic
response.
Purpose: This study aimed to establish whether higher force knee mobilisations have a greater local and systemic hypoalgesic effect than low force mobilisations.
Methods: This study employed a randomised single blind, within-subject, repeated measures, cross-over design. Three interventions: control (supine lying), low force
(30N) and high force (350N) posteroanterior knee mobilisation were applied in a random order, at least 48 hours apart. Mobilisation was applied for 3 sets x 1 minute
with a 1 minute interval between sets. The control intervention involved the participant lying supine for the same duration. PPT was measured before and
immediately after the intervention at the knee and the contralateral hand to establish local and systemic hypoalgesic effects.
Results: There was a significant time*condition interaction effect (F=8.749, p=.001) demonstrating that force had a significant influence on the pre -post intervention
PPT. Post hoc analysis revealed that there was no significant difference in change in PPT with low force mobilisations compared to control (F=0.30, p=.87) . However
there was a significant difference between high and low force mobilisation (F=13.44, p=.001) and control and high force mobilisation (F=11.13, p=.002). There was a
significant site* time interaction (F1, 31=p=.000) demonstrating a greater post intervention increase in PPT locally compared to distal to the treatment.
Conclusion: This study found that high force mobilisation elicited a significantly greater increase in PPT than control or low force mobilisation. There was no
significant change in PPT following control (supine lying) or low force knee mobilisation demonstrating that high force knee mobilisation was required to achieve a
hypoalgesic effect in an asymptomatic population. A greater increase in PPT was observed local to the intervention suggesting that the hypoalgesic effect was
mediated by local analgesic mechanisms such as pain gate. Further research is needed on symptomatic participants to establish whether higher treatment forces
result in a greater analgesic effect in patients.
Implications: This study found that applying higher force mobilisations was required to produce a hypoalgesic effects and suggests that where pain allows, therapists
should consider using higher treatment forces.
Funding Acknowledgements: Unfunded
Ethics Approval: This study was approved by the University of Brighton, School of Health Science Research Ethics and Governance Committee.
Disclosure of Interest: None Declared
Keywords: knee, mobilisation, treatment force

Intergrating Research into practice


OR-MT-032
THE MECHANISM OF ACTION OF SPINAL MOBILISATIONS: A SYSTEMATIC REVIEW.
I. Lascurain*

Background: Spinal mobilisations - low velocity passive oscillatory movements - reduce spinal pain in some spinal pain patient subgroups. Identifying patients likely to
respond to mobilisations remains a challenge since mobilisations mechanism(s) of action are unclear.
Purpose: To review the evidence regarding the mechanism of action of mobilisations.
Methods: A systematic review was conducted. Medline, Web of Science, Cinahl, Embase and Scopus databases were searched for relevant studies. Reference lists of
included studies were hand searched. Studies were included if the intervention was passive spinal mobilizations, participants were symptomatic and outcomes
evaluated possible mechanisms of action. Methodological quality was independently assessed by two assessors using a modified Cochrane Back Review Group tool.
Results: 24 studies were included in the review. Four were classified high risk, fourteen moderate risk, and four low risk of bias. Commonest methodological
limitations were lack of participant blinding, adequate randomization and allocation concealment, and sample size calculation. Evidence suggests that spinal
mobilizations cause neurophysiological effects resulting in hypoalgesia (local and/or distal to mobilization site), sympathoexcitation and improved muscle function.
Mobilizations have no effect on temperature pain threshold. Three out of four studies reported reduction in spinal stiffness, heterogeneous in location and timing.
There is limited evidence (one study in each case) to suggest that mobilizations produce increased nociceptive flexion reflex threshold, improved posture, decreased
concentration of Substance P in saliva and improved sway index measured in cervical extension. Evidence does not support an effect on segmental vertebral
movement. Two studies investigated correlations between hypoalgesia and mechanism: one found a correlation with sympathoexcitatory changes, whereas the other
found no correlation with change in stiffness.
Conclusion: These findings suggest involvement of an endogenous pain inhibition system mediated by the central nervous system, although this is yet to be
investigated directly. There is limited evidence regarding other possible mechanisms.
Implications: Clinical reasoning models for spinal mobilisations should make greater emphasis on their neurophysiological effects. Further research is required to
ascertain to what extend neurophysiological and neuromechanical changes observed in these studies are associated with the hypoalgesic effect of mobilisations.
Direct measurement of the pain related regions of the central nervous system should be attempted.
Funding Acknowledgements: Ion Lascurain Aguirrebea is currently receiving a grant from the University of the Basque Country (Spain).
Ethics Approval: This study required no ethics approval.
Disclosure of Interest: None Declared
Keywords: mechanism, mobilisation, spine

