Poster Papers

Advanced assessment/practice and managing complex patients
PO1-AP-005
SYSTEMATIC REVIEWS CANNOT INFORM CLINICAL PRACTICE. AN EXAMPLE USING A CRITICAL APPRAISAL OF A SYSTEMATIC REVIEW OF SHOCKWAVE THERAPY.
V. Korakakis 1 2,*, R. Whiteley 1, A. Tzavara 2
1
Orthopaedic and sports medicine hospital, Aspetar, Doha, Qatar, 2HOMTD, Hellenic Orthopaedic Manipulative Therapy Diploma, Athens, Greece
Background: Physiotherapists have been recommended to use systematic reviews as a guide for evidence based clinical practice. There is growing evidence for the
effectiveness of shock wave therapy and increasing popularity in use as a therapeutic intervention.
Purpose: The aim of the present critical appraisal was to evaluate methodology, external validity, and bias of a systematic review assessing the effectiveness of shock
wave therapy in common lower limb pathologies including: Achilles tendinopathy, patellar tendinopathy, proximal hamstring tendinopathy, medial tibial stress
syndrome, and greater trochanteric pain syndrome.
Methods: From a critical viewpoint two assessors evaluated: the quality assessment tools used for randomised and non-controlled trials, the inclusion criteria used in
studies defining the included condition, the validity of clinical tests used, biases (funding, publication, reporting), and clinical applicability of protocols used and
reported.
Results: Several important shortcomings were identified in terms of: quality assessment, sub-grouping of patients, publication bias, external validity, level of
evidence, applicability of results in clinical practice and minimal reporting.
Conclusion: The systematic review was unable to generalize findings to the clinical population due to insufficient homogeneity of sub-groups analysed. This was seen
to be largely due to a lack of valid clinical tests capable of sub-grouping. Currently methods for the assessment of the quality of trials do not adequately document
clinical homogeneity, validity and reliability of the clinical tests employed, or account for inappropriate clustering of different treatment modalities, and publication
bias. Each of these shortcomings severely limit the generalizability of the findings of systematic reviews, and considered together render them bordering on clinically
useless.
Implications: Clinicians should interpret with caution the results provided by systematic reviews, at least for the example of shock wave therapy in lower limb
pathologies. We posit that these findings may generalize to other conditions and interventions commonly encountered clinically.
Funding Acknowledgements: None
Ethics Approval: Not applicable
Disclosure of Interest: None Declared
Keywords: critical appraisal, extracorporeal shock wave therapy, systematic review

PO1-CS-011
THE EFFECT OF ISOMETRIC INTERNAL AND EXTERNAL ROTATION ON THE ACROMIOHUMERAL DISTANCE IN SUBJECTS WITH SUB-ACROMIAL PAIN SYNDROME
D. Tailor 1,*, S. Deleany 1, M. Field 1, A. Kuncewicz 1, D. Critchley 1
1
Division of Health and Social Care Research, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
Background: Sub-acromial pain syndrome (SAPS) is one of the commonest disorders of the shoulder. SAPS may result from reduction of the sub-acromial space
causing compression of its contents. Resisted external (ER) and internal rotation (IR) exercises are commonly prescribed in the management of SAPS and are
suggested to increase the sub-acromial space. Their effect on the sub-acromial space in symptomatic subjects with SAPS is unknown.
Purpose: To determine the effect of isometric IR and ER contractions on the acromiohumeral distance (AHD), a measure of the sub-acromial space, in symptomatic
subjects with SAPS.
Methods: 33 participants with SAPS (6 with bilateral SAPS) were recruited from 3 private musculoskeletal physiotherapy clinics and faculty of King's College London.
Ultrasound measures of AHD at rest, and during isometric IR and ER contractions were taken with the shoulder positioned in neutral and 45 degrees abduction, at
50% and 100% of one-repetition maximal voluntary isometric contractions (MVIC).
Results: There was no significant difference in AHD between any of the test conditions tested in neutral. Mean (95% CI) AHD: Rest 11.7(11.1-12.47)mm; IR at 100%
MVIC 11.4(10.63-12.22)mm, 50% MVIC 11.5(10.76-12.43)mm; ER contractions at 100% MVIC 11.2(10.5-12.02), 50% MVIC 11.3(10.66-12.01)mm. There was no
significant difference in AHD between any of the test conditions tested in 45 degrees of abduction. Median (95% CI) AHD: Rest 10.5(9.8-12.4)mm; IR at 100% MVIC
12.4(11.1-13.1)mm, 50% MVIC 11.1(10.2-12.8)mm; ER contractions at 100% MVIC 10.8(9.6-11.5)mm, 50% MVIC 10.7(9.8-11.7)mm.
Conclusion: AHD does not change during resisted IR and ER contractions compared to rest. Ultrasound measurement of AHD has excellent intra-rater reliability. Other
mechanisms, such as loading tendons or reducing the threat response of the central nervous system, may explain the demonstrated benefits of IR and ER exercises.
Findings were instantaneous, the longer-term effects of exercise programmes on the subacromial space should be evaluated. AHD, a two-dimensional linear measure,
may not fully represent change in the three-dimensional sub-acromial space; further research using 3D imaging is suggested. There were large individual variations in
findings; investigating sub-classification of SAPS patients may improve understanding of this condition.
Implications: The clinical benefits of IR and ER exercises appear to be unrelated to changes in acromiohumeral distance.
Funding Acknowledgements: Unfunded
Ethics Approval: Kings College London Research Ethics Committee (Ref: BDM/13/14-81)
Keywords: Acromiohumeral distance, Exercise, Shoulder pain

PO1-CS-012
ALTERED MECHANICAL DEFORMATION OF THE TRAPEZIUS AND MULTIFIDUS MUSCLES REGISTERED WITH ULTRASONOGRAPHY IN WOMEN WITH CHRONIC
WHIPLASH-ASSOCIATED DISORDERS
A. Peolsson*, G. Peterson 1 2, J. Trygg 3, D. Nilsson 3
1
Medical and Health Sciences, Physiotherapy, Linkping University, Linkping, 2Centre for Clinical Research Srmland, Uppsala University, Eskilstuna, 3Department of
Chemistry, Computational Life Science Cluster (CLiC), Ume, Sweden
Background: The deformation and deformation rate of the dorsal neck muscle layers in individuals with chronic whiplash associated disorders (WAD) is rarely
evaluated, and the mechanical behaviour during dynamic neck extension remains to be investigated.
Purpose: To compare the deformation and deformation rate of dorsal neck muscles (trapezius, splenius capitis, semispinalis capitis and cervicis, and multifidus) in
women with chronic WAD compared with healthy controls during a dynamic resisted neck extension.
Methods: Nine women with chronic grade 2 and 3 WAD (mean age 38 years, standard deviation [SD] 11.3) and nine age- and gender-matched healthy controls (mean
age 38 years, SD 11.6) participated in this cross-sectional, controlled study. Ultrasonography movies and post-process speckle tracking were used to investigate realtime mechanical dorsal neck muscle behaviour at the C4 segmental level during a low-loaded dynamic standardized neck extension. Deformation (longitudinal
shortening and elongation) and deformation rate (speed of deformation) were calculated during the entire exercise sequence.
Results: There were significant differences between the WAD and control groups in total deformation for the trapezius (p < 0.04) and multifidus (p < 0.03). The WAD
group showed more shortening in the deformation pattern during the concentric contraction phase in the trapezius muscle, and during both the concentric and
eccentric phase in the multifidus muscle compared to healthy controls. There were no other significant differences between groups either in deformation or
deformation rate.
Conclusion: There were altered mechanical deformations of the trapezius and multifidus muscles, with preliminary evidence for overuse in individuals with WAD
compared to healthy controls. The findings must be interpreted with caution due to the small sample size.
Implications: An ultrasound investigation made it possible to non-invasively capture multi-layered muscles in real time, adding new information of value for clinical
practice of patients with WAD, which may impact future rehabilitation.
Funding Acknowledgements: The Swedish Research Council, the REHSAM foundation from the Swedish government, Linkping University, Centre for Clinical
Research Srmland at Uppsala University Sweden and Uppsala-rebro Regional Research Council Sweden.
Ethics Approval: Approved by the Regional Ethics Review Board, Linkping, Sweden.
Keywords: Whiplash injury, neck muscles, ultrasonography

PO1-CS-013
TWO POINT DISCRIMINATION IN THE UPPER LIMBS OF HEALTHY PEOPLE: AVERAGE VALUES AND INFLUENCE OF GENDER, DOMINANCE, HEIGHT AND BMI
G. Valagussa 1 2, R. Meroni 1, D. Andreotti 3,*, V. Maiorano, D. Parravicini, C. Cerri 1
1
School of Medicine and Surgery, University of Milano Bicocca, Milan, 2SMARTERehab, Besana Brianza, Italy, 3SMARTERehab, Gordola, Switzerland
Background: The literature suggests that in some chronic pain conditions such as chronic low back pain, complex regional pain syndrome and phantom limb pain
there may be structural and functional central nervous system changes. Clinical evidence of these changes may be an alteration of the ability to discriminate two
points (TPD). Moreover, there is evidence that TPD training may influence pain and function. To be able to determine the existence and extent of the TPD alteration it
is important to know normal TPD values in healthy subjects. A literature search of normative values in the upper limbs of healthy subjects was conducted. There is a
lack of proper normal values for TPD. Studies to date have evaluated only the dominant side, only a segment of the limb or only a single point within a segment and
TPD values of the scapular region have not been assessed. There is little information about the influence of gender, dominance, height and body mass index (BMI).
Purpose: The main purpose of this study was to find TPD values for the scapular region, arm, forearm and hand in both upper limbs in a healthy cohort. Secondary
purposes were: to assess the correlation of the TPD values between the analyzed points of the same regions, each of the ipsilateral regions and the same
contralateral regions; to investigate if these values are influenced by gender, dominance, height and BMI.
Methods: The study included fifty-four healthy subjects (30 males, 24 females; mean age 27.17 years SD 11.16 years). A TPD assessment was carried out for a total
of forty points, in a randomized order, using a previously described plastic calipers. The TPD was assessed in four regions: scapular region, arm, forearm and hand.
Nine points were assessed in the scapular region. The arm and forearm were each divided into four areas (anterior, posterior, medial and lateral) and one point for
each area was assessed. The hand was divided into two areas (dorsal and palmar). Two points were assessed in the palmar area and one point in the dorsal area. The
same assessment was carried out for both upper limbs.
Results: Overall, the mean value of the points for each of the following regions are: right scapular region 4.45 cm (1.61 SD), left scapular region 4.41 cm (1.51 SD);
right arm 4.01 cm (1.30 SD), left arm 4.03 cm (1.19 SD); right forearm 3.28 cm (0.98 SD), left forearm 3.42 cm (1.06 SD); right hand 1.15 cm (0.32 SD), left hand 1.19
cm (0.35 SD). We found a moderate to high correlation between the points of the same region. TPD mean values of all the ipsilateral regions was found to be
statistically different (p <0.05) and there was a moderate to high correlation among all of them. No statistical difference in TPD mean values of all the same
contralateral regions was found and there was a high correlation among all of them. TPD values are not influenced by gender but seem to be influenced by right and
left handedness. No correlation was found between TPD mean values and height or BMI.
Conclusion: This study provides TPD mean values for the scapular region and upper limb of healthy subjects. There is a moderate to high correlation between the TPD
mean values of the points of the same region. There is a moderate to high correlation among all the TPD mean values of all the ipsilateral regions and a high
correlation between the TPD mean values of all the same counterpart regions. It seems that TPD mean values are not influenced by gender, height and BMI in
healthy subjects.
Implications: Knowing the TPD mean values of the upper limbs in healthy people could help in the assessment of TPD in chronic pain patients with upper limb
symptoms. This may be immediately translated into clinical practice by participants using a plastic calipers.
Funding Acknowledgements: The work was unfunded.
Ethics Approval: Ethics approval was not required.
Keywords: healthy subjects, Two point discrimination, upper limb

PO1-CS-015
SENSORIMOTOR INCONGRUENCE AND VISUAL FEEDBACK IN PATIENTS WITH MUSCULOSKELETAL PAIN: A SYSTEMATIC REVIEW
S. Don 1,*, M. De Kooning 1, L. Voogt 1 2, M. Meeus 3 4, J. Nijs 1
1
Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel (VUB), Brussels, Belgium, 2Department of physiotherapy,
Rotterdam University of applied sciences, Rotterdam, Netherlands, 3Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health
Sciences, University of Antwerp, Antwerp, 4Department of Rehabilitation Sciences and Physiotherapy, Ghent University, Ghent, Belgium
Background: Musculoskeletal pain has major public health implications, but the theoretical framework remains unclear. It is hypothesised that sensorimotor
incongruence (SMI) might be a cause of long lasting pain sensations in patients with chronic musculoskeletal pain. Research data about experimental SMI triggering
pain has been equivocal, making the relation between SMI and pain elusive.
Purpose: The aim of this study is to systematically review the studies on experimental SMI in patients with musculoskeletal pain and healthy subjects.
Methods: PRISMA guidelines were followed. A systematic literature search was conducted using several databases until January 2015. To identify relevant articles,
keywords regarding musculoskeletal pain or healthy subjects and the sensory or the motor system were combined. Study characteristic were extracted. Risk of bias
was assessed using the Dutch CBO checklist for RCTs and level of evidence was judged.
Results: Eight cross-over studies met the inclusion criteria. The methodological quality of the studies varied and populations were heterogeneous. In patient
populations, level B evidence shows that pain outcomes were higher during all experimental conditions compared to baseline conditions. In healthy subjects, level B
evidence shows that pain reports during experimental SMI were very low or did not occur at all.
Conclusion: Based on the current evidence and despite some methodological issues, there is no evidence that experimental SMI triggers pain in healthy individuals
and in patients with chronic musculoskeletal pain. However, patients with chronic musculoskeletal pain report more pain during the experimental conditions,
indicating that visual manipulation influences pain outcomes in this population.
Implications: The current systematic review does not support the hypothesis of Harris, suggesting that SMI is a possible underlying mechanism that causes pain in
patients with chronic pain.
Funding Acknowledgements: none declared
Ethics Approval: Since our study was a systematic review, no ethics approval was required.
Keywords: Musculoskeletal Pain, sensorimotor incongruence, systematic review

PO1-CS-016
THE EFFECT OF THE NEURAC TRAINING ON SHOULDER ISOKINETIC PERFORMANCE IN PATIENTS WITH ACUTE-PHASE SUBACROMIAL IMPINGEMENT SYNDROME
S. Kim 1, O. Kwon 2, J. Weon 3, J. Oh 4,*
1
Rehabilitation Medicine, Pusan National University Yangsan Hospital, Yangsan-si, 2Physical Therapy, Yonsei University, Wonju-si, 3Physical Therapy, Joongbu
University, Geumsan, 4Graduate of Rehabilitation Science, INJE University, Gimhae-si, Korea, Republic Of
Background: Many clinician has reported that effect of exercise in patient with subacute and/or chronic subacromial impingement syndrome (SIS). Comparing with
subacute and/or chronic SIS, a few studies have determined the effect of exercise in patients with acute-phase SIS because there may be some pain following
exercise.
Purpose: The present study compared the effect of the Neurac training as pain free exercise on shoulder isokinetic performance, pain, function, and range of motion
(ROM) in patients with acute-phase SIS.
Methods: Twenty four patients with acute-phase SIS underwent a 4 week rehabilitation program. They were randomly assigned in either group; Neurac group (N=12)
or manual therapy group (N=12). The Neurac group performed four Neurac training (kneeling shoulder extension, kneeling push-up plus, supine shoulder abduction,
and supine shoulder external rotation) using a Redcord Trainer, while glenohumeral joint mobilization and scapular mobilization were applied in the manual therapy
group. The main outcome measures were pain (visual analogue scale; VAS), function (Shoulder Pain and Disability Index; SPADI), range of motion (ROM), and
isokinetic performance (peak torque; PT). Isokinetic performance of shoulder flexion, extension, abduction, adduction, internal rotation and external rotation were
measured at 60 /s and 180 /s using a Biodex System 4 dynamometer. The main effects and their interaction were analyzed using two-way repeated measures
analysis of variance. If a significant main effect or time-by-group interaction effect was detected, a posthoct-test was used.
Results: A significant time-by-group interactions were found for PT 60 /s and 180 /s of shoulder flexion, abduction, external rotation, and internal rotation (p<0.05).
An independent t-test revealed that the Neurac group had a greater PT at 60/s and 180 /sec of shoulder flexion, abduction, external rotation, and internal rotation
than manual therapy group. A post hoc paired t-test demonstrated that the PT at 60/s and 180 /s of shoulder flexion, abduction, external rotation, and internal
rotation significantly increased post-intervention in Neurac group (p<0.05). A significant main effect was found for time for PT at 60/s and 180 /s of shoulder
extension and adduction in the Neurac group. VAS and SPADI scores significantly decreased post-intervention in both groups (p<0.05) and ROM significantly increased
post-intervention in both groups (p<0.05).
Conclusion: Both the Neurac training and manual therapy improved pain, function, ROM. However, isokinetic performance of shoulder increased only in the Neurac
group. These finding suggest that Neurac training could be an effective treatment option for the rehabilitation of patients with acute-phase SIS.
Implications: The Neurac training propose for improving pain, function, ROM, and isokinetic performance of shoulder in patients with acute-phase SIS.
Ethics Approval: Ethics approval was obtained from the Inje University Ethics Committee for Human Investigations.
Keywords: Neurac; Shoulder isokinetic performance; Subacrominal impingement syndrome

PO1-CS-019
MOVEMENT AND PAIN PATTERNS IN EARLY STAGE PRIMARY/IDIOPATHIC ADHESIVE CAPSULITIS - DO THEY ASSIST DIAGNOSIS?
S. Walmsley 1,*, P. Osmotherly 1, D. Rivett 1
1
School of Health Sciences, The University of Newcastle, Callaghan, Australia
Background: Patterns of movement loss and associated pain are frequently associated with recognition of various musculoskeletal disorders. In particular the
capsular pattern of proportional loss of external rotation being greater than the proportional loss of abduction which is in turn greater than the proportional loss of
internal rotation has been traditionally suggested to facilitate the diagnosis of gleno-humeral capsular pathology. To date however, investigation of any pattern of
either active or passive movement loss and any associated pain has not been described for early stage primary/idiopathic adhesive capsulitis.
Purpose: To evaluate patients with a clinical diagnosis of early stage adhesive capsulitis to determine if it was possible to demonstrate any pattern of movement loss
and/or associated end range pain that may facilitate diagnosis.
Methods: The study used a cross-sectional design. Active and passive ranges of eight shoulder movements were measured on fifty-two patients diagnosed with early
stage adhesive capsulitis by a medical practitioner or physiotherapist. The pain level at the end of each movement as well as the limiting factor to movement was also
recorded.
Results: Factor analysis identified two groups for percentage loss of active range of movement. External rotation movements in both neutral and 90 degrees
abduction grouped separately from other movements. In contrast one group was identified for percentage loss of passive range of movement suggesting a nonspecific global loss. Pain at the end of active and passive ranges of movement performed differently for rotational and non-rotational movements, however a clear
delineation was not demonstrated. External rotation in 90 degrees abduction was the most painful active and passive movement, and the movement most frequently
limited by pain rather than resistance.
Conclusion: External rotation movements in neutral and 90 degrees abduction group together and behave differently to other measured shoulder movements with
external rotation in abduction the most painfully limited movement. Despite pain frequently being reported a characteristic of early stage adhesive capsulitis, this
study suggested it may be less useful than percentage loss of active range of movement in identifying the disorder in this stage. Further studies examining varying
shoulder diagnoses are required to determine if these patterns are unique to early stage adhesive capsulitis.
Implications: The capsular pattern may not be useful in identifying patients with early stage adhesive capsulitis. Active range of movement loss may be more useful
than pain in the early diagnosis of this disorder. Clinicians should include careful assessment of external rotation in 90 degrees abduction in patients presenting with
shoulder pain as it may be the most painful active and passive movement in early stage adhesive capsulitis.
Funding Acknowledgements: This study did not receive funding from any source.
Ethics Approval: The Human Research Ethics Committee of The University of Newcastle granted ethical approval for this study (H-2009-0234).
Keywords: factor analysis, range of movement, Shoulder pain

PO1-CS-021
CENTRAL SENSITIZATION IN TEMPOROMANDIBULAR PAIN: A SYSTEMATIC LITERATURE REVIEW
L. Pitance 1 2,*, H. Meulders 3, S. Pfluger, M. Meeus 4, N. Roussel 4
1
Clinical research institute, Universit Catholique de Louvain, 2Oral and maxillo-facial surgery , Cliniques Universitaires Saint-Luc, Bruxelles, 3Facult de sciences de la
motricit, Universit Catholique de Louvain, Louvain La Neuve, 4University of Antwerpen, Antwerpen, Belgium
Background: Patients with Temporomandibular disorders (TMD) might exhibit widespread clinical pain, as well as greater sensitivity to experimental pain than painfree controls, suggesting a role of central pathophysiologic mechanisms in TMD.
Purpose: Our study objective was to systematically review the current knowledge on the presence of central sensitization in patients with temporomandibular
disorders.
Methods: The search strategy was conducted in four databases: Pubmed, Cochrane Library, ScienceDirect and Scopus. Literature was screened and data were
extracted in duplicate on specific study characteristics. Studies evaluating central pain processing in conservatively treated patients with TMD were included. The
methodological quality of the articles was examined using a checklist derived from the website of the Dutch Cochrane Centre assessing the risk of bias in case controls
and cohort studies.
Results: Twenty-six articles were retrieved for data extraction. While nearly all studies (17/18 studies) demonstrated enhanced pain responses to various sensory
stimulations beyond the orofacial region in different subgroups of patients with TMD, only one study reported no differences between patients with TMD and control
subjects. Results of studies examining dynamical mechanisms (eg. mainly Conditioned Pain Modulation and Temporal Summation) are conflicting. Studies analyzing
brain structure and function in relation to experimentally induced pain provide preliminary evidence for altered central nociceptive processing in patients with TMD.
Conclusion: This systematic review shows that altered central pain mechanisms might be present at least in a subgroup of patients with TMD. Results demonstrated
evidence for extrasegmental hyperresponsiveness and generalized hyper-excitability in the central nervous system in patients with TMD. Regarding structural
evaluation of the brain in patients with TMD, it is tempting to speculate that ongoing nociception is associated with cortical and subcortical reorganization. Further
researches should unravel the importance of these pathophysiological findings and explore to what extent these changes are
Implications: Central sentitization pain mechanisms should be taken into account in temporomandibular patients.
Ethics Approval: None
Keywords: Central sensitization, temporomandibular disorders

PO1-CS-022
THE EFFECTIVENESS OF CONSERVATIVE TREATMENTS IN THE MANAGEMENT OF IDIOPATHIC FROZEN SHOULDER: A SYSTEMATIC REVIEW OF RANDOMISED
CONTROLLED TRIALS
E. Barrett*, N. de Burca 1, K. McCreesh 2, J. Lewis 3
1
NUI Galway, Galway, 2Department of Clinical Therapies, Univeristy of Limerick, Limerick, Ireland, 3University of Hertfordshire, Hertfordshire, United Kingdom
Background: Frozen shoulder (FS) is a longstanding and debilitating condition characterized by shoulder pain and a progressive loss of range of motion (ROM). In
current practice, FS patients are offered non-surgical and/or surgical treatment. Consensus is lacking regarding the optimum treatment pathway for patients with FS.
A previous review has gathered the evidence for the management of FS up to 2010 (Favajee et al 2011). Since the publication of this research, additional RCTs have
been published which may yield new insights into the management of this common and protracted condition.
Purpose: The aim of this systematic review was to review the body of evidence for the conservative management of FS since 2010.
Methods: The systematic review was registered with PROSPERO (registration number: CRD42015013728). Nine databases were searched by two independent
reviewers to identify RCTs. Trials were included if they investigated a conservative treatment approach in patients with idiopathic FS. Risk of bias was assessed by
two independent reviewers using the Cochrane Collaboration's Tool for assessing risk of bias. A grading system (Tugwell et al 2003) was used to rank the strength of
evidence. Effect sizes (Hedge's g) for pain, function and ROM were calculated to allow comparison between treatments.
Results: Twenty-six relevant RCTs (1488 participants) were included.Nine out of twenty-six trials were considered to have a low risk of bias. Eleven trials were
considered to be of moderate risk of bias. Six trials were considered to have a high risk of bias. The review found silver level evidence to support corticosteroid
injection, therapeutic exercise, shoulder joint mobilizations and acupuncture for improving pain, ROM and function in the short-term. There is single trial evidence to
suggest that intra-articular botox, capsular distension and shockwave therapy may be as effective as corticosteroids for improving pain and ROM in the short-term.
Whole-body cryotherapy, hyaluronic acid injections and suprascapular nerve nerve block (SSNB) were reported to be effective adjuncts to physiotherapy by single
trials. Supervised neglect and subcutaneous adalimumab injections were found to be ineffective by single trials.
Conclusion: Practitioners should consider corticosteroid injection, therapeutic exercise, shoulder joint mobilizations and acupuncture for improving pain, function and
ROM in patients with idiopathic FS. Botox injection, hyaluronic acid injection, capsular distention, whole-body cryotherapy, shockwave therapy and SSNB may also be
effective but require further research. There is a need for well-designed and appropriately powered RCTs with a focus on long-term follow-up to demonstrate the
most effective non-surgical care for FS sufferers. Future trials must also consider the stage of the disease process of their population.
Implications: This review is most applicable to patients with a diagnosis of idiopathic FS of less than one year duration. The largest effect sizes for pain were in favour
of mobilisations, cryotherapy, electrotherapy and SSNB. Mobilisation techniques, electrotherapy, static stretch orthoses and exercise produced the largest
improvements in ROM. The largest effect sizes for function were in favour of active approaches of exercise such as PNF movement patterns and intensive stretching.
These will inform clinicians in their trretment of patients with idiopathic frozen shoulder.
Funding Acknowledgements: This was funded by The Health Foundation, 90 Long Acre London, WC2E 9RA.
Ethics Approval: N/a
Keywords: Shoulder pain, systematic review, treatment

PO1-CS-023
INFLUENCE OF LONG-TERM IMMOBILIZATION OF THE WRIST ON MOTOR IMAGERY ABILITY.
B. Bernard 1 2,*, M. Foidart-Dessalle 1 2, A. Mounier-Poulat 2, M. Varlet 2, C. Demoulin 1 2, S. Grosdent 1 2, J.-M. Crielaard 1 2, B. Forthomme 1 2
1
Department of Physical Medicine and Rehabilitation, Lige University Hospital Center, 2Department of Sport and Rehabilitation Sciences, University of Lige, Lige,
Belgium
Background: Immobilization is known to cause a cortical reorganization. The proprioceptive deafferentation resulting from limb's disuse impairs the cognitive
representation, the articular mobility, but also the quality, the speed and the coordination of movements. Although mental practice with motor imagery (MI) has
been suggested to maintain and improve the cognitive representation of a limb, little is known regarding the impact of immobilization on motor imagery capacity
Purpose: This study aims to investigate the effect of a long-term immobilization of the wrist on MI ability assessed by means of several tests
Methods: 15 patients with wrist's trauma requiring at least of 4 weeks of immobilization, recruited in the emergency department of the Lige University Hospital
Center (Belgium), were included in the present study. They attended 2 assessment sessions, i.e. wirhin 24 hours after the trauma (pre-test) and when the cast was
removed (post-test). During each session, 3 tests were performed in a random order : the french version of the Movement Imagery Questionnaire-revised Second
version (MIQ-RS) which assesses the internally representation of movements by means of a visual (IMV) and kinesthetic (IMK) component, the Hand Laterality
Judgment task (HLJT) during which the response time and the success rate were recorded and a mental chronometry test consisting of comparing the time needed to
imagine and perform 8 different simple or complex tasks with wrist or fingers repeated 5 times. During the pre-test, the tasks were only performed on the healthy
side while during the post-test they were executed on the 2 sides.
Results: Although the IMK score decreased and the IMV score increased after the immobilization period, the changes were not statistically significant (p>0,30). As a
result, the overall MIQ-RS score did not significantly changed (p=0,58). Regarding the HLJT, the response time was significantly reduced after immobilization
(p=0,0003) (but it might result from the training effect already reported for that test) whereas the success rate remained stable (p>0,05). The MC score related did
not change regarding the healthy side (p>0,05) and the post-test MC score comparison between healthy and pathological sides shows no significant variation
excepted for 2 out of 8 tasks (pwst=0,009 and pfct=0,01). This difference can be explained by the imagination's time which is conserved after immobilization and which
is similar at the healthy side while the completion's time is increased in comparison of non-pathological hand, giving a negative MC pathological side.
Conclusion: The motor imagery ability doesn't change after a wrist's immobilization of more than 4 weeks.
Implications: Mental chronometry on traumatic side is not a suitable test to assess the MI ability after wrist's immobilization. Mental practice can be used
immediately during and after this immobilization
Funding Acknowledgements: No funds have been perceived for this study.
Ethics Approval: All participants were informed of the objective of the project and took part in the study after informed consent had been obtained.
Keywords: hand laterality, long-term immobilization, motor imagery ability

PO1-CS-025
A NOVEL TREATMENT OF DRY NEEDLING AND ECCENTRIC EXERCISE FOR PATIENTS WITH CHRONIC BICIPITAL TENDINOPATHY: A CASE SERIES
A. Mcdevitt*, L. Krause 1, M. R. Leibold 1, M. Borg 1, P. Mintken 2
1
Sports Physical Therapy and Rehabilitation, University of Colorado Hospital, Denver, Colorado, 2Physical Therapy Program, University of Colorado, Aurora, Colorado,
United States
Background: Chronic tendinopathy of the long head of the bicep (LHB) is a common condition that is often difficult to treat. The medical literature suggests few
treatment options beyond injections and surgery. There are very few studies that describe the conservative management of this condition. Eccentric exercise (EE) has
been reported to be an effective treatment for certain tendinopathies. Dry needling (DN) has been advocated as an intervention for tendinopathy to induce tendon
remodeling and a localized healing response. The effect of these combined interventions on bicipital tendinopathy in unknown.
Purpose: The purpose of this retrospective case series is to describe the use of the novel treatment approach of EE and DN in 10 patients with chronic LHB
tendinopathy.
Methods: All 10 patients (age range 26-54) had chronic anterior shoulder symptoms > 6 months, pain with palpation of the LHB, and a combination of positive results
on Speeds, Hawkins Kennedy, Neer and Yergasons tests. Of the 10 patients, 8 had failed traditional physiotherapy. One patient reported chronic biceps pain which
began 6 months after a biceps tenodesis. The average QuickDASH score at initial examination was 33.61%. The average numeric pain rating scale (NPRS) score at
initial examination was 6.1. All 10 patients were treated with 2-8 sessions of DN into the most painful and/or thickened areas of the tendon, confirmed with
palpation, 20-30 times per session. An EE program and stretching of the LHB tendon followed each DN session and was performed daily for the course of treatment.
Results: At the end of treatment, the average final QuickDASH score was of 7.75%, NPRS was 2.2 and the 10 patients had an average global rating of change (GROC)
of 5.4.
Conclusion: The findings of this retrospective case series suggest that EE and DN may be beneficial in patients with chronic LHB tendinopathy resulting in both
symptomatic and functional improvement.
Implications: The results of this case series suggest that DN and EE may be a useful treatment in recalcitrant LHB tendon pain. These interventions may compliment
traditional manual therapy and exercise which is typically utilized as an intervention to treat LHB tendon pain. Further exploration of this novel treatment approach is
warranted. Improving conservative management of this condition may help patients avoid more costly and invasive techniques including, injection, biceps tenotomy
and tenodesis.
Funding Acknowledgements: The above work was not funded
Ethics Approval: Due to the retrospective nature of the above case series, ethics approval was not deemed necessary.
Keywords: Tendinitis, tendinosis, tendon fenestration

PO1-EX-034
EXERCISE- AND STRESS INDUCED HYPOALGESIA IN MUSICIANS WITH AND WITHOUT SHOULDER PAIN: A RANDOMIZED CONTROLLED CROSSOVER STUDY.
K. Kuppens 1,*, F. Struyf 1, J. Nijs 2, P. Cras 3, E. Fransen 4, L. Hermans 5, M. Meeus 1 5, N. Roussel 1
1
Medicine and Health Sciences - Dept REVAKI, University of Antwerp, Wilrijk, 2Departments of Human Physiology and Physiotherapy, Faculty of Physical Education and
Physiotherapy, Vrije Universiteit Brussel, Brussel, 3Neurology, University Hospital Antwerp, 4Statua, University of Antwerp, Wilrijk, 5REVAKI, Universiteit Gent, Gent,
Belgium
Background: Professional and pre-professional musicians are characterized by physical and psychological demands inherent to their musical activity, and therefore at
risk for developing performance related musculoskeletal pain. Physical and psychological demands are known to influence human pain modulation.
Purpose: In this study we compared the influence of a physical and emotional stress task on pain thresholds in musicians with and without shoulder pain.
Methods: A single-blinded randomized and controlled crossover study design was used to compare the effects of a physical versus emotional testing procedure on
pressure pain thresholds (PPTs) in musicians with and without shoulder pain.
All data were obtained on field (e.g. at the physiotherapy accommodation in the Royal Conservatory).
During the physical testing procedure, the subjects performed an isometric exercise of the glenohumeral external rotators. The emotional task comprised watching
unpleasant images selected from the International Affective Picture System. The outcome was the assessment of change in PPTs before and after the physical and
emotional task.
Results: Our results indicate similar effects of both protocols in either group i.e. musicians with and without shoulder pain (p>0,05). All musicians showed elevated
PPTs at local and remote areas after isometric exercise (p<0,05). The emotional stress task increased PPTs at remote areas only (p<0,05).
Conclusion: In musicians with and without regional shoulder pain, no significant differences were found with respect to pain modulation during a physical and an
emotional stress task. Both interventions adequately activated central and widespread pain inhibitory mechanisms in both groups.
Implications: Exercise- and stress-induced hypoalgesia are extremely relevant in musicians as they experience high physical and psychological demands. Our results
suggest that in musicians with and without regional pain, brain-orchestrated endogenous analgesia is activated in response to physical and emotional stress.
Funding Acknowledgements: Kevin Kuppens was financially supported by a research grant supplied by the University of Antwerp. The funders had no role in study
design, data collection and analysis, decision to publish, or preparation of the manuscript. The authors declare no financial disclosure or conflict of interests.
Ethics Approval: Vrije Universiteit Brussel
Keywords: Musicians, Pressure pain threshold, Stress - and exercise induced hypoalgesia

PO1-LB-044
EFFICACY OF NEURODYNAMIC TECHNIQUES IN TREATMENT-BASED CLASSIFICATION SUBGROUP OF PEOPLE WITH MECHANICAL LOW BACK PAIN- A RANDOMIZED
CLINICAL TRIAL
S. K. Paramasivam 1,*, N. Rani 2
1
Physiotherapy, M.M Institute of Physiotherapy and Rehabilitation, M.M University, Mullana-Ambala, Ambala, 2Physiotherapy, Fortis Superspecialty Hospital, PhaseVIII, , Mohali, Punjab, India
Background: Mechanical low back pain (MLBP) is a non-specific neuromusculoskeletal disorder which
characteristically present with lumbar spine hypo/hyper mobility, myofascial pain and/or neural mechanosensitivity. The Treatment-based classification (TBC)
approach involved subgrouping MLBP patients into either of five homogenous groups- mobilization, stabilization, traction and specific exercise. The clinical prediction
rule for mobilization subgroup did not include neural mechanosensitivity and hence it was necessary to evaluate the efficacy of neurodynamic techniques addressing
neural impairments in mobilization subgroup of MLBP.
Purpose: To evaluate the efficacy of neurodynamic techniques as adjunct to TBC-based approach in treating the mobilization subgroup of MLBP patients.
Methods: The study was a randomized clinical trial with concealed treatment allocation performed on eighteen referred patients with CBPS who were purposively
sampled and recruited upon written informed consent as per approval of Institutional Research Ethics Committee of MMIPR. The participants were randomly
assigned to receive either a combination of Neurodynamic techniques (Slump and SLR mobilization, nerve massage) with TBC-based articular and myofascial
mobilization techniques or TBC-based mobilization alone depending upon neurodynamic testing and TBC-based assessment. The treatment sessions were of 50 mins
duration and were administered daily for five consecutive days. The outcome measurements included pain intensity (10cm visual analogue scale- VAS), flexion range
of motion- ROM (by double inclinometer), neurodynamic mobility (knee extension ROM in slump/SLR), and functional disability using modified Oswestry disability
index (m-ODI).
Results: There were statistically significant (p<.001) changes in all outcome measures with all change scores for between-group comparisons better for the combined
treatment group compared to control group, with improvements noted in both groups. All observed effects were beyond minimum clinically important difference for
all the outcomes.
Conclusion: The combined treatment comprising of Neurodynamic treatment and TBC-based mobilization was more effective than TBC-based mobilization alone to
reduce pain intensity, improve lumbar spine flexion mobility, increase neurodynamic mobility and improve self-reported function in people with MLBP Mobilization
subgroup.
Implications: Mobilization subgroup of MLBP patients who present with neural mechanosensitivity could be
effectively managed with a combined treatment approach comprising of Neurodynamic techniques along with TBC-based articular and myofascial mobilization
techniques.
Funding Acknowledgements: Funded by Senior Researcher project grant of Academy of Orthopaedic Manual Physical
Therapists (AOMPT Inc., India) under grant Ref.no: AOMPT-SRPF/2014/OMT-01
Ethics Approval: The study protocol was approved by Institutional Research Ethics Committee of M.M Institute of
Physiotherapy and Rehabilitation, M.M University, Mullana-Ambala, India under approval letter Ref.No: MMIPRIREC/2014/PT-10
Keywords: clinical decision making, lumbar spine rehabilitation, Neural mobilization