Intergrating Research into practice


OR-MT-035
DEVELOPMENT OF A NEW CONCEPTUAL FRAMEWORK FOR THE BIOPSYCHOSOCIAL CLINICAL APPROACH USING CONCEPT MAPPING METHODOLOGY
K. Duncan*, A. Bishop 1, N. Foster 1
1
Institute of Primary Care and Health Sciences, Keele University, Staffordshire, United Kingdom
Background: The biopsychosocial approach to the management of people with common musculoskeletal (MSK) pain is recommended in clinical practice guidelines
yet evidence suggests it is poorly implemented in practice. The biopsychosocial model is conceptually more complex than the dualistic biomedical model, and while
work to date has provided some guidance for incorporating psychosocial principles into clinical practice, a comprehensive conceptual framework for the
operationalisation of the biopsychosocial clinical approach is lacking.
Purpose: To create a comprehensive conceptual framework for the biopsychosocial clinical approach to treating people with MSK pain.
Methods: This study employed concept mapping which is a novel sequential mixed method combining group and individual qualitative components with multivariate
statistics. Two concept mapping workshops were conducted with a local and an international group. Participants in both groups were experienced clinicians and/or
researchers in the field of MSK pain. Both groups developed statements in response to the focus sentence Thinking as broadly as possible generate statements that
describe what a clinician who follows a biopsychosocial approach could consider relevant in common MSK pain problems. Individual participants then sorted the
statements into thematic groupings. The statement sorts were entered into the Concept Systems software which utilises multidimensional scaling and cluster
analysis to produce a visual representation (or map) of the groups conceptualisation. Multidimensional scaling positions statements frequently sorted together by
participants closer together, therefore creating conceptually distinct areas of the map. The resultant map was then interpreted and refined by members of the
original group. The two maps produced were thematically combined to produce an overall conceptual framework for the biopsychosocial clinical approach.
Results: There were 14 participants in the local and 26 in the international workshop. Both groups included physiotherapists, occupational therapists, GPs and
psychologists with a range of occupational roles in both clinical and research settings. Each group produced over 200 initial statements, which were reduced to sets
of 98 and 97 for sorting by the local and international group respectively. The final map produced by the local group contained 12 conceptual clusters and the
international group produced a map with 15 clusters. There was substantial similarity in the content of the two maps and following thematic analysis and synthesis of
the maps, an overall conceptual framework of six primary domains was established. These domains were: Bio-clinical, therapeutic relationship, individual patient
aspects, emotions, social and work. Each domain (except emotions) contains a number of secondary, and in some instances tertiary domains.
Conclusion: The resultant framework has a clear emphasis on the biological and clinical assessment elements of the biopsychosocial approach. It also includes a far
wider range of social constructs than are currently incorporated into routine clinical practice. Although psychological aspects of the approach are represented less
distinctly than in the literature to date, they inform much of the therapeutic relationship domain.
Implications: This study provides a robust and comprehensive conceptualisation of the biopsychosocial approach towards the treatment of people with MSK
pain. This framework offers great potential to physiotherapists as well as other clinicians and researchers wishing to develop, deliver and evaluate biopsychosocial
clinical practice.
Funding Acknowledgements: This work was funded by a Keele University ACORN Studentship and undertaken in the Arthritis Research UK Primary Care Centre at
Keele. Additional funding was provided by the Chartered Society of Physiotherapy Charitable Trust International Lecture Fund.
Ethics Approval: Ethical approval was provided by Keele University's Ethical Review Panel
Disclosure of Interest: None Declared
Keywords: Biopsychosocial, Conceptualisation, Implementation

Intergrating Research into practice


OR-PA-039
EXBEL: PATIENT BELIEFS AND PERCEPTIONS ABOUT EXERCISE FOR NON-SPECIFIC CHRONIC LOW BACK PAIN: A SYSTEMATIC REVIEW OF QUALITATIVE RESEARCH
S. Slade 1,*, S. Patel 2, M. Underwood 2, J. Keating 3
1
Physiotherapy, Monash University, Melbourne , Australia, 2Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom, 3Faculty of Medicine,
Nursing and Health Science, Monash University, Melbourne, Australia
Background: The global burden of low back pain is now the highest ranked condition contributing to years of living with disability and is an important source of longterm disability and absence from work. Exercise is effective for non-specific chronic low back pain but effects of different types of exercise are comparable and small
to moderate. Clinical practice guidelines recommend that patient preferences be considered and that exercises be individualised. Adherence/engagement may
improve if programs align with participant preferences/beliefs.
Purpose: To identifiy and synthesise qualitative studies that explored what people with non-specific chronic low back pain believe about exercise and physical activity
for the management of their condition and make recommenations for clinical practice.
Methods: Two independent reviewers conducted a structured review and meta-synthesis, of empirical qualitative research, informed by Cochrane Guidelines and the
PRISMA statement and a comprehensive set of search strategies recommended for identifying qualitative reports. Two independent reviewers use a priori inclusion
and exclusion criteria to screen titles and abstracts, extract data, appraise method quality, conduct thematic analysis and synthesise in narrative format.
Results: The search yield was 3431 titles, 48 papers were read in full and 15 studies were included. Four key themes emerged: 1) Perceptions and classification of
exercise; 2) Role and impact of the health professional. 3) Exercise and activity enablers/facilitators; 4) Exercise and activity barriers.
Levels of acquired skills and experience of the exercise culture require consideration in program design and decisions regarding exercise type, venue, entry level
performance and progression rates. People participating in exercise classes may be more comfortable when matched for abilites and experience. Care-seekers
perceive that when exercise disrupts everyday life, is ineffective or too difficult to implement they will make a reasoned decision to discontinue. Questions for
eliciting information about patient preferences are presented.
Conclusion: People are likely to prefer and participate in exercise programs that are designed with consideration of their preferences, fitness levels and exercise
experience. In exercise and low back pain research there is a paucity of qualitative data. This contrasts with over 500 randomised controlled trials of exercise for
chronic low back pain that are listed in Cochrane.
Implications: Consideration must be given to factors that facilitate participant engagement when designing programs and to identification and removal of barriers.
Research is recommended to test the effectiveness of patient preferences input.
Funding Acknowledgements: This work was unfunded
Ethics Approval: Ethics approval was not required
Disclosure of Interest: None Declared
Keywords: CHRONIC LOW BACK PAIN, EXERCISE, PATIENT BELIEFS

Intergrating Research into practice


OR-PA-040
DIFFERENTIATING NOCICEPTIVE AND NEUROPATHIC COMPONENTS OF CLINICAL PAIN PRESENTATIONS MATTERS!
B. Tampin 1 2,*, K. Briffa 1, H. Slater 1
1
School of Physiotherapy and Exercise Science , Curtin University, 2Physiotherapy, Sir Charles Gairdner Hospital, Neurosurgery Spinal Clinic, Perth, Australia
Background: Patients with non-specific neck-arm pain may present with clinical signs of heightened nerve mechanosensitivity (NSNAP) i.e.pain in response to limb
movements that cause nerve elongation. Based on the former definition of neuropathic pain (NeP), i.e. pain initiated or caused by a primary lesion or dysfunction of
the nervous system, the non compliance of neural tissues to limb movements could be interpreted as a dysfunction of the nervous system. Hence pain disorders
with heightened nerve mechanosensitivity have been labelled by some as a NeP disorder. However, in light of the new definition of NeP, i.e. pain caused by a lesion
or disease of the somatosensory nervous system, such interpretation may be inaccurate, as heightened nerve mechanosensitivity has been shown to be present in
the absence of nerve damage. The core signs of NeP are pain and sensory changes in the innervation territory of the affected nerve structure. Quantitative sensory
testing (QST) is a valuable tool for the standardized assessment of sensory alterations. Data generated from QST can be considered alongside a clinical examination to
more accurately inform clinical decision making whether or not a patient has NeP.
Purpose: To investigate the presence of sensory alterations and NeP in patients with NSNAP, using QST.
Methods: Ten patients with unilateral NSNAP (9 female, 42.414.8 years) in a C6/7/8 dermatomal pain distribution participated. Radiological and clinical signs of
cervical radiculopathy were excluded. QST was performed according to the protocol of the German Research Network on Neuropathic Pain in the maximal pain area,
as required for the assessment of NeP. QST measures were compared to QST data from 31 age-matched healthy controls (HC). QST data were z-transformed using
the included HC data. Sensory alterations outside the 95% HC confidence interval were defined as an abnormal sensory alteration.
Results: Three patients did not demonstrate any sensory alteration. Three patients demonstrated one sensory alteration (two showed cold hypersensitivity, one
reduced vibration sense). Two patients demonstrated two sensory alterations (increased mechanical/pressure sensitivity; increased heat sensitivity, reduced
vibration sense), one patient had three alterations (increased heat sensitivity, reduced mechanical/vibration sense) and one patient four sensory alterations
(increased cold and heat sensitivity, reduced mechanical and vibration sense) outside the 95% confidence interval.
Conclusion: QST outcomes revealed heterogenous sensory profiles across test modalities with a mix of negative and positive signs. However, in three patients no
sensory alterations were detected in their main pain area. Hence the condition of heightened nerve mechanosensitivity can present as a discrete disorder without
any signs of nerve damage and NeP, consistent with a non-neuropathic musculoskeletal pain condition.
Implications: The preliminary data suggest that clinical signs of heightened nerve mechanosensitivity do not necessarily imply the presence of NeP. Individual patient
assessment, including detailed sensory examination, is mandatory for the identification of NeP in patients with NSNAP. Health professionals should be mindful of
using specific sensory testing and other clinical tools to inform a diagnosis of NeP.
Funding Acknowledgements: This study was supported by the National Health and Medical Research Council (grant 425560), Arthritis Australia (Victorian Ladies
Bowls Association Grant) and the Physiotherapy Research Foundation (seeding grant).
Ethics Approval: Sir Charles Gairdner Group Human Research Ethics Committee HREC 2007-185,
Human Research Ethics Committee Curtin University HR 117/2007
Disclosure of Interest: None Declared
Keywords: heightened nerve mechanosensitivity, neck-arm pain , neuropathic pain