PO1-LB-045
THE EFFECTIVENESS OF DIRECT STRETCHING ON BILATERAL PSOAS MAJOR TO THE LUMBAR LORDOSIS
T. Otsudo*, K. Akasaka 1, K. Mimura 2
1
Health and Medical care, Japan, MoroyamaCity, Iruma Gun, Saitama, 2Rehabilitation, Akabane Rehabilitation Hospital, Kita-ku, Tokyo, Japan
Background: The psoas major muscle (PM) plays an important role in movement by stabilizing lumbar spine. It is widely considered that PM can be a pain source in
athletes, office workers or anyone who spends much of their day sitting. Sitting difficulty adopting neutral midrange lumbar lordosis postures has been observed in
individuals with low back pain. It is common that we apply their PM to stretch by passive hip extension in prone position in order to modify their lordosis. However,
low back pain could occur by the passive hip extension because of generating shear force to the facet joints among lumbar spines. In this case, direct stretching to the
PM from bilateral abdominal area at the side of rectus abdominis is considered to be useful because of attenuating shear force against the facet joint of lumbar spine.
Purpose: The aim of our study was to clarify the effectiveness of direct stretching on bilateral PM in supine position to the alignment of lumbar vertebrae compared
with a sham direct stretching.
Methods: Thirty-four healthy males were divided into PM stretching group (n=17, age: 21.8 1.1 years old, height: 174.0 9.2 cm, weight: 65.7 9.7 kg) and control
group (n=17, age: 21.7 2.1 years old, height: 171.0 3.3 cm, weight: 62.5 5.1 kg). 3D coodinates of spinous process of lumbar vertebrae at 15 of bilateral hip
extension were measured by 3D digitizer (Microscribe G2X, Revware Inc, USA and Rhinoceros ver.5.0, Robert McNeel & Associates, USA) during prone position on
the treatment table before and after direct stretching to bilateral PM. PM stretching group was applied direct stretching to bilateral PM which was identified using by
ultrasonography. Control group was applied direct stretching to their bilateral rectus abdominis in supine position as a sham stretching. Each of the stretching was
applied as much as strong for 15 seconds per a set, the total amount is 120 seconds (8 sets) intermittently and the average force that subjects could endure for 15
seconds was 39.17.2 N for PM stretching group and 34.25.9 N for control group by hand held dynamometer, respectively.
Results: 1st lumbar spinous process was displaced forward and 4th lumbar spinous process was significantly displaced backward against their upper vertebrae
(p<0.05). However, 2nd, 3rd and 5th were not displaced significantly. Sham stretching could not affect any lumbar lordosis.
Conclusion: Lumbar lordosis was weakened at 1st lumbar vertebrae by the direct stretching for PM. On the contrary, lumbar lordosis at 4th was strengthened. We
need to search the effectiveness of the direct stretching more distal part of PM.
Implications: Deeply located trunk muscles with segmental attachments to the lumbar vertebrae, such as PM is a common target for clinical interventions for low
back pain.
This result showed that this direct stretching for PM in supine position could be effective to modify the lumbar alignment of PM.
Ethics Approval: This project was approved by the Ethical Committee in Faculty of Health and Medical Care Saitama Medical University (No.118). The participants
gave their written and informed consent agreement to participate in this study, which was conducted according to the Helsinki Statement.
Keywords: psoas major, direct stretching, lumbar lordosis

PO1-LB-046
COMPARISON OF NOVEL KINEMATIC VARIABLES BETWEEN PATIENTS WITH DIFFERENT STAGES OF LOW BACK PAIN AND HEALTHY SUBJECTS
B. Hidalgo 1,*, T. Hall 2, M. Gilliaux 3, C. Detrembleur 4
1
Physiotherapy / Manual Therapy, Faculty of Motor Sciences / Parnasse ISEI / IREC-CARS, bruxelles, Belgium, 2Physiotherapy / Manual Therapy, School of
physiotherapy, Perth, Australia, 3Physiotherapy / Manual Therapy, Faculty of Motor Sciences , 4Physiotherapy / Manual Therapy, Faculty of Motor Sciences / IRECCARS, bruxelles, Belgium
Background: Growing evidence supports kinematic analysis to objectively measure functional trunk movement as well as to determine the effectiveness of physical
therapy in people who suffer from LBP. Two new kinematic algorithms (KA) have been recently described in this regard. The first is a measure of trunk ROM (KA-R)
and the second a measure of trunk speed (KA-S). KA-S is a comprehensive quantitative variable of speed of trunk movement indicating whether patients are moving
slowly or quickly. However, the quality of speed curves/forms is another movement characteristic that may be addressed by the smoothness of movement (SS), which
can be defined as the ratio between speed and peak speed. SS can also be described as a measure of parametric continuity along the speed curve, a kind of motion
signature. Despite a number of studies investigating kinematics in LBP, none have yet focused on SS.
Purpose: To determine whether KA-R, KA-S and SS from the kinematic model of the spine during trunk movements could distinguish people with acute low back pain
(ALBP) from those with chronic low back pain (CLBP) or asymptomatic healthy subjects.
Methods: This was a retrospective study of 60 subjects comprising non-specific ALBP (n=20), CLBP (n=20), and healthy controls (n=20) all aged between 30-65 years.
Three novel kinematic variables were evaluated during trunk movements in a sitting position, to observe differences between ALBP, CLBP and healthy subjects.
Moreover, the sensitivity and specificity of these variables to categorize subjects were determined.
Results: Variables KA-R, KA-S and SS significantly distinguished (p <0.05- p <0.001) the three populations. However, only KA-R failed to distinguish ALBP from CLBP
patients. The average sensitivity and specificity to distinguish the three populations for the KA-R, KA-S, and SS were respectively: 0.65 / 0.83, 0.77 / 0.80, and 0.76 /
0.71.
Conclusion: Variables KA-S and SS were both able to effectively differentiate the three populations. However in contrast, KA-R was unable to distinguish people with
ALBP from those with CLBP. This study provides novel objective kinematic variables to help in the diagnosis of non-specific LBP. These variables can be used to
determine the efficacy of physical therapy interventions in terms of function and activity (e.g. trunk flexion) in clinical practice and research trials. SS is a potential
new kinematic variable that may be used in the evaluation of LBP.
Implications: Kinematic analysis is a legitimate, evidence-based form of physical examination, which may have greater diagnostic implications than traditional
objective measurements such as medical imaging in the evaluation and management of non-specific LBP. The three variables measured reported here could
potentially also be used in treatment (as biofeedback), as well as when measuring the efficacy of a treatment following OMT in future clinical trials.
Funding Acknowledgements: No funding sources
Ethics Approval: The subjects provide signed informed consent, and ethical approval for this study was provided by the Commission dEthique Biomdicale
Hospitalo-facultaire (CEBFH) of the Universit Catholique de Louvain.
Keywords: Clinical Diagnostic, kinematics, low back pain

PO1-LL-052
DOES CHANGE IN QUADRICEPS MUSCLE TORQUE CORRELATE WITH CHANGE IN PAIN IN PEOPLE WITH JOINT HYPERMOBILITY SYNDROME WHO HAVE ANTERIOR
KNEE PAIN? PRELIMINARY DATA FROM A LARGER CASE CONTROL STUDY.
M. To 1,*, C. Alexander 2 3
1
Therapies, 2Physiotherapy, IMPERIAL COLLEGE LONDON HEALTHCARE NHS TRUST, 3Surgery and Cancer, Imperial College London, London, United Kingdom
Background: People with Joint Hypermobility Syndrome (JHS) have weak quadriceps. This may be due to connective tissue differences or reduced function. Either
way, strength programmes are prescribed. However, clinicians suspect that people with JHS struggle to strengthen at the same rate as people with average
flexibility. In a larger study, rate of change of muscle strength is being investigated and compared between groups who have anterior knee pain (AKP) and different
levels of flexibility. Using preliminary data from the larger study, this abstract explores the correlation between muscle torque and pain in participants with JHS and
AKP. We hypothesised that there will be little correlation between muscle torque and pain. This work is important as it will inform the choice of outcome measures
when designing an interventional study to test the effectiveness of strengthening people with JHS.
Purpose: To correlate strength with pain intensity in a cohort of people with JHS and AKP undergoing a 16-week strength programme.
Methods: With ethical approval and informed consent 45 people with JHS and AKP were recruited. JHS was classified using the Brighton criteria and AKP was
diagnosed by their clinician. Pain intensity was assessed using a visual analogue scale (VAS). Each participant was prescribed a tailored quadriceps strength
programme delivered by a senior physiotherapist with 10 years experience. The participants were asked to perform exercises 3 times a week on non-consecutive
days. Participants re-attended every 2 weeks for 16 weeks when exercises could be progressed, pain intensity assessed and both eccentric and concentric torque
measured using an instrumented leg press (Cybex International UK Ltd, Coalville).
Using intention to treat analysis, multiple imputations were performed for missing data from participants that were lost to follow up. Spearmans rho () was used to
investigate any correlation between eccentric and concentric torque and pain.
Results: Forty-five participants with JHS and AKP were recruited aged between 18 years and 56 years (mean age 34.7 10.6 years). The Beighton score was 7.0 1.7.
Initial pain intensity was 5.8 2.5. Seventeen participants (38%) were lost to follow up; their data was included in the analysis. There was a weak negative correlation
between eccentric torque and pain as well as between concentric torque and pain (=-0.26; p=0.01 and =-0.26; p=0.01 respectively).
Conclusion: There is only a weak negative correlation between muscle torque and pain.
Implications: An implication is that pain may reduce with increasing torque in patients with JHS and AKP. Functional change will be correlated with strength to see if
there is a stronger relationship. Function alongside change in pain may be important to test when investigating the effectiveness of strength programmes.
Funding Acknowledgements: Dr Alexander gratefully acknowledges the support of The National Institute of Health Research. May To gratefully acknowledges the
support of Imperial College Healthcare Charity.
Ethics Approval: The study was reviewed and approved by NRES Committee London Harrow (REC reference 12/LO/1756).
Disclosure of Interest: M. To Conflict with: Imperial College Healthcare Charity, Conflict with: Imperial College Healthcare NHS Trust, C. Alexander Conflict with:
National Institute of Health Research, Conflict with: Imperial College Healthcare NHS Trust
Keywords: anterior knee pain, Joint Hypermobility Syndrome, strength

PO1-LL-054
ACCELERATED REHABILITATION OF BILATERAL ACHILLES REPAIRS SECURED WITH A MIDSUBSTANCE SPEEDBRIDGE: A CASE REPORT
S. Bertrand*
Background: Acute and bilateral rupture of the Achilles tendon is a rare occurrence and literature related to rehabilitation following surgical intervention is lacking.
Recent advances in surgical techniques are purported to reduce the period of immobilization and improve the recovery time following Achilles tendon repair. One
such technique is the Achilles Midsubstance SpeedBridge Repair. This minimally invasive procedure uses suture-anchors to secure the Achilles tendon into the
calcaneus, eliminating the knots that typically approximate the two ends of the tendon and were a source of weakness in prior techniques. Although a patient
undergoing Midsubstance SpeedBridge Repair of the Achilles tendon is expected to begin active rehabilitation earlier than a patient with more traditional repair
procedures, accelerated pace rehabilitation programs and related clinical outcomes in this population have not been described.
Purpose: The purpose of this case report is to describe the accelerated rehabilitation of an active 48 year old female who underwent bilateral Achilles repairs with a
Midsubstance SpeedBridge Repair following acute rupture.
Methods: The patient was progressed from non-weight bearing to partial weight bearing in Aircast boots and heel lifts at 4 weeks post surgical intervention. At 6
weeks she was allowed to progress to full weight bearing in sneakers. The patient was assigned range of motion and stretching exercises until formal physical therapy
began 8 weeks after surgical intervention. Physical therapy included interventions designed to increase tensile load capacity of the Achilles tendon, restore muscle
performance and dynamic stability of the lower extremity, and restore normal gait pattern and walking tolerance using the AlterG treadmill system.
Results: After 12 weeks of physical therapy performed 2 times a week, the patient demonstrated important gains in pain reduction, range of motion, muscle
performance, gait speed and self-reported function as measured by the Patient Specific Functional Scale (PSFS), Foot and Ankle Ability Measure (FAAM), and the
Achilles Tendon Total Rupture Score (ATRS). The patient was able to return to full weight bearing by 6 weeks post surgical intervention which is 4 weeks earlier than
recent literature for the same patient population. She also scored a 31 on the ATRS at 4 months post surgical intervention which is 16 points higher than the current
literature for a similar population.
Conclusion: This case report demonstrates the accelerated rehabilitation and weight bearing status of a patient status post bilateral Achilles repair with Midsubstance
SpeedBridge procedure following acute rupture.
Implications: An accelerated rehabilitation program including early progression of weight bearing in patients following acute bilateral rupture of the Achilles tendons
may have the potential to return patient to their functional goals earlier than previously reported in the literature.
Funding Acknowledgements: Not Applicable
Ethics Approval: Ethics approval was not required for this case study
Keywords: Accelerated rehabilitation, Achilles Rupture, Midsubstance Bridge

PO1-MT-058
MOBILIZATION WITH MOVEMENT SYMPTOM MODIFICATION PROCEDURE FOR A 38 YEAR OLD MALE WITH PATELLA FEMORAL PAIN SYNDROME
E. Chaconas*, S. Gray, D. Kempfert 1
1
Doctor of Physical Therapy, University of St. Augustine, St. Augustine, United States
Background: Patellofemoral pain syndrome (PFPS) is among the most common musculoskeletal conditions seen by a physiotherapist. Current evidence suggests that
excessive hip adduction, internal rotation and ankle eversion has been associated with PFPS in females. A paucity of literature exists regarding males presenting with
PFPS and altered lower extremity kinematics including limitations of hip internal rotation and ankle eversion.
Purpose: The purpose of this case report is to describe the weight bearing manual therapy and exercise techniques utilized to restore hip internal rotation and ankle
eversion for a male with PFPS.
Methods: A 38 year old male presented with retro patellar pain during running and walking. The physical examination identified limited passive hip internal rotation
to 10 degrees and ankle eversion at 2 degrees. Pain levels as measured by the numeric pain rating scale (NPRS) were reported to be 7/10 with activity and 2/10 at
rest. Focus on Therapeutic Outcomes (FOTO) scores demonstrated a 64% disability. A symptom modification procedure reduced pain in weight bearing during
mobilization with movement to facilitate ankle eversion and hip internal rotation. The patient was seen for six weeks using a multi-modal approach including manual
therapy and exercise to facilitate weight bearing mobility of the lower extremity.
Results: After six weeks of rehabilitation the patient reported pain free running, NPRS of 0/10 with activity and a FOTO disability score of 0%. Hip internal rotation
improved to 23 degrees and ankle eversion to 7 degrees.
Conclusion: Facilitating femoral internal rotation and ankle eversion for a male presenting with PFPS resulted in reduced symptoms and full return to
function. Further research is needed to examine the efficacy of interventions targeting lower extremity kinematics in males with PFPS.
Implications: A lower extremity symptom modification procedure could benefit the decision making process for clinicians managing males with PFPS.
Funding Acknowledgements: This work was unfunded
Ethics Approval: IRB approval was not required for this retrospective case report but the patient did provide consent for the clinical data to be used for a case report.
Keywords: Biomechanics, Mobilization, Patellofemoral pain syndrome

PO1-MT-059
THE IMMEDIATE EFFECTS OF A SINGLE SESSION OF ACCESSORY SPECIFIC SOFT TISSUE MOBILISATIONS ON PAIN PRESSURE THRESHOLD ON SUBJECTS WITH MEDIAL
TIBIAL STRESS SYNDROME.
R. Losiute*, S. O'Neil
Background: Medial tibial stress syndrome (MTSS) is hypothesised to involve the Soleal Bridge- an aponeurotic insertion of the Soleus into the medial tibia. As such
specific soft tissue mobilisations (SSTMs) are commonly used in physiotherapy practice for the management of MTSS. Despite the common usage the effect of SSTMs
on the pain associated with MTSS is unknown. This is the first study to assess the effects of an SSTM for pain associated with MTSS.
Purpose: To determine the immediate effect of Accessory SSTMs on the pain pressure threshold (PPT) in subjects with MTSS.
Methods: 14 subjects met the inclusion criteria and were included in this quasi-experimental cohort study. Pressure pain thresholds were measured pre and post an
Accessory SSTMs. The assessment points were 3 pre-determined standardised points along the medial aspect of the tibia within the symptomatic zone. 3 points were
marked along the medial distal 1/3 of the tibia with the centre point located over the subjects most sensitive area. The same examiner applied the Accessory soft
tissue mobilisations for a duration of 5 minutes along the Soleal bridge, within the sensitive regions. The three measurements were then analysed in SPSS software
package.
Results: A paired t test demonstrated a statistically significant (P =0.0002) increase in pressure pain threshold after the SSTM. The mean increase in pressure pain
threshold was 34.1%.
Conclusion: These results show an immediate increase in pressure pain threshold after SSTMs in a population of subjects with MTSS. This increase in pressure pain
threshold relates to a reduction in a patient's pain perception. Further work is needed to determine the length of treatment effect.
Implications: The results of this study support the use of accessory SSTMs in the short term management of patients with MTSS.
Funding Acknowledgements: Unfunded Work
Ethics Approval: The ethical approval was granted by the Coventry and Leicester Universities Ethics Committees (United Kingdom) prior the study conduction.
Keywords: Medial Tibial Stress Syndrome, Pain Pressure Threshold, Specific Soft-tissue Mobilisations

PO1-MT-060
COMBINED TREATMENT OF MANUAL THERAPY, TAPING AND HOME EXERCISES IN PATIENTS WITH PAINFUL SHOULDER SYNDROME
D. Saorn-Morote 1,*, A. Gmez-Conesa 2, A. Velandrino-Nicols 3
1
Physiotherapy, 2Physioterapy, 3Psychology, Murcia University, Murcia, Spain
Background: The painful shoulder syndrome is characterized by pain located in the shoulder region, sometimes spread to the upper limb, which may constitute an
emergency for the functional disability it causes. It accounts for between 16% and 26% of musculoskeletal pain.
The thoracic spine should maintain some mobility to adequately adapt to the kinematics of the shoulder. Both McConnell Taping and Kinesio Taping have shown to
influence biomechanics and shoulder muscle activity. In addition, improvements in motor control of the shoulder joint complex bring on a good functioning.
To our knowledge, it has not carried out any study that combines manual therapy with thoracic analytic mobilization and taping, for the treatment of painful shoulder
syndrome.
Purpose: To determine the efficacy of the treatment of manual therapy with thoracic analytic mobilization and taping (McConnell Taping or Kinesio Taping), along
with a home exercise program on pain having patients diagnosed with painful shoulder syndrome.
Methods: A double-blind randomized clinical trial was performed.
Sixty patients (56.7% women; mean = 50.1 years; SD = 15.28), diagnosed with painful shoulder syndrome, formed the study sample, being randomized into two
groups: manual therapy with thoracic analytic mobilization, McConnell Taping (Group 1: n = 30) or Kinesio Taping (Group 2: n = 30), and a home exercise program.
The treatment lasted until the symptoms disappear or stagnation of the clinic, with a mean of 4.2 sessions (SD = 2.22).
Pain was assessed by Visual Analogue Scale (VAS) before (Pre-treatment) and after the first session (Post-First session), at the end of treatment (Post-treatment), and
three months later (Follow-up).
None of the patients withdrew from the study.
Results: In both groups, pain decreases with statistically significant differences in the four times evaluated.
No differences between the two treatment groups were found.
Group 1: F (2, 58) = 637.4, p < 0.05, with a high effect size (w2 = 1.01).
Group 2: F (2, 58) = 311.9, p < 0.05, with a high effect size (w2 = 0.96).
The post hoc comparisons, p < 0.05, indicate that such differences are found between the mean scores of the Pre-treatment (Group 1: Mean = 6.99, SD = 1.06; Group
2: Mean = 6.66, SD = 1.42) with Post-First session (Group 1: Mean = 2.76, SD = 1.09; Group 2: Mean = 3.28, SD = 1.78); Pre-treatment with Post-treatment (Group 1:
Mean = 0.10, SD = 0.19; Group 2: Mean = 0.30, SD = 0.44); and Pre-treatment with Follow-up (Group 1: Mean = 0; SD = 0; Group 2: Mean = 0.03, SD = 0.12) moments.
Conclusion: The manual therapy treatment with thoracic analytic mobilization, combined with taping (McConnell Taping or Kinesio Taping), along with a home
exercise program, reduces pain in patients with painful shoulder syndrome, both immediately and mid term, staying this effect three months later.
There is no difference between using McConnell Taping and Kinesio Taping in this study.
It might be advisable to check longer follow-up duration of this effect.
Implications: The treatment given to patients with painful shoulder syndrome has proven to be effective in reducing pain immediately and mid term; and three
months later the improvement is maintained.
Funding Acknowledgements: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Ethics Approval: This research was approved by the Ethics Committee for Research of the Murcia University (ID: 1123/2015). Murcia, Spain.
All patients signed an informed consent document in accordance with the ethical code of the World Medical Association (Helsinki Declaration).
Keywords: Musculoskeletal Manipulations, Shoulder Pain, Taping

PO1-PA-063
PATIENT PERCEPTIONS OF THE ROLE OF PSYCHOSOCIAL FACTORS IN NON-SPECIFIC CHRONIC SPINAL PAIN: A SYSTEMATIC REVIEW AND META-SYNTHESIS.
M. O'Keeffe 1,*, J. Ryan 1, I. Leahy 1, S. Bunzli 2, P. O'Sullivan 2, W. Dankaerts 3, K. O'Sullivan 1
1
Clinical Therapies, University of Limerick, Limerick, Ireland, 2School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia, 3Department of
Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven - University of Leuven, Leuven, Belgium
Background: While non-specific chronic spinal pain (NSCSP) was previously viewed as a purely structural and biomechanical issue, recent research highlights that it is
a complex disorder associated with a wide range of other factors. These include cognitive (e.g. unhelpful thoughts and beliefs), psychological (e.g depression and
anxiety) and social (e.g. socio-economic status and job satisfaction) factors. However, patients frequently report physical factors as the main trigger for their spinal
pain. No review has investigated patient perceptions of the role of psychosocial factors in non-specific chronic spinal pain.
Purpose: This qualitative systematic review and meta-synthesis investigated patient perceptions of the role of psychosocial factors in non-specific chronic spinal pain.
Methods: Ten databases were searched using an agreed range of keywords. Qualitative studies including participants with NSCSP (neck, thoracic, low back, or pelvic)
greater than 3 months in duration and between 18 and 65 years of age, were eligible. Studies were required to examine patient perceptions of the role of
psychosocial factors in NSCSP. Studies were excluded if participants recently received an intervention primarily delivered by a psychologist or psychiatrist. Two
reviewers independently selected articles, assessed their methodological quality using the Critical Appraisal Skills Programme (CASP) and performed the three-step
analytical process; extraction of findings, grouping of findings (codes), abstraction of findings.
Results: 16 studies were included. Patients frequently reported that their pain had a major psychosocial impact through; changing their identity, not being
understood, affecting them emotionally in terms of stress and depression and having a negative influence on hobbies, work and family function. While patients in one
study referred to the importance of the body/mind interaction in pain and that stress could cause pain, overall there was very little reference to psychosocial factors
contributing to pain. Where psychosocial factors were mentioned as contributing to pain, patients often displayed resistance, choosing instead to attribute their pain
to physical causes. Patients were unhappy with the notion that pain maybe be caused by psychosocial factors.
Conclusion: Patients believe that spinal pain has a large psychosocial impact. However, they generally do not view psychosocial factors as contributors to pain.
Implications: Physiotherapists may need to give more time educating patients on the role of psychosocial factors in contributing to spinal pain, and reassure patients
that such a contribution is common and does not delegitimise their pain.
Funding Acknowledgements: Mary OKeeffe was funded by the Irish Research Council.
Ethics Approval: Not applicable.
Keywords: non-specific chronic spinal pain, psychosocial factors, qualitative systematic review

PO1-PA-064
DO PHYSICAL THERAPIST UNDERSTAND THE PERCEPTIONS AND HEALTH BEAVIOUR OF PATIENTS WITH CHRONIC MUSCULOSKELETAL PAIN
P. Van Wilgen*, N. Roussel 1, M. Leysen 2, A. Beetsma 3, K. Kuppens 2, J. Nijs
1
Department of Rehabilitation Sciences and Physiotherapy (REVAKI), Faculty of Medicine and health Sciences, University of Antwerp, , 2Department of Rehabilitation
Sciences and Physiotherapy (REVAKI), Faculty of Medicine and health Sciences, University of Antwerp, Antwerp, Belgium, 3Physiotherapy, Hanze University of Applied
Sciences, Groningen, Netherlands
Background: For physical therapists, a patients health-behavior is an important outcome of treatment, especially in patients with chronic musculoskeletal pain (MSK
pain). Physical therapists therefore need to identify the factors related to this health behavior. In the last decades research showed that perceptual and cognitive
factors are underlying a patients health behavior. An important theoretical framework that links perception and health behavior is Leventhals Common Sense Model
(CSM).
Purpose: The purpose of this study was to analyze how physical therapists (PT) working in primary care integrate illness perceptions to understand health behavior
during the first assessment of patient with MSK low back pain.
Methods: An exploratory-qualitative design was used to investigate the integration of illness perceptions in the assessment of PTs. The participating PTs were asked
to audio-tape their interview during the first consult of a patient with MSK low back pain. Afterwards the interviews were transcripted verbatim and a deductive
approach, with the domains of the CSM, was used to analyze the illness perceptions asked for by the PT during the interviews. Analysis was complete if saturation
was achieved.
Results: In total 19 physical therapists participated and 27 assessments were recorded. Physical therapists ask for causes of pain, identity and consequences of the
pain, questions regarding timeline, treatment control, coherence and emotional representation were seldom asked. Overall the questions in all domains that were
asked for were biomedical orientated and not biopsychosocial.
Conclusion: Although the bio-psycho-model is underlined by guidelines for MSK pain and physical therapists have become aware that psycho-social and behavioral
factors interfere with the pain of their patients with MSK pain, the integration of these psycho-social factors needs more attention. Several domains of the CSM
should be asked more specifically in this patient group as well as more questions regarding psychological and social factors should be asked.
Implications: This study showed that more education is needed to integrate illness perceptions and a biopsychosocial view in the assessment of PTs.
Funding Acknowledgements: All PT' and patients that particiapted in the study
Ethics Approval: The Human Research Ethics Committee of the Vrije Universiteit Brussels approved the study and in case both the physical therapists and the patient
agreed to participate, written informed consent was obtained from all participants prior to testing.
Keywords: Musculoskeletal pain, illness perceptions, health behavior

PO1-PA-065
SHOULD CENTRAL PAIN BE SUB-CLASSIFIED? A HYPOTHESIS OF MUSCULOSKELETAL BODY IMAGE PAIN - INITIAL INSIGHTS INTO DIAGNOSTIC CRITERIA
S. Gibbons 1,*
1
SMARTERehab, St John's, Canada
Background: Sub-classification of pain mechanisms is recommended over time frame based pain classification. The concept of central sensitization (CS) has been
critical to interpreting pain presentations. Despite the importance, CS does not adequately explain complex presentations such as: phantom limb pain, complex
regional pain syndrome, fibromyalgia, thalamic pain, zero gravity symptoms or laboratory induced sensory incongruence. These presentations are either left
unexplained, sub-grouped along with CS or labeled as "dysfunctional pain". An understanding of the characteristics of these presentations can lead to a diagnosis and
treatment strategies.
Purpose: The purpose of this study was describe the clinical characteristics of a sub-group of dysfunctional pain patients that could not be sub-classified by a pain
mechanism to provide a preliminary strategy to diagnosis of a possible separate central pain mechanism.
Methods: A chart review was done to collect self report and physical assessment items for 131 patients who had dysfunctional pain. They were dichotomized into (1)
those who did not fit a preliminary clinical prediction rule for CS and did not have neuro-immune-endocrine-autonomic symptoms in all bodily systems (NSB) (2) and
those that did (SB). Descriptive statistics were used to describe items relating to central pain. The items were dichotomized into being present or not being present.
Those which were present in over 80% of subjects were placed in a standard 2 x 2 table to calculate odds ratios (OR). Sensitivity (SN) and specificity (SP) were also
calculated to provide initial insights into diagnostic accuracy.
Results: The self report items identified were the Kinesthetic and Visual Imagery Questionnaire (KVIQ) and Body Image Drawing (BID). The physical assessment were
the Cross March Midline Test (CM) and the Infinity Pattern (IP) Oculomotor Test. The OR of NSB were: KVIQ: 26; BID: 114; CM: 1.88; IP: 1.50. The SN and SP of NSB
were: KVIQ: 0.92, 0.70; BID: 0.99, 0.62; CM: 0.97, 0.66; IP: 0.88, 0.64, respectively.
Conclusion: Musculoskeletal body image pain (MBIP) may be a unique sub-group of central pain. Preliminary findings suggest that it may be identified by the inability
to perform internal intrinsic motor imagery, the inability to draw the outline of their body image, or use their symptoms as feedback for drawing, and poor ability to
cross midline. This group lacks extreme widespread sensory hypersensitivity, as assessed by quantitative sensory testing, and high constant pain. MBIP provides a
logical sub-classification of other central or dysfunctional pain syndromes by adapting Moseley's definition of pain. Here, the "threat" may be interpreted as the brain
not knowing what is happening in the body. The result is that pain and musculoskeletal symptoms are produced to act as a default sensory system. Further research is
needed to confirm the validity of MBIP and the diagnostic accuracy.
Implications: Clinicians can use the self report and physical assessment items to help differentiate MBIP from central sensitization. SP and SN should be interpreted
with caution since there is no true gold standard established.
Funding Acknowledgements: The work was unfunded
Ethics Approval: The Human Investigation Committee of Memorial University of Newfoundland deemed the project as program development, therefore full ethics
approval was not required. All subjects gave written consent for their chart information to be used.
Keywords: central sensitization, central pain, Sub-classification

PO1-PA-067
PAINDETECT FOR SCREENING NEUROPATHIC PAIN: THE ENGLISH VERSION IS RELIABLE
T. Bohne*, M. Callan 1, M. Kvia 1, A. Melson myhre 1, E. C. Neoh 2, C. Bharat 3, H. Slater 1
1
School of Physiotherapy and Exercise Science, 2School of Physiothearpy and Exercise Science, Curtin University, 3Centre for Applied Statistics, Universit of Western
Australia, Perth, Australia
Background: The painDETECT questionnaire (PD-Q) is a self-reported screening tool for the identification of neuropathic pain (NeP), The questionnaire contains seven
weighted sensory descriptors, one item relation to spatial pain characteristics and one item relating to temporal characteristics. A PD-Q total score ranging from -1 to
38 can be calculated. The total score is divided into three PD-Q categories (unlikely NeP (<13), unclear (13-18), likely NeP (>18)). While the English version of PD-Q has
been used in clinical and research settings, its reliability has not been investigated.
Purpose: The objective of this study was to determine the reliability of the English version of the PD-Q pre- and post-clinical consultation (T0-T1) and at one-week
follow-up (T0-T2) in patients attending a Neurosurgery Spinal Clinic and Pain Management Department.
Methods: Consenting participants completed the PD-Q at three time points: prior to a consultation with a Physiotherapist, Pain Specialist Physician or Neurosurgeon,
immediately following their consultation, and one-week post-consultation. The one-week post-consultation PD-Q was delivered via registered post. A Patient Global
Impression Scale (PGIC) was included to measure any perceived symptomatic change. Intra Class Correlation Coefficients (ICC) assessed the agreement of the PD-Q
total scores between T0-T1 and T0-T2. Weighted Kappa statistic was used to assess agreement of PD-Q categories (unlikely NeP, ambiguous, likely NeP) between
these time points. Patients scoring 2 or 6 on the PGIC were excluded from the T0-T2 analysis.
Results: At T0 and T1, 150 and 144 participants completed the PD-Q, respectively. Accounting for missing data, 138 patients (mean (SD) age: 57 (15.12) years, 53.6%
male) were included in the T0-T1 analysis and 69 patients in the T0-T2 analysis. There was almost perfect agreement between total scores of the PD-Q at T0-T1 (ICC
0.911; 95% CI: 0.882, 0.941), and substantial agreement between total scores at T0-T2 (ICC 0.792; 95% CI: 0.703 0.880). PD-Q categories were found to be in
substantial agreement at both T0-T1 (Kappa 0.771; 95% CI: 0.683, 0.858) and T0-T2 (Kappa 0.691; 95% CI: 0.553 0.830).
Conclusion: The results show that the English version of the PD-Q is reliable pre and post-consultation, and at one-week follow-up. Our results are consistent with
results of previous studies evaluating the reliability of various translated versions of the PD-Q, and support the use of the English PD-Q in clinical and research
settings. Our study included a larger sample size and a wider range of age, symptom duration and diagnoses than previous studies, allowing greater generalizability to
a wider range of individuals with from persistent pain.
Implications: Clinicians are provided with greater confidence in using the PD-Q in the clinical setting, and the utility of the PD-Q as a screening tool for NeP is
strengthened.
Funding Acknowledgements: This study is funded by Sir Charles Gairdner Hospital and Curtin University.
Ethics Approval: The study had institutional ethics approval from Sir Charles Gairdner Group Human Research Ethics Committee (HREC 2015-064) and Curtin
University Human Research Ethics Committee, ethics number 2015-064 and HR149/2015 respectively.
Keywords: painDETECT; Reliability; Neuropathic pain; Clinical assessment, Screening tool

PO1-SP-070
ASSOCIATIONS BETWEEN BRAIN MORPHOLOGICAL FINDINGS AND PAIN MEASURES IN CHRONIC SPINAL PAIN: PRELIMINARY BASELINE RESULTS OF A
RANDOMIZED CONTROLLED TRIAL
J. Kregel 1,*, I. Coppieters 2, A. Malfliet 3, M. Dolphens 1, N. Roussel 4, K. Caeyenberghs 5, L. Danneels 1, M. Meeus 1, J. Nijs 3, B. Cagnie 1
1
Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, 2Dept of Rehabilitation Sciences and Physiotherapy, Faculty of
Medicine and Health Sciences, Ghent University, Ghent, 3Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education &
Physiotherapy, Vrije Universiteit Brussel, Brussels, 4Department of Health Sciences, Artesis University College Antwerp, Antwerp, 5School of Psychology, Faculty of
Health Sciences, Australian Catholic University, Melbourne, Belgium
Background: Chronic spinal pain (CSP) accounts for a large proportion of patients with chronic musculoskeletal disorders. It includes in particular chronic low back
pain, failed back surgery, chronic whiplash associated disorders, and non-traumatic neck pain. A substantial amount of studies provided already evidence for impaired
motor control of spinal muscles in CSP and corresponding central findings in the brain. During the last decade, evidence of several brain abnormalities has been found
in chronic pain patients. A tendency exists regarding reduced global and regional grey matter volumes, however, regional grey matter increases have also been
reported. Regarding these abnormalities, not only motor control-related brain areas are involved, also brain-orchestrated pain processing is malfunctioning in CSP. As
a result, many CSP patients experience higher pain sensitivity, pain to non-painful stimuli, and several other physical and psycho-social problems. Here, baseline
findings of a randomized controlled trial evaluating a modern neuroscience approach to CSP are reported.
Purpose: The primary objective was to assess the possible associations of brain morphology with clinical pain assessments. A secondary objective was to evaluate the
differences between neck and low back pain patients and gender differences on the identified associations and pain assessments.
Methods: A total of 97 CSP patients underwent an anatomical MRI scan and pain assessments. Processing of MRI images included the calculation of subcortical grey
matter volume, cortical grey matter volume, area, and thickness. Clinical pain assessments included pain pressure algometry on symptomatic and asymptomatic body
regions, and conditioned pain modulation (CPM).
Results: No differences between neck and back pain patients were found with respect to the pain pressure thresholds (PPT) before and during CPM and the
corresponding CPM effect. Men scored significantly higher on all pain outcome measures, except for a single asymptomatic PPT. Several significant correlations were
found between pain measures and regional grey matter measures, including subcortical grey matter volume, cortical grey matter volume, cortical thickness, and area.
Amongst these associations, a consistent negative correlation regarding regional cortical grey matter and pain duration was found.
Conclusion: Pain processing is associated with measures of brain structure and longer pain duration negatively influences regional grey matter quantity. Chronic neck
and back pain patients do not differ in pain processing, but a gender difference is present. Further analyses should evaluate whether these associations still exist
during the follow-up of the treatment, which may imply that a normalization of pain is associated with a corresponding normalization of brain structure.
Implications: These results contribute to the limited evidence for associations of structural brain abnormalities and clinical pain measures in CSP. It furthermore gives
rise for a modern neuroscience approach in the management of CSP.
Funding Acknowledgements: This work is funded by the Agency for Innovation by Science and Technology (IWT) - Applied Biomedical Research Program (TBM),
Belgium
Ethics Approval: Approval was granted by the Ethics Committee of the Ghent University Hospital and the University Hospital Brussels.
Keywords: brain, chronic spinal pain, Magnetic Resonance Imaging