Intergrating Research into practice


OR-SH-049
KEY OUTCOMES FOR SHOULDER PROBLEMS: AN ICF-BASED STUDY TO DETERMINE HOW WELL PATIENT REPORTED MEASURES CAPTURE PATIENTS PERSPECTIVES.
C. Payne 1,*, C. Jerosch-Herold 2, R. Mason 2
1
Physiotherapy Department, Norfolk & Norwich University Hospital, 2School of Health Sciences, University of East Anglia, Norwich, United Kingdom
Background: Evidence that patients are able to provide valid and reliable judgements about changes in their health status underpins the use of patient reported
outcome measures (PROMs) that assess different aspects of physical, emotional and social functioning. However the extent that shoulder or upper extremity regionspecific PROMs reflect the outcomes that patients with a musculoskeletal shoulder problem (MSP) consider important is not known.
Purpose: The purpose of this mixed methods study was to identify which PROMs should be used in the self-assessment of outcome for MSP, from the patient's
perspective.
Methods: A qualitative approach was used to gain patients' perspectives. A purposive maximum variation sampling strategy was used to capture a breadth of
relevant experiences of MSP, and in-depth individual interviews were conducted with fifteen patients at the outset of treatment. Transcribed, anonymised interview
data were analysed using a four-stage analytical framework. Meaningful comparisons were made within and across individual accounts to identify important
outcomes for patients. To facilitate comparison of the content of PROMs and the views of patients the outcomes assessed in twelve shoulder or upper extremity
region-specific PROMs with acceptable psychometric properties identified through a systematic literature review were collated and linked to relevant categories of
the International Classification of Functioning, Disability and Health (ICF). The unifying language and conceptual framework of the ICF was then used to compare the
outcomes that patients identified as important and the content of PROMs to determine how adequately individual PROMs capture patients' perspectives.
Results: Patients with a range of sociodemographic characteristics that typify a shoulder problem articulated personally relevant and important outcomes.
Everyone expected to be symptom free, regain their former level of upper limb use, resume usual daily activities, regain a sense of emotional well-being, resume
former family relationships and social interactions, and most expected to independently manage their own shoulder problem. Of the PROMs that have been most
extensively investigated in validation studies there is accumulating evidence for the psychometric properties of validity, reliability, responsiveness, and practicality
across a range of shoulder problems. The Disabilities of the Arm, Shoulder and Hand (DASH) reflected all ICF-based outcomes that patients identified as important. Of
the remainder five PROMs included three-quarters, four one half and two one quarter of important outcomes for patients.
Conclusion: Patients expect relief of symptoms to enable them to resume activities of daily living, work and recreation and get back to some sort of normality. Overall
PROMs satisfactorily capture patients perspectives. The DASH should be used as the primary outcome measure for the assessment of shoulder symptoms and
physical functioning, and the Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons assessment form (ASES), or the Shoulder Pain and Disability Index
(SPADI) should be considered as secondary outcome measures, with the SPADI being recommended for the assessment of pain.
Implications: Future research should seek to gain a widely accepted expert consensus on a core set of PROMs that should be adopted for use either at the end point
in effectiveness trials, or on a case-by-case basis in clinical practice. Use of the same PROMs in published studies may facilitate the pooling of data in future metaanalyses, and in turn the development of best practice guidelines that are integral to the implementation of evidence-based practice. Research findings therefore
have the potential to enable patients to participate in evaluating and improving the quality of their own future healthcare.
Funding Acknowledgements: The principal investigator (CP) received an Action Arthritis Trust Award (Reference: R15387).
Ethics Approval: Ethical approval was gained from the Norfolk Research Ethics Committee prior to commencement of the study (Reference 07/Q010/58).
Disclosure of Interest: None Declared
Keywords: outcome measure, patients' perspectives, shoulder

Intergrating Research into practice


OR-SH-050
SHOULDER PAIN, PROGNOSTIC FACTORS FOR THE OUTCOME OF PHYSIOTHERAPY TREATMENT. RESULTS FROM A PROSPECTIVE MULTICENTRE COHORT STUDY
R. Chester*, C. Jerosch Herold 1, L. Shepstone 2, J. Lewis 3
1
School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, 2School of Medicine, Faculty of Medicine and Health Sciences, Norwich,
3
Department of Allied Health Professions, School of Health and Social Work, , University of Hertfordshire, Hatfield, United Kingdom
Background: The most effective treatment for musculoskeletal shoulder pain is unknown. Physiotherapy is often the first point of referral. However, there is
uncertainty as to which patients will benefit.
Purpose: To identify which patient and clinical characteristics, commonly assessed at the first physiotherapy appointment, are associated with better or worse
patient rated shoulder pain & function six weeks and six months later.
Methods: This prospective multicentre cohort study recruited patients referred to physiotherapy for the management of musculoskeletal shoulder pain. It took place
within 11 NHS trusts and social enterprises in the East of England, including primary and secondary care, between November 2011 and October 2013. Seventy one
potential prognostic factors were collected prior to and during the patients first physiotherapy appointment and included individual and lifestyle characteristics,
psychosocial factors, shoulder symptoms, general health, clinical examination findings, activity limitations and participation restrictions. Physiotherapy treatment was
unaffected. Outcome measures included two self-report postal questionnaires; the Shoulder Pain and Disability Index (SPADI) (MacDermid et al, 2006; Roach et al,
1991) and the Quick Disability of the Arm, Shoulder and Hand (QuickDASH) (Beaton 2005). Multivariable linear regression was used to analyse prognostic factors
associated with outcome. The protocol has been published previously (Chester et al, 2013).
Results: 1030 participants were recruited and provided baseline data, 82% (n=840) provided outcome data at 6 weeks, 79% (n=811) at 6 months. Ten prognostic
factors were consistently associated with the SPADI and QuickDASH at one or both time points. Five factors were associated with better outcomes at both time
points: lower baseline disability, patient expectation of complete recovery compared to slight recovery as a result of physiotherapy treatment, higher pain selfefficacy, lower pain severity at rest, and for patients who were not retired, being in employment or education. Only three clinical examination findings were
associated with outcome and each at one time point only. For the SPADI in particular, a greater range of shoulder abduction was associated with a better outcome at
six weeks follow up, and a smaller difference between active and passive abduction was associated with a better outcome at six months follow up. For both the SPADI
and QuickDASH, at six months follow up only, a reduction in pain or increase in range of shoulder elevation with manual facilitation of the scapula during elevation of
the arm, was associated with a better outcome.
Conclusion: A wide range of biopsychosocial factors were associated with patient rated outcome. Psychological factors were consistently associated with outcome at
both time points. Clinical examination findings associated with a specific structural diagnosis were not. Clinical examination findings associated with symptom
modification during manual facilitation of the scapula during elevation of the arm was consistently associated with both outcomes at six months.
Implications: When assessing people with musculoskeletal shoulder pain psychological in addition to medical information should be considered.
Funding Acknowledgements: Rachel Chester was funded by a NIHR CAT Fellowship during the duration of this study. The views expressed are those of the authors
and not necessarily those of the NHS, the NIHR, or the Department of Health.
Ethics Approval: Obtained July 2011 from National Research Ethics Service (NRES), East of England, Norfolk (ref 11/EE/0212).
Disclosure of Interest: None Declared
Keywords: Physical Therapy, Prognosis, Shoulder