PO2-AP-001
OBSERVATIONAL STUDY ON POSTURAL AND BIOMECHANICAL PATTERNS IN PATIENTS UNDERGOING ROBOT ASSISTED RADICAL PROSTATECTOMY WITH AND
WITHOUT STRESS URINARY INCONTINENCE
G. Donvito 1,*, G. Fusco 2, F. Pacelli 3, M. Scarcia 4, G. Cardo 4, M. Romano 4, G. M. Ludovico 4, F. P. Maselli 4
1
Frelance Physiotherapist, Gioia del Colle, 2Freelance Physiotherapist and Osteopath, Afragola, 3University of Padua, Padua, 4Department of Urology, General Hospital
"F. Miulli", Acquaviva delle Fonti, Italy
Background: Stress urinary incontinence (SUI) after radical prostatectomy (RP) continues to be a significant problem with several implications including patient
quality of life and other critical postoperative outcomes despite recent developments in surgical techniques such as robot assisted radical prostatectomy (RRP). SUI is
present in 3%>10% of patients undergoing RRP. Several factors influence its pathogenesis. Recent evidence shows that the role of posture and pelvic girdle may be
important in maintaining urinary continence.
Purpose: The aim of this study is to explore if there are common postural and biomechanical patterns in patients with and without SUI undergoing robot assisted
radical prostatectomy.
Methods: From January to October 2015, 62 patients were valuated post robot assisted radical prostatectomy (between 2013 and 2015). The sample was evaluated
with questionnaires ICIQ (International Consultation on Incontinence Questionnaire) short form and 24-hours pad test, in order to see if there were subjects with
stress urinary incontinence. Patients underwent postural and biomechanical assessment using the following tests: One Leg Standing Test, ASLR (active straight leg
raise) test, Distraction Test, Compression Test, Patrick's Faber Test, to evaluate the biomechanical patterns of the pelvic girdle; palpation test of long dorsal sacroiliac
ligament, clinical evaluation of the lumbosacral angle, activation of transversus abdonimis (TrA) and multifidus, for the form closure and force closure of the
pelvic girdle; the modified Oxford grading scale scheme for the pelvic floor muscles power (P) evaluation (0 = no contraction; 1 = flicker; 2 = weak; 3 = moderate; 4 =
Good; 5 = strong). Data were analysed using the t student functions and Pearsons Coefficient.
Results: Of the 62 subjects, 32 were incontinent (SUI) and 30 non-incontinent. The average age of the subjects was 64.6 5.3 years. The compared data on the
performance of the tests revealing a significant difference between subjects with and without SUI; particularly for the following tests: One Leg Standing Test (weightbearing limb) (p<0.0001); Patricks Faber test (p<0.0001); palpation test of long dorsal sacroiliac ligament (p<0.0001); clinical evaluation of the lumbosacral angle
(p<0.0001); activation of TrA and multifidus (p<0.0001 and p<0.001). There is also a significant correlation between P (power) < 3 and SUI (p <0.0001).
Conclusion: The study results show the association between SUI (after RRP) and some biomechanical and postural patterns: it seems to be that subjects with stress
urinary incontinence shows non-optimal strategies for transferring load through the sacroiliac joint probably linked to an asymmetry in force and form closure.
Furthermore, the data on the powers contraction of the pelvic floor muscles suggest that a week contraction can lead to SUI. However, we believe that the study
population is numerically too low to draw any meaningful conclusions. The evaluation of a larger number of cases may provide more evidence, and possibly
determine whether these postural and biomechanical changes, of the pelvic girdle, can be predictive or influence for stress urinary incontinence.
Implications: If biomechanical and postural patterns are predictive of urinary incontinence, we may be able to offer patients a rehabilitation program to follow to
avoid symptoms.
Funding Acknowledgements: This work was unfunded.
Ethics Approval: COMITATO ETICO INDIPENDENTE DELLOSPEDALE GENERALE REGIONALE FRANCESCO MIULLI DI ACQUAVIVA DELLE FONTI (BA)
Keywords: Pelvic Floor Muscles, Pelvic Girdle Assessment, Stress Urinary Incontinence

PO2-AP-002
INTEGRATING THE SYSTEMS: IS THERE A LINK BETWEEN BACK PAIN AND STRESS INCONTINENCE IN ADULTS WITH CYSTIC FIBROSIS?
J. Ashbrook*
Background: There is a growing body of evidence to suggest a link between back pain, respiratory disease and urinary incontinence in the general population.
Compromised respiratory function and suboptimal musculoskeletal support commonly found in Cystic Fibrosis (CF) is thought to enhance the prevalence and severity
of back pain and urinary incontinence in this population already laden with a huge burden of care.
It is important to inform the evidence base of any links found in CF in order to help guide further research into considerations for a management approach
incorporating multiple systems.
Purpose: This study was undertaken in order to evaluate Manchester Musculoskeletal Screening tool data collected over a one year period. This includes pain scores,
urinary incontinence scores and lung function measures and is recommended to be collected yearly to monitor prevalence and change in these conditions in people
with CF. It is theorised that deteriorating musculoskeletal health combined with lung disease in an ageing CF population is contributing to the increased prevalence of
back pain and urinary incontinence, however there is no data to support this.
The primary objective of the study was to establish whether there is a direct link between back pain and urinary incontinence and to discuss the reasons for this.
The secondary objective was to establish whether lung function is a contributing factor to the presence of back pain or stress urinary incontinence.
Methods: This study is a retrospective analysis of Manchester Musculoskeletal Screening Tool data collected at annual review by trained physiotherapists to measure
musculoskeletal complications of CF such as pain and urinary incontinence. The results of the pain scores (McGill Pain Questionnaire Short Form and Visual Analogue
Scale) were correlated with an urinary incontinence score (International Consultation on Incontinence Short Form) using a Spearmans rank correlation coefficient.
Results: Patients with back pain were significantly more likely to suffer with SUI. Pain and urinary incontinence were positively correlated (p<0.001).
There was no statistically significant correlation found between lung function (FEV1%predicted) and either of the variables, pain or stress UI.
Conclusion: This study confirms a link between back pain and SUI in adults with CF, both of which are clinical manifestations of trunk and pelvic floor muscle
dysfunction. Further research is needed to explore possible reasons for this link such as muscle co-ordination related to cough, movement and respiratory mechanics.
Examination of the effects of a co-ordinated multi-system muscle retraining programme on back pain and urinary incontinence would be beneficial to inform future
management of these associated conditions.
Implications: These results are an indication of the intricate relationships that exist between the respiratory, continence and musculoskeletal systems and must be
addressed by the multi-disciplinary team when planning the details of each individualized, specific and holistic package of care.
Musculoskeletal practitioners must consider the respiratory and continence systems in the assessment and management of individuals presenting with back pain in
the general population.
Funding Acknowledgements: This study was undertaken as an Msc project at Manchester Metropolitan University funded by the Manchester Adult Cystic Fibrosis
Centre.
Ethics Approval: Ethical approval was not required. Permission for analysis and publication of patient data was sought and granted from the data control department
at the University Hospital South Manchester.
Keywords: Back pain, respiratory system, urinary incontinence

PO2-AP-008
INNOVATIVE PHYSIOTHERAPY LED SERVICE IN GREATER MANCHESTER & CHESHIRE, "THE NETWORK METASTATIC SPINAL CORD COMPRESSION (MSCC) SERVICE"
L. Richards, S. Greenhalgh 1,*
1
Bolton NHS Foundation Trust, Bolton, United Kingdom
Background: The Manchester Cancer network Metastatic Spinal Cord Compression (MSCC) service is an innovative service launched in November 2013 and addresses
inequalities in care in Greater Manchester and Cheshire. It was developed and is led by a physiotherapist. Physiotherapists have a vital role in the diagnosis and
management of this oncology emergency. The service has significantly improved the care of cancer patients who develop this devastating condition across our region
(population of 3.2 million).
Purpose: MSCC is estimated to occur in 5-10% of cancer patients affecting quality of life and prognosis. Prompt diagnosis and treatment is essential to prevent
paralysis and failure to recognise the early signs can have devastating implications. NICE MSCC guidance (2008) recommended that each cancer network should have
a Coordinator in place.
Methods: The service, based at the Christie provides a single point of contact for primary, secondary and tertiary care. It offers advice and coordinated care following
a network pathway built on evidence-based guidelines. Patients are triaged and referred for surgical opinion, radiotherapy, systemic treatment or best supportive
care. Rehabilitation is embedded within the pathway from diagnosis to care in the community. Data is collected prospectively for service evaluation.
Results: Evaluation has demonstrated improvements in the management of patients with MSCC. In the first year, 616 patients were referred. 96% had an MR scan
within 24 hours, out of these, 275 patients had confirmed MSCC and 69 had impending. 22% of patients were treated with surgery and 63% with radiotherapy.
All patients had a clear treatment decision within 24 hours of diagnosis which meets the NICE Quality Standards.
Conclusion: Awareness amongst patients and clinicians has significantly increased, resulting in timely diagnosis, treatment and rehabilitation. Education which is
integral to the role has been implemented across Greater Manchester & Cheshire to health professionals from different disciplines and at all levels. This has resulted
in a pathway which is working well across the whole cancer network.
Implications: The MSCC pathway is now streamlined offering a consistent level of care, including rehabilitation, for all patients across Greater Manchester and
Cheshire. It has contributed to effective lines of communication between primary and secondary care and the specialist treating centres.
Appropriate patients received radiotherapy within 24 hours and the numbers of patients discussed with the surgical team with subsequent surgery has trebled
compared with the data prior to the launch of the service. The education programme has increased the skills of physiotherapists in recognising the vital red flags and
given them the confidence to deliver effective rehabilitation.
Funding Acknowledgements: The Christie NHS Foundation Trust
Ethics Approval: Not required.
Keywords: Cancer, Red flags, Spinal cord compression

PO2-CS-010
ALTERED MOVEMENT STRATEGIES DURING FUNCTIONAL TASKS IN INDIVIDUALS WITH CHRONIC IDIOPATHIC NECK PAIN
S. Snodgrass 1,*, R. Cooper 1, S. Edwards 2, D. Moghaddas 1, S. Blyton 1, R. de Zoete 1, D. Rivett 1
1
Discipline of Physiotherapy, 2School of Environmental & Life Sciences, The University of Newcastle, Callaghan, Australia
Background: Chronic idiopathic neck pain is costly and disabling, leading to difficulties performing functional tasks requiring neck rotation such as reaching for an
object or driving. Aberrant movement strategies during these functional activities may contribute to or perpetuate movement difficulties and/or pain, but few studies
have analysed neck kinematics during functional tasks.
Purpose: To determine differences in neck motion during functional activities between individuals with chronic idiopathic neck pain and age and gender-matched
healthy control participants, and whether functional movement performance is correlated with self-reported pain intensity and neck disability.
Methods: Ten participants with chronic idiopathic neck pain (> 3 months) and 10 healthy control participants performed five repetitions each of two tasks (overhead
reach to the right, and putting on a seatbelt). During each task, three-dimensional kinematics were measured using six Oqus 300 cameras (Qualisys, Sweden).
Movement phase for each task was defined when the hand segment (reach) or hand marker (seatbelt) velocity was zero, just before the initial hand movement
(start), and when the participant grasped the object (end). Kinematic variables calculated during each phase were: peak joint angle and range of motion for right
rotation and flexion-extension joint angles (, head segment relative to neck segment [head-neck joint]; and head/neck segment relative to upper thoracic segment
[head/neck-trunk joint]), peak and mean resultant head rotation velocity (mm/s), time from start to time of peak right rotation joint angle and resultant head rotation
velocity (%), and mean hand segment velocity (mm/s). Self-reported pain intensity was defined as the average pain over the previous four weeks, measured using a
100 mm visual analogue scale anchored by no pain on the left and worst pain imaginable on the right. Neck disability was quantified using the Neck Disability Index
(NDI) scored out of a total of 50. Between-group differences in movement variables were analysed using independent t-tests, and correlations between movement
variables and pain and disability were determined.
Results: Mean pain intensity was 45.2mm (SD 16.3, 95% CI 33.5 to 56.9, range 18-74), and NDI 14.2 (SD 3.6, range 8-19) for participants with neck pain. During
overhead reach to the right, peak resultant head rotation velocity was significantly less (mean difference 24.0 mm/s, 95% CI 2.1 to 46.0, p = .034), and the time of
peak right rotation head-neck joint angle was significantly earlier in participants with neck pain (20.3%, 4.2 to 36.5, p = .018). No other kinematic variables for the
reach or seatbelt task were significantly different between groups. For right overhead reach, higher neck disability was significantly correlated with lower peak (r =
.788, p = .007) and mean head rotation velocity (r = .651, p = .041). Other variables for reach and for the seatbelt task were not significantly correlated with pain or
disability.
Conclusion: Individuals with chronic idiopathic neck pain move their head at a slower velocity than healthy individuals during functional movement, and the slower
the velocity the greater neck disability. They also demonstrate different timing of head movement in relation to the task, suggesting altered coordination of
movement.
Implications: Observing slower movement velocity of the head and neck during clinical assessment may suggest chronicity in the presence of neck pain, and greater
neck-related disability. Slow velocity and altered timing of movement may explain, in part, why individuals with neck pain report difficulties with functional tasks
requiring head movement at speed, such as turning the head to check traffic while driving.
Funding Acknowledgements: This project was funded by the Ramaciotti Charitable Foundation.
Ethics Approval: Approved by the University of Newcastle Human Research Ethics Committee.
Keywords: head movements, kinematics, neck pain

PO2-CS-011
EVALUATION OF CLASSIFICATIONS OF NECK PAIN: A SCOPING REVIEW OF DIAGNOSTIC AND PROGNOSTIC CLASSIFICATION SYSTEMS.
J. Taddeo 1,*, L. Santaguida 2
1
Clinical Sciences, Northern Ontario School of Medicine, Thunder Bay, 2McMaster University, Hamilton, Canada
Background: The prevalence of neck pain (NP) is high with estimates up to 66.7% in the general population. It has the potential to limit functional abilities and reduce
quality of life. Approximately 4.6% of adults experiencing NP have significant disability. As prognosis is variable, and treatment of NP is paramount, it is important to
ensure clinical management is guided by best evidence. Despite some treatment recommendations, there may be little at present, and approximately 50-80% of
those with NP have an underlying pathology that cannot be addressed under a patho-anatomical model. An understanding of the current methods of classifying
disorders and then diagnosis formation, prognostic stratification, and how these factors incorporate into the clinical reasoning process around treatment are of
importance to clinical practice.
Purpose: A scoping review was aimed at identifying the breadth of classification systems used in understanding NP. Based on a previous review of spinal pain, we
anticipated that these systems would fall into three main categories: diagnostic, prognostic and treatment-based classifications. Understanding the empirical basis for
current classification systems for NP may guide clinical reasoning and research. A scoping review was chosen due to the diverse nature of the topic, in order to map
the literature.
Methods: A systematic search was performed in four bibliographic databases (MEDLINE; Embase, CINAHL and Psychinfo) for literature published from 1990 to April
2015. Studies were eligible if they included a described classification system for NP. Publications that focused on diagnostic criteria within an established classification
system were excluded. Two raters screened all citations and conflicts were resolved by a third. Once eligible, studies were grouped into three categories: diagnostic,
prognostic and treatment subgroups. Treatment subgroup publications were based on Kamper et al. (2010) schema. Characteristics of the publications were
extracted and then qualitatively synthesized.
Results: The search yielded 1834 citations. We are currently in the final stages of eligibility screening phases of the scoping review. The majority of publications
describe diagnostic classification systems with fewer describing prognostic and treatment-based systems. Some publications provide validation of these classification
systems. Our presentation will focus on comparing the different diagnostic and prognostic classification systems.
Conclusion: Our screening shows the largest proportion of classification systems are diagnostic in nature; some of these classification systems include aspects of
prognosis or treatment subgrouping. Our preliminary extraction shows a variety of systems with different underlying assumptions of the causes and factors relating
to NP disorders. Currently there is no standard method of forming or applying diagnostic or prognostic-based classification systems. Within these classification
systems, the criteria that qualifies as diagnosis related to the NP pain disorder, is not well established.
Implications: Classification systems guide clinical diagnostic test selection and treatment strategies for patients with NP. An understanding of the variety of
classification systems and the underlying assumptions about the etiology of NP will clarify diagnosis and treatment approaches. Although diagnostic and prognostic
classification systems are frequently used, the differences between these systems may account for variation in clinical decision-making. Knowledge of the breadth of
such systems will assist in further refinement of diagnosis and management of NP.
Funding Acknowledgements: The Canadian Institute of Health Research (CIHR) provided funding available to the study.
Ethics Approval: Ethics approval are not required for scoping reviews.
Keywords: Cervical spine, Classification system, Neck pain

PO2-CS-012
IMMEDIATE EFFECTS OF MANUAL THERAPY TARGETING THE CERVICAL OR OROFACIAL REGION IN NECK SYMPTOMS IN PATIENTS WITH MYOFASCIAL
TEMPOROMANDIBULAR PAIN
J. Salom-Moreno 1,*, J. de-Diego-Garca 1, M. Palacios-Cea 1, R. Ortega-Santiago 1, A. I. de-la-Llave-Rincn 1, S. Ambite-Quesada 1, J. L. Arias-Bura 2, C. Fernandez-DeLas-Peas 1
1
Fisioterapia, Terapia Ocupacional, Rehabilitacin y Medicina Fsica, UNIVERSIDAD REY JUAN CARLOS, ALCORCON, 2Fisioterapia, Universidad Francisco de Vitoria,
Madrid, Spain
Background: The impact of the cervical spine in individuals with temporomandibular (TMD) pain can be explained by the trigemino-cervical nucleus caudalis.
Numerous patients with TMD also suffer from neck symptoms. Several manual therapies targeting posterior (neck muscles) and anterior (hyoid musculature) are
clinically used in the management of these patients. No previous study has compared the effects on neck pain symptoms of manual therapies targeting the posterior
or anterior tissues of the cervical spine in patients with TMD pain.
Purpose: To compare the effects of manual therapy targeting the posterior neck structures versus manual therapy targeting the anterior neck tissues on neck
symptoms in subjects with TMD pain
Methods: A pilot randomized clinical trial was completed. Twelve patients (7 men, 5 women, mean age: 222 years) with myofascial TMD pain were randomly
assigned to either the cervical (posterior structures) or hyoid (anterior structures) groups. Both groups received 3 sessions, over a 3-week time frame. The cervical
group received the following manual therapies targeting the upper cervical spine: unilateral P/A joint mobilization on C1-C2 grade II-III for 1 min each side and manual
compression of the suboccipital musculature. The hyoid group received the following techniques targeting the masticatory musculature: manual stretching of the
supra-hyoid muscles, longitudinal stokes of the hyoid musculature and compression of the masseter muscles. Outcomes including self-reported neck pain (numerical
pain rate scale, 0-10), neck pain-related disability (Neck Disability Index-NDI, 0-50), and pressure pain thresholds (PPT) over the C5/C6 joint, masseter muscle and
second metacarpal were assessed at baseline and one week after the last session by an assessor blinded to the treatment allocation of subjects. Separated repeated
measures analyses of variance (ANOVA) were conducted for each outcome.
Results: No significant Group * Time interaction was observed for intensity of neck pain intensity (F=1.354, P=0.272), neck-related disability (F=0.282, P=0.607), PPT
over the masseter (F=1.090, F=0.321), second metacarpal (F=0.233, P=0.639), and C5/C6 joint (F=0.688, P=0.426): both groups experienced similar improvements in
pain, disability and pressure pain sensitivity.
Conclusion: The current study found that application of manual therapies targeting the posterior or anterior structures of the neck was similarly effective for reducing
pain, disability and pressure pain hypersensitivity in patients with myofascial TMD.
Implications: Current results suggest that clinicians can apply manual therapies targeting the cervical spine for the management of patients with myofascial TMD pain
and that perhaps addressing both posterior and anterior structures might result in even greater benefit.
Funding Acknowledgements: No funds were received for this study.
Ethics Approval: The current study was approved by Local Ethical Committee (URJC 2014-21)
Keywords: cervical spine, Manual Therapy, temporomandibular pain

PO2-CS-013
ALTERATIONS IN THE MOTOR NETWORK OF PATIENTS WITH CHRONIC NECK PAIN: AN EXPLORATORY GRAPH THEORETICAL ANALYSIS APPROACH.
R. De Pauw 1,*, I. Coppieters 1, H. Aerts 2, K. Caeyenberghs 1 3, B. Cagnie 1
1
Rehabilitation Sciences and Physiotherapy, 2Data analysis, Ghent University, Ghent, Belgium, 3School of Psychology, Australian Catholic University, Melbourne,
Australia
Background: Patients with chronic neck pain, especially patients with whiplash-associated disorder (WAD) often suffer from a wide range of symptoms, even years
after their injury. However, the underlying mechanisms behind persistent symptoms remain largely unknown. Central factors might be one of many influencing
factors associated with these symptoms. Moreover, in recent years, the graph theoretical approach has emerged as a useful tool for characterizing brain network
(connectome) changes. This type of analysis moves away from the traditional neuroimaging approach of examining isolated brain regions, towards characterizing
regional or global structure of networks revealing information about how the information is conveyed across the different brain regions of a network.
Purpose: This study aims to investigate differences in network topology between healthy controls (HC), patients with idiopathic neck pain (INP), and patients with
WAD.
Methods: Twenty-nine healthy controls (HC), 37 patients with chronic idiopathic neck pain (INP), and 34 patients with chronic whiplash associated disorders (WAD)
were included in this study (female, mean age: 36.29). Resting-state fMRI data was acquired using a Siemens Tim Trio scanner (TR: 2.00s, TE: 0.003s, voxelsize: 3x3x3
mm, TA: 10:12 min) and pre-processed using FSL, resulting in functional connectivity matrices (including different motor areas from the AAL-atlas). Small-worldness
was calculated for each subjects network (using the Brain Connectivity Toolbox), by dividing the normalized clustering coefficient (a measure of network segregation)
by the normalized characteristic path length (a measure of network integration). An ANCOVA analysis was conducted to investigate differences in small-worldness
between the groups, controlling for age. Post-hoc Tuckey HSD corrections for multiple comparisons between groups were carried out at the 5% significance level.
Results: Small-worldness was present in all groups, although a trend towards decreased small-worldness was observed in patients with chronic neck pain (mean
difference of 0.02) compared to healthy controls. Both a decrease in clustering as an increase in average pathlength seem to contribute to this observation.
Conclusion: No statistical difference in small-worldness was found. Further analysis using this innovative technique should however be considered in future studies
aiming to look for the underlying factors that are associated with the persistence and maintanance of symptoms seen in patients with chronic neck pain. Further
analysis with larger sample sizes or a different approach using other graph measures might give clarity on whether or not alterations of functional connectivity are
present in patients with chronic neck pain.
Implications: Although this study did not find any significant differences between the three groups, graph measures for brain topology could be used in other studies
to measure topological brain changes on a macroscopic scale. Furthermore, the influence of pain and therapy on brain topology remains largely unknown. This study
can therefore be seen as a first exploratory study aiming at trying to understand the underlying factors of symtoms seen in patients with chronic pain.
Funding Acknowledgements: No funding was received for this study.
Ethics Approval: Ethical approval was provided by the ethical committee of the Ghent University Hospital.
Keywords: brain networks, chronic neck pain, graph analysis

PO2-CS-014
EXTENSION AND FLEXION IN THE UPPER CERVICAL SPINE IN NECK PAIN PATIENTS
M. Ernst 1,*, R. Crawford 1 2, A.-K. Rausch-Osthoff 1, M. Barbero 3, J. Kool 4, C. Bauer 1
1
School of Health Professions, Zurich University of applied Sciences, Winterthur, Switzerland, 2Faculty of Health Sciences, Curtin University, Perth, Australia,
3
Department of Business Economics, Health and Social Care, University of Applied Sciences and Arts of Southern Switzerland (SUPSI, Manno, 4Clinic of Valens, Valens,
Switzerland
Background: Neck pain is a common problem in the general population with high risk of ongoing complaints or relapses. Range of motion (ROM) assessment is
scientifically established in the clinical process of diagnosis, prognosis and outcome evaluation in neck pain. Anatomically, the cervical spine (CS) has been considered
in two regions, the upper and lower CS. Disorders like cervicogenic headache have been clinically associated with dysfunctions of the upper CS (UCS), yet ROM tests
and measurements are typically conducted on the whole CS.
Purpose: The aim of the present study therefore was to assess the ROM in the UCS and the whole CS in neck pain patients, and to investigate the correlation between
ROM and the patients' pain and disability
Methods: A cross-sectional study assessing 19 subjects with non-specific neck pain was undertaken to examine UCS extension-flexion ROM in relation to selfreported disability and pain (via the Neck Disability Index (NDI)). Two measurement devices (CROM goniometer and electromagnetic tracking) were employed and
compared.
Results: Correlations between ROM and the NDI were stronger for the UCS compared to the CS, with the strongest correlation between UCS flexion and the NDIheadache (r =- 0.62). Correlations between UCS and CS ROM were fair to moderate, with the strongest correlation between UCS flexion and CS extension ROM (r = 0.49). UCS flexion restriction is related to headache frequency and intensity. Consistency and agreement between both measurement systems and for all tests was
high.
Conclusion: Upper cervical flexion shows moderate, and extension fair, correlation with headache frequency and intensity. Higher levels of headache are associated
with less UCS flexion. Relationships between cervical spine extension-flexion, and neck pain or disability, are weaker than those for the upper cervical spine. The need
for a separate extension and flexion ROM assessment for the upper cervical spine has been supported. Using a common procedure, the CROM and the
electromagnetic tracking device achieve similar results in measuring upper cervical extension-flexion in patients with neck pain.
Implications: Upper cervical F/E ROM are distinct from whole CS F/E ROM measurements.
There is an associations between UCS F/E and headache in terms of:
The more headache the less upper cervical flexion ROM
The measurement set-up cannot isolate UCS Extension motion
Funding Acknowledgements: The study was funded by an internal grant of the Zurich University of Applied Sciences (ZHAW), Health departement.
Ethics Approval: The study was approved by the regional etics committee of the Kanton Zurich, Switzerland.
Keywords: extension and flexion, Headache, Upper cervical spine

PO2-CS-016
DIFFERENCES BETWEEN TRAUMATIC AND NON-TRAUMATIC CHRONIC NECK PAIN PATIENTS: THE ROLE OF CENTRAL PAIN MODULATION, COGNITIVE
FUNCTIONING AND PSYCHOSOCIAL CHARACTERISTICS
I. Coppieters 1,*, B. Cagnie 1, R. De Pauw 1, L. Danneels 1, K. Ickmans 2, M. Meeus 1 3
1
Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, Ghent University, Ghent, 2Human Physiology and Rehabilitation Sciences,
Faculty of Physical Education and Physiotherapy, Free University of Brussels, Brussels, 3Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health
Sciences, University of Antwerp, Antwerp, Belgium
Background: Scientific research has demonstrated impaired central pain modulation, cognitive and psychosocial deficits in patients with chronic whiplash associated
disorders (CWAD). However, the underlying mechanisms remain unclear. To date, research regarding central pain modulation, cognitive performance and
psychosocial characteristics in patients with chronic non-traumatic neck pain is lacking.
Purpose: To examine central pain modulation (i.e. central sensitization), cognitive and psychosocial functioning in patients with CWAD and chronic idiopathic neck
pain (CINP) compared to healthy individuals.
Methods: Ninety-five women, 28 healthy pain-free controls, 35 CINP and 32 CWAD patients were enrolled. First, all participants filled out psychosocial
questionnaires, namely the Short Form Health Survey (SF-36), the Neck Disability Index (NDI) and the Central Sensitization Inventory (CSI). Next, they were subjected
to cognitive performance assessments and experimental pain measurements. Participants completed the modified Perceived Deficits Questionnaire (mPDQ) in order
to evaluate self-perceived cognitive deficits. Subsequently, they performed the Trail Making Test (TMT), an objective cognitive test. Afterwards, pressure pain
thresholds (PPTs), and conditioned pain modulation (CPM) were examined. The Kruskal-Wallis test was applied to explore differences between all study groups. Posthoc comparisons with a significance threshold of p<0.017 were performed using the Mann-Whitney U test.
Results: All study groups were comparable for age. Neck pain intensity and duration were comparable between both patient groups. Diminished health-related
quality of life was observed in both neck pain groups compared to healthy individuals. Limitations on health-related quality of life as well as pain-related limitations
on activities of daily living were higher in CWAD compared to CINP (SF-36, NDI). Furthermore, CWAD patients experienced more central sensitization symptoms
compared to CINP, based on the CSI.
CWAD patients displayed diminished psychomotor speed (TMT A) and decreased task-switching performance (TMT B) compared to CINP and controls. Further, both
patient groups reported more self-perceived cognitive deficits (mPDQ) compared to healthy women. Noteworthy, within both patient groups, CWAD patients
reported more severe cognitive deficits compared to CINP.
Decreased PPTs were demonstrated at the m. Trapezius, m. Quadriceps, lumbar region and hand in CWAD and at the m. Trapezius in CINP, compared to healthy
women. PPTs increased during the cold pressor test in the CINP and control group, indicating properly working CPM. However, in the CWAD group, PPTs at the m.
Quadriceps remained the same during this CPM paradigm. Thereby, CPM efficacy was decreased in patients with CWAD compared to both other groups.
Conclusion: Primary hyperalgesia was demonstrated in traumatic and non-traumatic neck pain patients. However, secondary hyperalgesia and decreased CPM
efficacy was shown in CWAD but not in CINP, which is indicative for the presence of central sensitization in CWAD patients. Additionally, these results provide
evidence for cognitive and psychosocial deficits in CWAD and to a lesser extent in CINP patients. Future research is warranted to unravel whether brain alterations
are present in these patients and whether these alterations are related to clinical correlates of pain.
Implications: These results provide preliminary evidence for the clinical importance to distinguish the rehabilitation approach between chronic traumatic and nontraumatic neck pain patients. It can be recommended that the evaluation of central sensitization, cognitive and psychosocial functioning should be taken into
account. Accordingly, individually tailored therapy, which targets the observed disabilities, should 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.
Keywords: central sensitization, chronic neck pain, cognitive impairment

PO2-CS-017
PREDICTION OF OUTCOME IN WOMEN WITH CARPAL TUNNEL SYNDROME WHO RECEIVE MANUAL THERAPY
C. Fernandez-De-Las-Peas 1,*, J. Cleland 2, J. Salom-Moreno 1, M. Palacios-Cea 1, A. I. de-la-Llave-Rincn 1, R. Ortega-Santiago 1
1
Fisioterapia, Terapia Ocupacional, Rehabilitacin y Medicina Fsica, UNIVERSIDAD REY JUAN CARLOS, ALCORCON, Spain, 2Physical Therapy, Franklin Pierce University,
Manchester, United States
Background: A clinical prediction rule (CPR) to identify women with carpal tunnel syndrome (CTS) who were likely to respond favorably to a manual therapy approach
was recently developed. This CPR identified 3 predictive variables associated with a positive outcome: pressure pain threshold (PPT) over the affected C5-C6 joint
<137kPa; heat pain threshold (HPT) over the affected carpal tunnel <39.6C, and general health >66 points.
Purpose: To assess the validity of the original CPR by determining whether status on the rule predicted improved treatment response to physical therapy compared
to surgery in CTS.
Methods: A secondary analysis of a randomized controlled trial investigating the efficacy of manual physical therapies including desensitization manoeuvres of the
central nervous system in 120 women with CTS was performed. Patients were randomized to receive 3 sessions of manual therapy (n=60) or surgical
release/decompression of the carpal tunnel (n=60). Pain intensity (mean pain and the worst pain, NPRS 0-10), and Boston Carpal Tunnel Questionnaire (functional
status and symptoms severity scales), were assessed at baseline, and 1, 3, 6, and 12 months. Self-perceived improvement with a Global Rating of Change (GROC) was
also assessed at 6 and 12 months follow-up. Status on the clinical prediction rule (responders were those who met at least 2 of the criteria) was measured at baseline.
The primary aim (treatment group*time*status on the rule) was examined using linear mixed models with repeated measures.
Results: Women with a positive status on the rule who received manual therapy did not experience different outcomes than those with a negative status on the rule:
mean pain (P=0.65), worst pain (P=0.86), function (P=0.99) or symptoms severity (P=0.85). There was not a 3-way interaction for either outcome. No differences in
self-perceived improvement was observed at either 6 (P=0.67) or 12 (P=0.368) months according to the rule.
Conclusion: Regardless of a patients status on the CPR, patients receiving manual therapy or surgery achieve similar improvements in pain and function at 3, 6, and
12 months and also similar self-perceived recovery at 6 and 12 months.
Implications: Manual therapy resulted in similar outcomes as in surgery at long-term for the management of women with CTS. No predictors have been found to
identify women with CTS who will achieve better outcomes with manual therapy
Funding Acknowledgements: The study was funded by 2 research project grants from the Health Institute Carlos III (Spanish Government): PN I+D+I 2012-2014 (FIS
PI11/01223) and PN I+D+I 2015-2017 (FIS PI 14/00364).
Ethics Approval: The current study was approved by Local Ethical Committee (PI01223-HUFA12/14)
Keywords: Carpal tunnel syndrome, clinical prediction rule, manual therapy

PO2-CS-018
SHORT- AND LONG-TERM EFFECTS OF EXERCISE ON NECK MUSCLE FUNCTION IN CERVICAL RADICULOPATHY: A RANDOMIZED CLINICAL TRIAL
M. Halvorsen 1,*, D. Falla 2, L. Gizzi 2, K. Harms-Ringdahl 1, A. Peolsson 3, . Dedering 1
1
Department of Physiotherapy, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden, 2Department of Neurorehabilitation Engineering,
Bernstein Focus Neurotechnology Gttingen, Gttigen, Germany, 3Department of Medical and Health Sciences, Physiotherapy, Faculty of Health Sciences, Linkping
University, Linkping, Sweden
Background: Evidence for the benefit of active exercises in the treatment of patients with cervical radiculopathy (CR) is sparse and no studies have investigated the
physiological effects of exercise in patients with CR. In this study we evaluated the effects of specific versus general exercise on neck muscle function including
endurance, myoelectric manifestations of fatigue, co-activation and ratings of fatigue and pain, 14 weeks and 12 months following a program of neck-specific training
or physical activity in patients with CR
Purpose: The purpose of the study was to compare short and long term changes in neck muscle endurance, neck muscle activation and fatigue recorded with
electromyography, and ratings of fatigue and pain after neck-specific training or physical activity in people with CR.
Methods: Design: Randomized clinical trial. ClinicalTrials.gov identifier: NCT01831271.
A total of 75 patients with CR verified by magnetic resonance imaging and clinical examination participated. Patients underwent neck-specific training in combination
with a cognitive behavioural approach or prescribed physical activity over 14 weeks. Immediately after the intervention and 12 months later, surface
electromyography was recorded from neck flexor and extensor muscles during neck endurance tests. Time to task failure, amplitude and median frequency of the
electromyography (EMG) signal, and subjective fatigue and pain ratings were analyzed in 50 patients who completed at least one follow-up.
Results: A significant increase in neck flexor endurance time was observed for both groups at 14 weeks compared to baseline and this was maintained at the 12month follow-up (p<0.005). No change was identified for the slope of the EMG median frequency. For the neck-specific training group, splenius capitis was less active
during neck flexion at both follow-ups (p<0.01), indicating reduced muscle co-activation.
Conclusion: Both specific and general exercise increased neck flexor endurance however, only neck specific training reduced co-activation of antagonist muscles
during sustained neck flexion.
Implications: It might be of benefit for patients with CR to receive neck-training to reduce co-activation. Although increased co-activation may be beneficial in acute
pain to enhance cervical stability, it may have negative long-term consequences.
Funding Acknowledgements: The study was supported by grants from the Karolinska Institutet, Stockholm, Sweden and Stockholm County Council ALF, Sweden.
Ethics Approval: The study was approved by the Regional Ethics Committee of Stockholm, Sweden.
Keywords: Cervical radiculopathy, Electromyography, Exercise

PO2-CS-019
LOW SELF-EFFICACY IN ACUTE WHIPLASH ASSOCIATED DISORDER (WAD) PATIENTS PRESENTING TO AN EMERGENCY DEPARTMENT (ED) IN AN URBAN CENTRE IN
IRELAND.
L. Keating 1,*, B. Kennelly 1, C. Browne 2
1
School of Physiotherapy, RCSI, 2Physiotherapy Dept, Connolly Hospital Blanchardstown, Dublin, Ireland
Background: A systematic review of education for WAD suggested that strong evidence exists that advice and education (oral and written), in combination with
exercise and behavioural programmes, are effective in reducing pain and disability in acute WAD (usually 72 hours) (Meeus et al 2012). What is less clear from
available research is the impact WAD has on self-efficacy and the impact of education on self-efficacy in WAD. Sderland et al (2000) showed that both low selfefficacy and high disability levels in acute WAD were significant predictors of pain at 6 month follow-up, in patients with Grade I III WAD. Sub-acute WAD patients
(average duration = 66 days) have been shown to have lower self-efficacy (mean SES= 134, SD 30) than an age and gender-matched control group (mean SES = 170 SD
41) taken from the general population (Bunketorp-Kll et al, 2007). Acute WAD patients (average duration = 20 days) have also been shown to have lower selfefficacy SES= 140-152 (SD 26-32) however the natural history of self-efficacy during the recovery phase of WAD is unclear.
Purpose: The primary aim was to assess the effect of written education on the self-efficacy of acute Grade I-III WAD (less than 7 days) patients presenting to an ED.
The secondary objective was to assess the effect of written education on self-reported pain and disability.
Methods: Consecutive patients presenting to ED with acute (less than 10 days) Grade I-III WAD were invited to participate in this 2 group RCT by ED doctors acting as
gatekeepers. Upon consenting by the ED senior physiotherapist, participants were then randomly allocated to one of two groups by an independent academic
colleague, using computerised random number generation. The intervention group (IG) received the Whiplash Book (Waddell et al 2001) and the control group did
not. The Self Efficacy Scale (SES) (Bunketorp-Kall 2007)., Numerical Pain Rating Scale (NPRS) and Neck Disability Index (NDI) (Vernon & Mior 1991) were administered
at baseline and 1 week after receiving the booklet by a blinded assessor. All participants were referred for physiotherapy, as per usual ED care. Pilot work was
undertaken to establish mean SES values to estimate sample size. Postulating a mean difference of 30/200 in SES between groups as a minimum clinically important
difference, to achieve a significance level of 0.05, at 80% power, a sample size of n=24 per group was required. Allowing for a 10% dropout rate, n=53 subjects was
the target sample size for this study.
Results: This small trial only recruited n=18 participants and so was not powered to identify between group differences. However, when combined with pilot study
data (n=13), baseline data on 31 participants can be presented. The mean (SD) age of the 31 participants was 39 years (13.4) and 16 were male. The majority of
participants presented with Grade II WAD (n=17). Only 5 participants were diagnosed with Grade III WAD. Mean NPRS score over 24hrs was 5.9 (+/- 1.8). Mean NDI
score was 23 (7.6). Mean SES score was 94 (47.4). The majority of participants (n= 28) were taking a range of prescribed medication for their pain, including
paracetamol, tylex, tramadol, solpadeine & NSAIDs. Groups were comparable at baseline.
Conclusion: Moderate levels of pain and disability were observed at baseline in this study. However, baseline SES scores in Ireland were noticeably low, particularly in
comparison to other published data from Scandinavia, suggesting that acute patients have lower self efficacy in an Irish setting. A larger cohort is needed to confirm
this finding.
Implications: Low self-efficacy should be considered a target of any educational intervention for acute WAD patients, in addition to pain & disability.
Funding Acknowledgements: RCSI Summer Student Research Alumni Award.
Ethics Approval: Received from Connolly Hospital Research Ethics Committee, Dublin.
Keywords: education, Self-efficacy, Whiplash Associated Disorders