Intergrating Research into practice


OR-SH-051
QUANTIFYING STATIC SHOULDER STABILITY USING ACCELEROMETERS.
R. Bewes 1,*, A. Callaway 2, J. Williams 1
1
Physiotherapy, 2Sports and physical activity, Bournemouth University, Bournemouth, United Kingdom
Background: Sensory Motor Control (SMC) describes the integration of sensory, motor and central processing to control and coordinate movement and is known to
be impaired secondary to pain or following injury. There is a lack of supporting evidence for the role of SMC in shoulder rehabilitation. This may be due to the lack of
viable measurement method and no normative database available for performance comparison. Subsequently, evidence is lacking for the effectiveness of
interventions designed to alter SMC in the shoulder.
Purpose: To investigate using accelerometers for quantifying static shoulder stability, as a measure of SMC.
Methods: Thirty participants with non-painful shoulders completed the Static Shoulder Stability Test (SSST) in supine. Participants held one arm in a 90o flexed
position for one minute with eyes closed. There were rests between each of three repetitions. Measurements of limb accelerations (corrected for tilt) were taken
using accelerometers (THETAmetrix) placed immediately superior to the styloid process at the wrist. Participants were instructed to maintain full elbow
extension. Accelerations were used to determine three measures of performance based on the sway trace of the sensor; Mean Path Length (MPL), Sum Path Length
(SPL) and Resultant Acceleration (RA).
Reliability and consistency of the three measurements were determined using intra-class correlation coefficient (ICC) and Cronbachs alpha from which Standard Error
of Measurement (SEM) and Minimal Detectable Change (MDC) values were calculated. Pearsons correlations between the performance metrics were explored to
determine if similar constructs were being measured.
Results: ICCs identified excellent consistency for MPL (0.96: CI (0.93-0.97)) and SPL (0.96: CI (0.93-0.96)) but only modest consistency for RA (0.67: CI (0.50-0.79))
indicating errors between repeated measures. Cronbachs alpha was high for MPL (0.96) and SPL (0.96) reinforcing a close relationship between repeated
measures. SEM and MDC values were excellent for MPL (SEM 0.005: CI (0.022-0.034): MDC 0.001 (3.8%)) and good for SPL (SEM 17.4: CI (68-103): MDC 4.2 (5.3%))
indicating high levels of accuracy. A strong correlation between MPL and SPL (Pearsons = 1.0) indicates measurement of the same construct.
Significant differences between dominant and non-dominant arms were found suggesting the test is sensitive enough to detect differences in limb dominance (MPL
and SPL p = 0.01).
Conclusion: Accelerometers are a reliable measure of the static shoulder stability test using either description of path length. RA did not provide a consistent
measure. MPL and SPL appear to measure the same construct and are sensitive enough to identify differences between the dominant and non-dominant limb. This
study suggests accelerometers may be a viable measure of static shoulder stability and future studies can utilise such test for quantifying static shoulder stability an
indicator of SMC.
Implications: Encouraging results indicate accelerometers may be clinically useful in assessing static shoulder stability, an indicator of SMC. A valid and reliable
outcome measure allows therapists in practice to assess static stability accurately and determine the effectiveness of rehabilitation interventions.
Funding Acknowledgements: With thanks to the Musculoskeletal Association of Chartered Physiotherapists (MACP) for supportive funding towards this research.
Ethics Approval: Ethical approval for this research was granted by Bournemouth University Ethics Committee.
Disclosure of Interest: None Declared
Keywords: Accelerometer, Shoulder , Stability