PO2-CS-020
IS THERE AN OPTIMAL MANUAL MUSCLE TEST FOR SUBSCAPULARIS?
D. Reed 1,*, M. Halaki 2, C. Jones 1, A. Downes 1, K. Ginn 1
1
Sydney Medical School, 2Faculty of Health Sciences , The University of Sydney, Sydney, Australia
Background: Subscapularis is the largest and only anterior muscle of the rotator cuff. It is crucial to normal shoulder function producing internal rotation and dynamic
stability at the glenohumeral joint. Manual muscle tests (MMTs) to assess the integrity of subscapularis have traditionally involved its action of internal rotation. An
optimal MMT for subscapularis would ideally activate the subscapularis to a high level and significantly higher than the other internal rotators of the shoulder.
Alternative exercises that recruit subscapularis in its stabilising role (eg. extension) may also fulfil the criteria for an optimal MMT. However, no study has compared
common subscapularis MMTs and included a shoulder extension test. Therefore, it is still unclear if one test more effectively fulfils both criteria for an optimal
subscapularis MMT.
Purpose: To compare the activation levels of the internal rotators of the shoulder during six MMTs to determine if there is an optimal MMT for subscapularis.
Methods: Twenty asymptomatic volunteers performed maximum isometric contractions during the lift off test, belly press, shoulder extension and shoulder internal
rotation at 90 and 0 abduction in standing and 90 abduction in supine. A combination of indwelling and surface electrodes recorded activation levels from
subscapularis, latissimus dorsi, teres major, pectoralis major and anterior deltoid. Activation levels were normalised to maximum voluntary contractions (MVC) and
averaged.
Results: Average muscle activation of subscapularis ranged from 35% MVC during standing internal rotation at 90 abduction to 51% MVC during the lift off test, with
no significant difference between all six tests (p=0.50). The belly press test was the only test in which subscapularis activation levels was significantly higher than all
other internal rotators of the shoulder (p<0.01). All other tests had one or more shoulder muscles activated at similar or higher levels than subscapularis.
Conclusion: All six tests activated subscapularis to similar moderately high levels and therefore fulfil the first criteria for an optimal subscapularis MMT. However,
only the belly press also activated subscapularis significantly higher than all other internal rotators of the shoulder, fulfilling both criteria for an optimal MMT.
Implications: The belly press is recommended as an optimal MMT to assess the integrity of subscapularis.
Ethics Approval: Ethics was approved by the Human Research Ethics Committee at the University of Sydney, 2012/538.
Keywords: electromyography, manual muscle test, subscapularis

PO2-CS-021
THE RELATION BETWEEN PAIN EXTENT AND QUALITY-OF-LIFE, PSYCHOLOGICAL FACTORS AND NECK FUNCTION IN PATIENTS WITH CHRONIC NECK PAIN.
I. Ris*, M. Barbero 1, D. Falla 2, M. Holst Larsen 3, M. Nielsen Kraft 3, K. Sgaard 3, B. Juul-Kristensen 3
1
Department of Sports Science and Clinical Biomechanics, University of Applied Sciences and Arts of Southern Switzerland, Manno, Switzerland, 2Pain Clinic, Center
for Anesthesiology, Emergency and Intensive Care Medicine, University Hospital Gttingen, Gttingen, Germany, 3Department of Sports Science and Clinical
Biomechanics, University of Southern Denmark, Odense, Denmark
Background: Neck pain is a common disease ranking 4th highest as years lived with disability according to Global Burden of Disease 2010. Patients with chronic neck
pain often present with a variety of other symptoms. Some of these may depend upon the origin being traumatic or not.
Pain drawings are used widely clinically in the initial phase of assessment of neck pain patients. Pain drawing is a method of gathering data, the pain area, regarding
patients pain extent. The drawing represents the patients perception of pain localisation and pain extent. Pain areas may represent psychological factors and/or
decreased function of the involved body parts.
Purpose: To study the relation between pain extent with 1) quality of life, 2) kinesiophobia, depression, 3) cervical muscle function and mobility and additionally the
relation of pain extent with the origin of pain being traumatic or non-traumatic in chronic neck pain patients.
Methods: In this correlation-study patients from primary and secondary healthcare locations with chronic neck pain (200) with traumatic or non-traumatic origin
participated. Participants completed pain drawings, as well as questionnaires: Short Form 36 (SF36), Tampa Scale of Kinesiophobia (TSK), Beck Depression InventoryII (BDI-ll), Neck Disability Index (NDI) and clinical tests: Craniocervical Flexion Test (CCFT), Cervical Extension Test (CE), and Cervical Range of Motion (CROM).
Results: Significant positive correlations were observed between pain extent and NDI (r = 0.33; p<0.001), TSK (r=0.21; p=0.012) and BDI-II (r=0.29; p<0.001), in
addition to significant negative correlations of pain extent to CCFT (r=-0.24; p=0.001) and CE (r=-0.19; p=0.006). Correlations between pain extent and SF-36 or CROM
were non-significant, and there was no difference in pain extent related to the origin being traumatic or non-traumatic.
Conclusion: Pain extent extracted from pain drawings are moderately correlated with patient-reported neck function, and weakly correlated with depression,
kinesiophobia and cervical clinical tests. In clinical decision-making, pain extent may indicate reduced neck function and be a sign for possible depression,
kinesiophobia and poor cervical muscle function in chronic neck pain patients of both traumatic and non-traumatic origin.
Implications: For the clinician, information gained from pain drawings can indicate the need for assessing these factors with a more in-depth examination. Pain
drawings may therefore assist in guiding and targeting the clinical assessment. Therefore, use of pain drawings in clinical assessment may be relevant as part of the
clinical decision-making process and be used for generating clinical hypotheses as part of the functional assessment, and in conjunction with other relevant
outcomes.
Funding Acknowledgements: This study received funding from the Research Fund of the Region of Southern Denmark, the Danish Rheumatism Association, the
Research Foundation of the Danish Association of Physiotherapy, Fund for Physiotherapy in Private Practice, and the Danish Society of Polio and Accident Victims
(PTU).
Ethics Approval: The trial was registered in www.ClinicalTrials.gov identifier NCT01431261. The Regional Scientific Ethics Committee of Southern Denmark approved
the study (S-20100069).
Keywords: Chronic neck pain, pain drawing, quality of life

PO2-CS-022
USE OF NEUROSCIENCE EDUCATION, TACTILE DISCRIMINATION, LIMB LATERALITY AND GRADED MOTOR IMAGERY IN A PATIENT WITH FROZEN SHOULDER
P. Mintken 1,*, A. McDevitt 2, E. Puentedura 3, A. Louw 4
1
Physical Therapy, University of Colorado Anschutz Medical Campus, Aurora, 2Physical Therapy, University of Colorado Anschutz Medical Campus, Aurora, Colorado,
3
Physical Therapy, University of Nevada Las Vegas, Las Vegas, NV, 4International Spine and Pain Institute, Story City, Iowa, United States
Background: It has been reported that aggressive physical therapy in the freezing/painful stage of frozen shoulder may prolong the course of recovery. Central
sensitization may play a role in the early stages of frozen shoulder. Neuroscience education (NE), limb laterality (LL), tactile discrimination (TD) and graded motor
imagery (GMI) have been used with success in a number of conditions with known central sensitization.
Purpose: The purpose of this case report is to describe the examination and treatment of a patient in the painful stage of frozen shoulder using NE, LL, TD and GMI
training.
Methods: The patient was a 54 yo female with insidious onset of right shoulder pain at the deltoid insertion 2 months prior. She was diagnosed with a frozen
shoulder by an orthopedic surgeon and sent for aggressive daily physical therapy which resulted in a worsening of her pain and disability, She was then referred to
the primary author for a second opinion. At the time of the initial appointment, she had 7/10 pain at rest on a Numerical Pain Rating Scale (NPRS) and a Shoulder Pain
and Disability (SPADI) score of 62%. She had 61 degrees of active flexion, 32 degrees of active abduction and 3 degrees of active external rotation. Her Fear Avoidance
Beliefs Questionnaire (FABQ) scores were 34 and 22 on the Work and Physical Activity subscales, respectively. Two-point discrimination at the right shoulder was
58mm and her hand and shoulder laterality accuracy was 50 and 60% respectively. She also had hypersensitivity to cold, heat and pressure, suggesting central
sensitization. Due to her fear of movement and being touched, we instituted a graded, top-down program focusing on central sensitization. Treatment began with
pain science education and progressed to laterality training, tactile discrimination, and graded motor imagery including mirror therapy. During the initial 6 weeks, no
therapy was delivered to the shoulder. After 6 weeks a regional interdependence approach using manual therapy and exercise was initiated. The patient was seen for
20 visits over 12 weeks.
Results: After 6 weeks of a top-down approach, her resting pain decreased to a 2/10, the SPADI decreased to 32%, and her active flexion, abduction and external
rotation had improved to 129, 79 and 42 degrees respectively. Her hand and shoulder laterality accuracy was normal at 80% and her 2-point discrimination improved
by 10mm. At the end of 12 weeks following the addition of manual therapy and exercise, her SPADI had decreased to 22%, her NPRS at rest was a 0/10, her FABW
was 14 and her FABQPA was 8. Her active flexion, abduction and external rotation had improved to 162, 111 and 65 degrees, respectively.
Conclusion: Aggressive physical therapy in the early stages of frozen shoulder can be detrimental. In this case, a top-down approach including NE, LL, TD and GMI
training led to clinically meaningful improvements in pain, motion, function, limb laterality and tactile discrimination in the first 6 weeks of treatment.
Implications: This case study suggests that clinicians should consider using a top-down approach in patients with painful frozen shoulder. Traditional approaches
using aggressive physical therapy in the early stages of this condition may be detrimental to long term outcomes. This approach allows clinicians to educate patients
about pain and calm the central nervous system which may lead to a quicker transition from the freezing stage to the thawing phase of frozen shoulder.
Ethics Approval: Ethics approval was not required as this was a case report.
Keywords: adhesive capsulitis, central sensitization, chronic pain

PO2-CS-023
QUANTIFYING SENSORY THRESHOLD USING SEMMES-WEINSTEIN ESTHESIOMETER: AN INTER-EXAMINER RELIABILITY STUDY OF MANUAL THERAPISTS
E. Almpanidis*, N. Heneghan 1
1
School of Sport, Exercise & Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
Background: Reported physiotherapy assessment of cutaneous sensory testing uses light touch and results in a binary response of, yes, or no. However, that
response does not provide adequate clinical information to examine subtle change in sensory acuity over time and may lead to misinterpretation during the
formulation of a clinical hypothesis. The Semmes-Weinstein Esthesiometer (SWE) provides a performance based outcome measure (PBOM) that can quantify
cutaneous sensory threshold. Using a series of numbered monofilaments of different lengths, the SWE allows the application of a consistent rather than a one off
stimulus which is susceptible to measurement error through application of different pressure.
Purpose: To investigate the inter-examiner reliability of Semmes-Weinstein Esthesiometer (SWE) for quantifying cutaneous sensory threshold in manual therapists.
Methods: A prospective, double-blinded, within day, inter-examiner reliability study was designed. From a power calculation, a convenience sample of asymptomatic
subjects was recruited along with two examiners (experienced manual therapists). Exclusion criteria: evidence of neurological deficit (sensory loss, motor weakness,
abnormal reflexes) or presence of upper limb pain. Cutaneous sensory thresholds were recorded from skin over the thenar eminence.
Results: A sample of convenience comprised of 26 subjects (11 males), mean age (SD) 26.5 years (3.5). Descriptive statistics (mean scores), data normality testing,
reliability statistics {intraclass correlation coefficient (ICC: 2,1) and Bland-Altman limits of agreement} were undertaken. Probability was set at <0.05. Results showed
significant inter-examiner agreement of 0.7 (95% CI: 0.274 0.854, p=0.003).
Conclusion: This is the first study to evaluate inter-examiner reliability of manual therapists using the SWE. Preliminary evidence supports the use of SWE to assess
cutaneous sensory threshold.
Implications: The SWE can provide a clinically useful tool in the use of manual therapists. The findings support the use of SWE in routine manual therapy practice over
the common binary measure of light touch and promptly, it can be used in patients with spinal and/or peripheral neuropathic presentations.
Funding Acknowledgements: This study was not funded.
Ethics Approval: Ethics Committee of the University of Birmingham, United Kingdom
Keywords: Cutaneous Sensory Threshold, Quantitative Sensory Testing, Semmes-Weinstein Esthesiometer

PO2-CS-025
MEASURES OF UPPER LIMB FUNCTION FOR PEOPLE WITH NECK PAIN: A SYSTEMATIC REVIEW OF MEASUREMENT AND PRACTICAL PROPERTIES
A. S. E. Alreni*, D. Harrop 1, S. M. McLean 1
1
Health and Social Care Research, Sheffield Hallam University, Sheffield, United Kingdom
Background: Patients with neck pain frequently report upper limb functional limitation. Evidence from recent literature suggests that optimal management of neck
pain requires utilisation of a standardised upper limb measurement instrument in the assessment and the management process. However, clear guidance regarding
the suitability of available measures is not available.
Purpose: The aim of this research was to identify all available measures of upper limb function developed or evaluated for neck pain patients, critically evaluate their
measurement properties and finally develop recommendations about the most promising measures.
Methods: This research was conducted in two phases. Phase one identified all measures used to evaluate upper limb function for patients with neck pain. Phase two
identified all available studies on the measurement properties of all identified measures. The COSMIN checklist was used to evaluate the methodological quality of
the included studies. Best evidence synthesis was performed using COSMIN outcomes and the quality of findings.
Results: The search strategy used in phase one resulted in a total of 982 unique papers and five different instruments were identified: (1) the DASH questionnaire, (2)
the QuickDASH questionnaire, (3) the NULI questionnaire, (4) the Shoulder Functional Assessment and (5) the SAMP test. The phase two specific search for each
identified instrument resulted in six articles evaluating the measurement properties of four of the identified instruments. Contacting key authors and experts resulted
in another five unpublished studies evaluating the measurement properties of the SAMP test.
Conclusion: The findings of this research suggest that four of the identified instruments: the DASH questionnaire; the QuickDASH questionnaire; the NULI
questionnaire; the SAMP test are promising measures of upper limb disability for patients with neck pain. There is no need for the development of new instruments
to measure upper limb disability for neck pain patients until the currently available measures have been adequately investigated.
Implications: This research demonstrated that all identified instruments were shown to have positive results, but the evidence for each measurement property was
either limited or unknown. The DASH and QuickDASH questionnaires were developed and extensively evaluated originally to measure upper limb disability/symptoms
(hand, wrist, elbow and shoulder), but it was poorly evaluated for use in patients with neck pain. The NULI questionnaire was designed and evaluated for Canadian
workers only, and it lacks published studies in English. The Shoulder Functional Assessments were designed to assess employment status (e.g. benefit suspension or
claim closure), and it involves the use of expensive equipment (Sim-II). The SAMP test lacked information regarding the development process and its evaluation was
performed on non-patient populations only. However, of the five measures the SAMP test is the only performance-based measure.
Further high quality developmental and evaluative studies of the identified measures are warranted and the COSMIN checklist should be used when designing
measurement developmental and/or evaluative studies.
Ethics Approval: This work was ethically approved by Sheffield Hallam University.
Keywords: Neck pain populations, Outcome measures, Upper limb function

PO2-CS-026
IS THERE A RELATIONSHIP BETWEEN IMPAIRED MEDIAN NERVE EXCURSION AND CARPAL TUNNEL SYNDROME? A SYSTEMATIC REVIEW
R. Ellis 1,*, R. Blyth 1, N. Arnold 1
1
Physiotherapy, AUT University, Auckland, New Zealand
Background: Carpal tunnel syndrome (CTS) is the most common peripheral neuropathy. There is growing support for the assessment of median nerve movement or
excursion to be an integral diagnostic factor for CTS. However, the aetiology of CTS is multifactorial with controversy existing as to the role that median nerve
excursion plays. A better understanding of the research that has assessed median nerve excursion, in people with CTS, will provide a significant step forwards in
appreciating the potential utility this may have as a diagnostic finding.
Purpose: The primary objective of this study was to conduct a systematic review of research which has examined whether there is a relationship between impaired
median nerve excursion and CTS.
Methods: A systematic review of literature, utilising the PRISMA Guidelines, was conducted in a wide range of clinical databases. Studies were included if CTS was the
primary condition of interest and where participants with a diagnosis of CTS were compared to a control group. The primary outcome measure must have included a
method of real-time, in-vivo assessment of median nerve excursion. The methodological quality of included studies was assessed using the Newcastle-Ottawa Quality
Assessment Scale (NOS) which is a valid and reliable tool for assessing case-control or cohort studies. The NOS uses a star system, with a maximum of nine stars
awarded over the three categories.
Results: Following the literature search, nine articles met the inclusion and exclusion criteria and were included in the review. All nine studies were of case-control
design and used ultrasound imaging as the means to quantify in-vivo median nerve excursion. Following the review of methodological quality, via the NOS, seven of
the nine studies scored 7/9 stars, whilst the remaining two studies scored 6/9 stars. A majority of studies (7/9) concluded a significant decrease in median nerve
excursion for participants with CTS compared to controls. One study concluded no difference in median nerve excursion between the two groups. One study
concluded significantly greater median nerve excursion in the participants with CTS compared to controls. A systematic review of case-controls studies (such as this
review) represents level 3a evidence suggesting clinicians should take note of the evidence whilst being aware of other research.
Conclusion: A majority of studies (7/9) found a significant decrease in median nerve excursion in participants with CTS compared to healthy controls. However the
findings of two studies were in contrast to this, which does highlight the controversy that exists when claiming that impaired median nerve excursion is an integral
aetiological factor in CTS.
Implications: There is growing evidence that impaired median nerve excursion may be an important aetiological factor for CTS. A majority of studies included in this
review concluded that median nerve excursion is significantly reduced in people with CTS compared to people without CTS. Following this review, it would appear to
be appropriate for clinicians to consider that impaired MN movement may be an influencing factor in the aetiology of CTS. This finding supports the growing
suggestion to routinely include median nerve excursion assessment in the diagnosis for CTS.
Funding Acknowledgements: This research was unfunded
Ethics Approval: This research did not require ethics approval
Keywords: Carpal tunnel syndrome, Median nerve movement, systematic review