Teaching, Learning and Professional Development


OR-ED-007
CREATING A LEARNING CULTURE FOR DEVELOPING CLINICAL REASONING THROUGH POSTGRADUATE MANIPULATIVE PHYSIOTHERAPY EDUCATION
M. Madi 1,*, M. Griffiths 1, A. Rushton 1, N. Heneghan 1
1
School of Sport, Exercise & Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
Background: Studies that evaluated health care and medical postgraduate (PG) education have only focused on identifying programme outcomes and impact. There
is a little evidence describing how PG programme curriculum and teaching methods bring about changes. In the context of PG manipulative physiotherapy (MPT)
education, there is no evidence regarding the learning culture through which these PG programmes facilitate the advancement of clinical reasoning (CR) skills. In line
with identified international research priority within MPT education, this innovative study looked at how the learning culture of PG programmes advance CR skills.
Purpose: To explore how PG MPT education advances CR skills. The study aimed to understand how the culture of the participants, their background, and their
biography fit with the culture of the programme.
Methods: A qualitative case study approach was utilised drawing on a PG MPT programme. Staff members (n=6) involved in the delivery of an approved IFOMPT
route participated in semi-structured interviews. Semi-structured interviews and focus groups were also conducted with students (n=6) at different stages of their
MPT programme. A critical review of existing literature around constructivist learning environment and adult learning theory informed the topic guide for the
interviews. Inductive data analyse data using constructivist version of Grounded Theory was then used to identify the educational activities, features and context of
the programme that facilitated change.
Results: Four themes were constructed that illustrated how the programme facilitated the advancement of CR. Themes illustrated how learning was an outcome of
students critical social interactions with specific programme practices.
1. Creating collaborative and interactive learning environment;
2. Challenging learners biography;
3. Ensuring relevance and authenticity;
4. The context in which the above themes works in.
Conclusion: CR skills can be advanced in a critical collaborative learning culture. Professional socialisation encouraged students to critically reflect on their
programme experiences and on their professional biography. Interactive sharing of experiences and reflective conversations during challenging clinically relevant
problem solving activities facilitated depth of analysis. This collaborative working environment facilitated identifying areas of application and relevance to practice.
Implications: The study provided evidence that would support planning and delivery of PG MPT education aiming to advance CR skills.
- In terms of curriculum planning, the programme should be creating social spaces that: Allow critical collaborative problem solving, reflection and peer review;
Challenge students identity and professional experience; Are relevant to participants practice.
- Educators who aim to advance CR should have pedagogical skills to facilitate such environment instead of only delivering content.
- Engagement in this constructivist learning culture would therefore facilitate therapists advanced practice skills.
- Practitioners who actively build similar learning culture at their practice have the potential of sustaining the gains of advanced CR skills.
Funding Acknowledgements: Unfunded
Ethics Approval: Ethical approval was granted by the Ethical Review Committee at the University of Birmingham. Application reference: ERN_14-0747.

Disclosure of Interest: None Declared


Keywords: Clinical Reasoning, Learning Culture, Postgraduate Education

Teaching, Learning and Professional Development


OR-ED-008
PROFESSIONAL IDENTITY AND CLINICAL DECISION-MAKING OF MUSCULOSKELETAL THERAPISTS
N. J. Petty 1,*, O. Thomson 2, A. Altamimi 3
1
School of Health Sciences, University of Brighton, Eastbourne, 2British School of Osteopathy, London, United Kingdom, 3Physiotherapy Department, King Abdullah bin
Abdulaziz University Hospital, Riyadh, Saudi Arabia
Background: Clinical decision-making in relation to examination, assessment, treatment and management of people with musculoskeletal conditions is fundamental
to clinical practice and central to professional autonomy and accountability. With the advent of patient-centred care, collaborative decision making has been
advocated between patients and therapists, however little research has explored how practitioners make decisions with their patients. Furthermore, research
suggests that how musculoskeletal practitioners identify with, and conceptualise key aspects of their professional practice, such as the body, the patient and their
therapeutic role, influences how they work clinically with their patients.
Purpose: To explore practitioners clinical decision-making.
Methods: This paper draws on three qualitative grounded theory studies carried out at doctoral level to offer new unpublished data and insights into clinical decisionmaking. Fifty-one semi-structured interviews and 3 video-prompted reflective interviews were carried out with 21 physiotherapists and 12 osteopaths, who had
between 4 and 25 years of clinical experience. Two studies were carried out in the United Kingdom and one with physiotherapists in Saudi Arabia.
Results: Practitioners were characterised as Treater, Teacher or Communicator and this professional identity influenced how they approached clinical decision
making. Treaters focused on effective diagnosis and treatment, held a technical rationale view of practice and decision-making was practitioner-led. Teachers focused
on listening and learning from patients in order to teach them how to manage their condition, held a professional artistry view of practice and facilitated patients to
make decisions about their treatment and management. Finally, communicators focused on the interests, values and expectations of the patient, held a professional
artistry view of practice and facilitated shared decision-making. Practitioners starting a postgraduate musculoskeletal physiotherapy course were considered Treaters
but post qualification widened their repertoire to appreciate the role of teacher and/or communicator.
Conclusion: There was similarity in musculoskeletal clinical decision-making amongst physiotherapists and osteopaths across the two countries. Practitioners identity
influenced how they practiced and the degree to which they enabled patients to participate in decisions about their treatment and management.
Implications: Awareness of professional identities and subsequent conceptions of practice and clinical decision-making may enable practitioners to bring their
preferences under conscious control so that appropriate, deliberate management strategies can be chosen for individual patients. It might be posited that this would,
in part, be a characteristic of clinical expertise.
Funding Acknowledgements: Thanks to the British School of Osteopathy and the Osteopathic Educational Foundation for their support of OTs doctoral research.
Ethics Approval: Ethical approval was obtained for each of the three studies from the University of Brighton Faculty of Health and Social Science Ethical and
Governance Committee.
Disclosure of Interest: None Declared
Keywords: Clinical decision making, Identity, qualitative grounded theory

Teaching, Learning and Professional Development


OR-ED-010
COMBINING PATIENT CENTRED SIMULATION WITH AN ONLINE ADAPTIVE LEARNING PLATFORM TO ASSIST STUDENTS IN DEVELOPING CLINICAL AND REASONING
SKILLS TO TRANSITION FROM CLASSROOM TO CLINICAL PRACTICE
N. Tuttle 1 2,*, A. Bialocerkowsk 1 2, E.-L. Laakso 1 2
1
Griffith University, School of Allied Health Sciences, 2Menzies Health Institute Queensland, Gold Coast, Australia
Background: Students commencing clinical placements typically have the building blocks of their technical skills but have difficulty putting the blocks together into
meaningful clinical interactions to hit the ground running when they commence clinical placement. The advantages of patient-centred simulation using actors as
simulated patients are well known and can provide a bridge to clinical practice by enabling students to develop both communication and reasoning skills. Patient
centred simulations however can be resource intensive and expensive. Simulating clinical interactions through an online adaptive learning platform (ALP) can engage
students in case studies and develop reasoning processes, but without human interaction. In the ALP, students interact with a software-based scenario without the
added complexity of working with a simulated or real patient. Students elicit information or perform tests and indicate the effect of each on their hypothesis
generation. The student and facilitator can then retrace and dissect the journey. Advantages of this approach include: 1) The ALP enables students to put their
clinical reasoning skills together separately from the complexity of human interaction, 2) The ALP can be used to leverage the resource intensive live simulation
activities enabling the patient-centred simulation activities to be targeted more specifically, and 3) Within the ALP, scenarios can be altered simply and easily.
Purpose: The aim of this presentation is to describe and evaluate a pilot rollout of the integration of patient centred simulation with an online adaptive learning
platform (ALP) to assist students to transition from classroom to placement.
Methods: The program was run over five days with each student receiving 20 hours of simulated learning environment. Penultimate year physiotherapy students
undertook the program immediately prior to their five-week musculoskeletal placement. Students were surveyed before the simulation week about their confidence
in areas of practice and after the week about their confidence and the effectiveness of aspects of the program.
Results: There was a significant increase in confidence from before to after the week in all 12 areas that were surveyed. Average confidence across a range of areas
increased from 3.4/6 (range 2.9 4.2) to 3.9/6 (range 3.7 - 4.5) and 91% felt it made them better prepared for placement. Students rated working with peers and
being able to make mistakes in a less risky environment as highly positive aspects of the project. Interestingly students considered that the activity not being
assessable resulted in them being more engaged and learned more effectively.
Conclusion: The simulated learning environment increased student confidence and their perceived preparedness for clinical placement.
Implications: A hybrid simulations combining a software-based ALP with patient focussed simulation may increase the sustainability of SLEs while enabling students
to reach relative independence earlier in their clinical placements. Evaluations are ongoing to determine the impact on their performance during clinical placement.
Funding Acknowledgements: This project was supported by funding from the Australian Government
Ethics Approval: Ethics approval was received from the Griffith Universtiy Ethics Review Board
Disclosure of Interest: N. Tuttle Conflict with: Australian Government, A. Bialocerkowsk Conflict with: Australian Government, E.-L. Laakso: None Declared
Keywords: clinical education, e-learning, simulation

Teaching, Learning and Professional Development


OR-ED-011
WHEN DOCUMENTATION REQUIREMENTS CHALLENGE PATIENT-CENTRED CARE: AN EXPLORATION OF PATIENT-PHYSIOTHERAPIST INTERACTIONS IN THE
OUTPATIENT SETTING
V. Schoeb 1,*, A. Hiller 2
1
Department of Rehabilitation Sciences, Hong Kong Polytechnic University, Hong Kong, Hong Kong, 2Department of Physiotherapy, University of Melbourne,
Melbourne, Australia
Background: Documenting patient information is standard practice and considered essential from clinical, legal and ethical perspectives. Studies within other health
professions have demonstrated that the use of computers and documentation impacts the patient-health professional interaction, sometimes restricting patient
participation and thereby impeding patient-centred care. Thus far, the role of documentation in the patient-physiotherapist interaction has not been explored in this
manner.
Purpose: The aim of this study was to explore how documentation effects the patient-physiotherapist interaction in outpatient settings.
Methods: This paper combines data from naturally occurring physiotherapy consultations. 79 patients being treated by 21 physiotherapists in a Swiss context, and 52
patients treated by 8 physiotherapists in Australia were observed. Interpretative paradigm, drawing on ethnomethodology and ethnography, informed the data
collection and analysis. Sequences were transcribed and analysed taking into account verbal and non-verbal aspects of communication.
Results: Our data demonstrated that documentation affects the sequence of topics covered and the wording used by physiotherapists in their communication with
patients. Many questions were worded as written on documentation forms. For example, questions about goals were asked immediately after aspects of the medical
history and phrased explicitly as per the form (e.g. what is your goal?), often creating interactional difficulties. Furthermore, the paper or computer used for the
purposes of documentation became another player in the interaction as both patient and physiotherapist looked at and attended to the paper or computer. This
item for documentation therefore created an external focus that impacted the communication between patient and physiotherapist.
Conclusion: We argue that therapists may constrain their communication along the direction pre-set by documentation forms. This is often detrimental to the
achievement of a smooth, straightforward and patient-centred approach. These findings extend previous insights from medical and nursing practice, and show that
documentation or computer use may restrict patient participation if tools are used in a standard format. Future research should consider optimising documentation
with respect to institutional, legal and ethical requirements as well as a patient-centred approach.
Implications: Documentation has been previously described as challenging with regards to content and time constraints. In addition to these difficulties, our findings
highlight the importance of documentation with regard to interaction. Physiotherapists, managers and educators need to be aware of how documents impact
patient-physiotherapist interaction, often making it difficult for patients to actively participate, thereby hindering the achievement of patient-centred care.
Funding Acknowledgements: The Swiss study was funded by the Swiss National Science Foundation, Do-RE funds (No. 13DPD6_124565) and the Research Funds
RSar of University of Applied Sciences, Western Switzerland, HES-SO. The Australian study was funded by an Australian Postgraduate Award Scholarship.
Ethics Approval: Approval obtained from the Cantonal Ethics Committee in Switzerland and from the University of Melbourne Human Ethics Sub-Committee in
Australia.
Disclosure of Interest: None Declared
Keywords: documentation, patient-centred care, patient-therapist interaction

Teaching, Learning and Professional Development


OR-ED-012
THE ART AND SCIENCE OF MITIGATING RISK: A QUALITATIVE STUDY OF THE TEACHING AND LEARNING OF CERVICAL SPINE MANIPULATION
K. Yamamoto 1,*, V. Johnstone 1, C. Haldane 1, S. Jaffrani 1, L. Condotta 1, P. Jachyra 2, B. E. Gibson 1, E. Yeung 1
1
Physical Therapy, 2Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada
Background: The intent of much of the published literature concerning the risks and benefits of cervical spine manipulation (CSM) is to ensure the safe practice of
CSM. These same concerns have also prompted the establishment of international standards that stress the importance of mentorship in developing the requisite
knowledge and skills for performing CSM by Orthopaedic Manual Physical Therapists (OMPT). Yet, the manner in which safe practice for performing CSM is perceived
and promoted within the mentorship context remains unstudied.
Purpose: To examine how risks and benefits of CSM were framed and discussed in the mentorship context and their impact on the perception of safe practice of CSM.
Methods: A descriptive, qualitative, multi-method approach was used, including: A document analysis of Rushton et al. (2014) International Framework for
Examination of the Cervical Region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy Intervention to gain insight into current
standards of practice and to explore how risks and benefits of CSM were framed; observations of mentoring sessions to explore the interactions between mentors
and mentees regarding CSM; individual face-to-face interviews of five mentees in the process of learning CSMs, and four mentors with OMPT certification.
Observation notes and interview transcripts were reviewed, codes were developed, and a framework was created to distinguish relationships between the codes and
to identify common themes.
Results: Participants clinical decision-making processes to perform CSM were largely dependent on the mitigation of risk. Achieving proficiency in the science of
clinical reasoning and the art of technical skill mastery were viewed as means to mitigating risk and enhancing confidence to use CSM safely in clinical practice. The
'science' refers to participants step-wise reasoning process that focused on screening out risk factors to avoid serious adverse events. The 'art' refers to the attention
paid to refining technical skills as a strategy to increase the effectiveness of CSM techniques and to reduce the likelihood of adverse responses.
Conclusion: The significant emphasis on risks of adverse events associated with CSM may be contributing to therapists apprehension to use CSM in clinical practice.
This emphasis also appears to have shaped mentees clinical reasoning processes to focus primarily on identifying and mitigating risks, with less consideration for
individual patient factors. While the art of technical skill mastery is viewed as highly important to developing competence in performing CSM, it was discussed as
distinct from clinical reasoning.
Implications: The current conceptualization of clinical reasoning for performing CSM may place significant emphasis on the importance of the science while
undervaluing the art of practice. Promoting a more balanced and integrated use of the art and science of safe practice for CSM in OMPT training may result in
greater confidence and judicious use of CSM by physical therapists.
Funding Acknowledgements: This work was unfunded.
Ethics Approval: This research was approved by the University of Toronto Health Sciences Research Ethics Board, Protocol ID #30911.
Disclosure of Interest: None Declared
Keywords: Cervical Spine Manipulation, Manual Therapy, Mentorship