PO2-CS-027
A NOVEL CLINICAL PROTOCOL TO OPTIMISE INTRA- AND INTER-RATER RELIABILITY OF VIBRATION SENSIBILITY TESTING OF THE MEDIAN NERVE IN A POPULATION
WITH CHRONIC WHIPLASH ASSOCIATED DISORDER
I. Tyros 1,*, A. Soundy 2, N. Heneghan 2
1
Physio1st LTD, 2School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
Background: Whiplash Associated Disorder II (WAD) is the most prevalent group of whiplash patients that are seen on a regular basis by musculoskeletal
physiotherapists, with 4060% of those injured going onto become chronic. Impairment of vibration sensibility is an early indicator of nerve pathology. Within the
assessment of WAD, vibration testing can be utilised to differentiate degrees of severity and evaluate the progression of treatment. The tuning fork (TF) (128Hz) is an
inexpensive and clinically available tool to assess vibration sensibility but research regarding its psychometric properties and guidance for a testing protocol is lacking.
Existing reliability research in the field has demonstrated almost perfect and moderate reliability values, but there was considerable variation between the used
protocols and a number of limitations that could have affected results. This research seeks to investigate a novel testing protocol that addresses the limitations
previously found and provide users with guidance on how to reliably perform vibration sensibility testing in clinical practice.
Purpose: To investigate the intra- and inter-rater reliability of vibration sensibility of the median nerve in chronic WAD II (CWADII) using a novel, standardised
protocol.
Methods: A prospective, double blinded, within day intra- and inter-rater reliability study was undertaken. A convenience sample of 26 individuals with CWADII was
recruited. Exclusion criteria: WAD I, III & indications of neurological deficits. Two raters with specialist training in musculoskeletal physiotherapy were recruited. Prior
to the measurement raters were trained to use the protocol. In a supine lying position, vibration attenuation times were recorded from skin innervated by the
median nerve (thenar eminence).
Results: Demographics: 8 males, 18 females, age mean (SD) 29.9 (10.0) years. Descriptive statistics (mean scores) and reliability statistics [intraclass correlation
coefficient (ICC: 2,1) and Bland and Altman limits of agreement] were undertaken. The p value was set at 0.05. Almost perfect intra-rater reliability (ICC: 0.972-0.955)
and inter-rater reliability (ICC: 0.983) were identified. Confidence Intervals (CI) for inter-rater reliability were 95% CI: (-1.461 to -0.056).
Conclusion: This study found almost perfect reliability scores across intra- and inter-rater reliability and provides evidence that, with a standardised testing protocol
the TF can be a highly reliable means of vibration sensibility testing in clinical practice.
Implications: The study provides evidence that may further assist differentiation between whiplash II and III, and inform the management of patients with CWADII.
This encourages the use of vibration sensibility testing in clinical practice employing a clinically available tool. Future research could focus on evaluating the validity of
this protocol against the vibrameter which remains the gold standard for measuring vibration thresholds.
Funding Acknowledgements: Chartered Society of Physiotherapy (CSP), Elsevier and Musculoskeletal Association of Chartered Physiotherapists (MACP), for
supporting this study with educational bursaries.
Ethics Approval: School of Health Sciences, University of Birmingham (Ethics Reference number: PGT_1314_037).
Keywords: Reliability, Vibration testing, Whiplash Associated Disorders

PO2-EX-031
EFFECTS OF A THERAPEUTIC EXERCISE PROGRAM BY A FEEDBACK AND MOTOR CONTROL TRAINING SYSTEM IN ELDERLY POPULATION WITH MOBILITY
RESTRICTIONS
A. Ruiz De Escudero Zapico, O. Lucha Lpez, C. Hidalgo Garca*, S. Prez Guilln, J. M. Trics Moreno, E. Bueno Gracia, P. Fanlo Mazas, M. Malo Urris, S. Cabanillas
Barea, A. Carrasco Uribarren
Background: The growth of adult age groups in the European Union has raised the interest in promoting active aging. The limitations in mobility and changes in the
central and peripheral nervous systems are very common in adulthood and often the first clear sign of functional decline. Following the recommendations for physical
activity and public health in the age-related decline, there is a need to validate a new training system which considers these recommendations and is adaptable to
aged population who is likely to benefit from the intervention.
Purpose: To know the effects of a therapeutic exercise intervention by a feedback and motor control training system in pain, functional ability, quality of life, personal
autonomy and motor control, and to compare those effects with a control group of the same characteristics.
Methods: The clinical trial involved an intervention group that was treated by a therapeutic exercise program with a 8 exercise machines which used feedback and
motor control for training. There was also a control group that was not treated and maintained daily habits constant during the treatment period.
114 subjects were measured and divided in the two groups, the inclusion criteria were the following: age range between 50 and 80 years, ability to fulfill in the selfadministered questionnaires, ability for independent walking and to show pain and/or preclinical mobility restrictions in absence of important impairments. People
with contraindications for physical activity and people receiving pharmacological of physical therapy treatment during the treatment period were excluded.
The training group received an 8 week training program with 3day/week frequency.
Body composition was measured by a TANITA system, pain by a Visual Analogue Scale, functional ability by clinical functional tests for the upper and lower
extremities (TUG, 20m Walking test and FIT-HaNSA tests) and also by the measurements of ranges of movement, quality of life by SF-36, personal autonomy by a
Visual Analogue Scale in daily living activities and motor control by the software system with machines which recorded the percentage of correct repetitions with
previously determined parameters.
The previous variables were measured pre-treatment and post-treatment after the 8 weeks in both groups.
Results: Pain reduction was observed mainly in the upper extremities, functional tests and ranges of movement improved both for the upper and lower extremities
and also compared with the control group. Quality of life improved mainly in the health related and daily living activities subscales as well as the own perception of
health compared with the control group. Personal autonomy mostly improved in performing activities above the head which was related to the improvement in
function and ranges of movement of the upper extremities. Regarding motor control, the percentage of correct repetitions significantly improved, both for the upper
and lower extremities as for the trunk.
Conclusion: The studied training program has proven to be effective in reducing symptoms, improving functional ability, quality of life, personal autonomy and motor
control. Suggestions for future work are to analyze the effects of the training system in concrete age-related dysfunctions such as osteoarthritis, osteoporosis or
different rheumatic diseases and also to study the superiority of this innovative training system over other training machines currently on the market.
Implications: This training helps in achieving successful aging, due to the improvement of dysfunction, the increasing of the level of physical activity and the active
involvement in a social activity. The effects of the intervention are clear evidence of the capacity of modifying the age-related decline.
Funding Acknowledgements: This work was funded by a Centre for the Development of Industrial Technology (CDTI) grant, which is a public corporation under the
Ministry of Economy and Competitiveness in Spain.
Ethics Approval: The study followed the Ethical Principles for Medical Reserch Involving Human Subjects (Helsinki Declaration, 2008) and was approved by the Ethics
Committee for Clinical Research of Aragon (CEICA). Aragon Institute of Health Sciences (IACS).
Keywords: Elderly Care, motor control, therapeutic exercise

PO2-EX-032
A COMPARISON OF LUMBO-PELVIC HIP KINEMATICS IN PROFESSIONAL FOOTBALL PLAYERS AND HEALTHY PARTICIPANTS: IMPLICATIONS FOR EXAMINATION AND
REHABILITATION
R. Bailey*
Background: Controlling dynamic interactions between the lower limb and ground is important for skilled locomotion and may influence injury risk in athletes (1).
Clinicians commonly use tests including the Trendelenburg Test (2), Single Leg Squat (3) and the observation of gait (4,5) to help examine this interaction. These
clinical tests are used to examine the Lumbar spine, Pelvis and Hip regions moving in relative isolation during weight bearing (2,3,6,7). Clinical gait observation maybe
used to evaluate the movements of the Lumbo-Pelvic Hip region in unison during function (4,5). Investigators however have presented very little detail for the
biomechanics during weight bearing Lumbo-Pelvic Hip tests or walking and running gait in this population.
Purpose: To investigate the biomechanical characteristics of the Trendelenburg Test, Single Leg Squat, walking, and running in normal healthy male participants and
male Professional Football Players and to compare these data between the groups.
Methods: 14 male participants and 18 Professional Football players who had no pain, injury, or neurologic disorder were recruited. An optoelectronic movement
analysis tracking system was used to assess hip and pelvic movements during the Trendelenburg, Single Leg Squat, walking and running. The Lumbo-Pelvic Hip 3dimensional ranges of movement for the clinical tests were compared to walking and running. The differences between the two groups were determined using an
unpaired t-test with a significance level set to 5% (p<0.05) for each parameter.
Results: There was a significant decrease in the trunk sagittal plane range of movement in Professional Football Players during both lower limb weight bearing; non
dominant (mean difference = -2.70, p=0.000), dominant (mean difference = -2.40, p=0.000). In the trunk coronal plane there was a significant decrease in Professional
Football Players range of movement; non dominant lower limb weight bearing; (mean difference = -1.40, p=0.002), but an increase in the transverse plane during
dominant lower limb weight bearing (mean difference= 2.60, p=0.021). For the pelvis there was a significantly decreased range of movement between the groups in
the sagittal plane during non dominant lower limb weight bearing, (mean difference = -1.80, p=0.000), and in the coronal during both lower limb weight bearing, non
dominant (mean difference = -1.80, p=0.006), and dominant (mean difference= -1.40, p=0.026), and in the transverse plane, during non dominant lower limb weight
bearing (mean difference= 9.10, p= 0.000), and dominant lower limb weight bearing; (mean difference= 10.20, p= 0.000). For the hip; there was a statistically
significant reduction in range of movement between the groups during both non dominant lower limb weight bearing in the sagittal plane, non dominant lower limb
weight bearing (mean difference = -8.40, p=0.000), and dominant lower limb weight bearing (mean difference= -7.50, p= 0.000).
Conclusion: Professional Football Players exhibit reduced trunk and pelvis sagittal and coronal plane mobility, but increased transverse plane mobility when
compared to healthy participants. Professional Football Players exhibited reduced hip sagittal plane mobility, but their coronal and transverse plane mobility was
similar to healthy participants. The decreased hip sagittal plane movement found in this study was consistent with previous studies.
Implications: Professional Football Players exhibit differences in range of movement at the trunk and pelvis in each of the three cardinal planes. Of clinical
importance, Professional Football Players exhibited reduced hip sagittal plane mobility. The decreased hip sagittal plane movement found in this study may explain
the high incidence of hip pathology existing in professional football players.
Ethics Approval: Study approved by the Faculty of Health Research Ethics Committee, University of Central Lancashire
Keywords: Biomechanics, Lumbo-Pelvic Hip, Professional Football

PO2-LB-035
COGNITIVE FUNCTIONAL THERAPY FOR THE MANAGEMENT OF A 36 Y/O FEMALE WITH PERSISTENT BACK PAIN AND MODIC CHANGES TYPE 1
K. Ussing 1,*, P. Kjaer 2, P. O'Sullivan 3
1
Medical Department, Spine Centre of Southern Denmark, Middelfart, 2Department of Sports Science and Clinical Biomechanics, University of Southern Denmark,
Odense, Denmark, 3School of Physiotherapy and Exercise Science, Curtin University of Technology, Perth, WA, Australia
Background: Chronic low back pain continues to challenge health care practitioners and the individual sufferer. It is widely accepted that various interacting biopsycho-social risk factors have the potential to influence low back pain. These factors include: structural factors (eg. Modic changes), cognitive factors (e.g. negative
beliefs, fear of movement and poor coping strategies. Emotional factors (stress, anxiety, depression), social factors (family stress and low job satisfaction),
neurophysiological factors (impaired pain modulation and altered body perception), physical behaviors (avoidance, maladaptive movement patterns and pain
behaviors) and lifestyle factors (sleep deficit, obesity, smoking, inactivity and sedentary behavior). Recently, Modic changes type 1 have been reported to be strongly
associated with low back pain and resistant to care, leading to speculation with regards to its best management.
Purpose: The purpose of this case is to describe and to discuss the management of a 36-year-old female with persistent low back pain and Modic changes type 1 and
severe disc degeneration within a multidimensional, person centered framework, using cognitive functional therapy (CFT).
Methods: This is a single case study with twenty months follow-up. The baseline and follow- up measures included: Pain intensity, Roland Morris Disability
Questionnaire, patient satisfaction and general health as well as validated screening questions for: anxiety, depression, fear of movement and catastrophizing. The
CFT intervention was delivered during four individualized sessions over a period of eight weeks and targeted unhelpful beliefs, fear, distress, protective and avoidant
functional behaviors and lifestyle factors.
Results: The patients pain intensity reduced from 5/10 to 1/10 and disability from 43% to 0% at 20 months. Furthermore, at the same time-point, a substantial
reduction in fear of movement (6/10 to 0/10) and anxiety (8/10 to 0/10) was observed as well as improvement in general health from 50/100 to 90/100.
Conclusion: This case highlights the application of a person-centered cognitive functional approach to management of low back pain associated with Modic changes,
where previous interventions had failed. The case proposes an alternative model for managing these disabling disorders. Larger case series and randomized trials are
needed to further investigate the efficacy of cognitive functional therapy for chronic low back pain and Modic changes.
Implications: The CFT intervention aimed to address modifiable risk factors of negative beliefs, distress and maladaptive movement and postural behaviors while
aiming to achieve the patients self-nominated goals of enhancing physical activity levels. We hypothesis that targeting modifiable lifestyle, psychosocial and physical
factors may be effective in the management in people with Modic changes type 1.
Funding Acknowledgements: This study did not receive any external funding.
Ethics Approval: The project was notified to The Regional Committees on Health Research Ethics for Southern Denmark (ID: S-20142000-15HLP) and did not need
approval.
Keywords: None

PO2-LB-038
DEADLIFT VERSUS LOW LOAD MOTOR CONTROL FOR PATIENTS WITH MECHANICAL LOW BACK PAIN.
P. Michaelson 1,*, D. Holmberg 2, B. Aasa 3, U. Aasa 4
1
Division of Health and Rehabilitation, Department of Health Science, Lule University of Technology, 2Cederkliniken Primary health care center, Department of
Research, The Norrbotten County Council, Lule, 3Department of Surgical and Perioperative Sciences, Ume University, Norrlandskliniken Primary Health Care Centre,
4
Division of Physiotherapy, Department of Community Medicine and Rehabilitation, Ume University, Ume, Sweden
Background: Low back pain (LBP) is a common health problem. Patients with LBP can be classified into sub-groups based on the neurophysiological mechanisms
responsible for generating and maintaining the pain. One of the categories proposed is nociceptive pain, with a subcategory of mechanical pain, whereas the pain
condition has a consistent and proportionate mechanical pattern that can be reproduced by movements. Evidence has concluded that motor control exercises can
reduce pain more effectively than general exercises for patients with low back pain. Previously, a pilot study have indicated that deadlift could be an effective form of
intervention for pain and disability. Deadlift is an exercise that includes motor control components. This as the deadlift, when performed correctly, requries a neutral
position of the lumbar spine by activating trunk muscles, while flexing the hip and knee. It has previously been shown that the deadlift, if performed with sufficient
intensity, can activate stabilizing muscles to a greater extent than core instability exercises.
Purpose: The aim of the study was to compare the effects of the deadlift exercise to low load motor control (LMC) exercises on pain intensity, disability, and healthrelated quality of life for patients with mechanical low back pain.
Methods: This was a randomised controlled trial for patients with mechanical low back pain as their dominating pain mechanism. The intervention program consisted
of the deadlift exercise, while the control group received LMC exercises over eight weeks (12 sessions), with pain education included in both intervention arms. The
primary outcome was pain intensity and disability, and the secondary outcome was health-related quality of life.
Results: Each intervention arm included 35 participants analysed following 2-, 12- and 24- month follow-up. There was no significant difference between the deadlift
exercise and LMC interventions for the primary or secondary outcome measures. Between 50% and 80% of the participants reported a decrease in perceived pain
intensity and disability for both short and long-term follow up
Conclusion: No difference was observed between the deadlift exercise and LMC interventions. Both interventions included retraining of movement patterns and pain
education, challenging beliefs about pain interference in everyday life. These components might explain the positive results over time.
Implications: First, the deadlift must be used wisely and performed correctly if to be used in rehabilitation. This study shows that the deadlift and pain education can
be an alternative rehabilitative intervention for both men and women with persistent mechanical low back pain. Further, it gives indications that it is possible to train
patients with persistent pain with a high intensity exercise and achieve good results.
Funding Acknowledgements: This study was founded by grants from Visare Norr, Sweden and Norrbottens County Council, Sweden.
Ethics Approval: The study was approved by the Regional Ethical Review Board at the University of Ume (nr 09-200M)
Keywords: exercise therapy, Mechanical low back pain, pain intensity

PO2-LB-039
CORRELATION OF REGIONAL LUMBAR KINEMATICS BETWEEN FORWARD FLEXION AND FUNCTIONAL ACTIVITIES IN PATIENTS WITH CHRONIC LOW BACK PAIN
G. Christe 1,*, L. Redhead 2, B. Jolles-Haeberli 3, J. Favre 4
1
Physiotherapy, HESAV, Lausanne, Switzerland, 2School of Health Sciences, University of Brighton, Eastbourne, United Kingdom, 3Orthopedics and Traumatology
Department, 4Swiss BioMotion Lab, CHUV-UNIL, Lausanne, Switzerland
Background: Decreased lumbar spine range of motion has been repeatedly described in chronic low back pain (CLBP) patients. Particularly, it has been suggested that
many patients adopt a strategy of limited spinal motion, which might increase spinal stiffness and possibly sensitize spinal structures. Traditionally, spinal range of
motion has been assessed by cardinal movements. However, it is not known if movement deficits are correlated between cardinal movements and various functional
activities. This is a critical missing knowledge, as there is growing interests for functional activities in assessment and treatment of CLBP patients.
Purpose: To analyse the relationship between spinal flexion angle during forward flexion and functional activities.
Methods: Eleven patients with non-specific CLBP (with minimal and moderate disability; 55% male; 38.96.8 years old; 22.11.7 kg/m^2) were asked to perform
standing forward flexion, sit to stand (STS) and stepping-up at three different heights. A validated multi-segment spinal model was used to calculate sagittal-plane
flexion angle at the lower-lumbar (LLS), upper-lumbar (ULS) and lower-thoracic (LTS) spine. Data was collected by a camera-based motion capture system (VICON,
UK). Pearson correlation coefficients were calculated between peak flexion angles during these different movements.
Results: Peak flexion during forward flexion and STS were highly correlated at ULS (r=0.82; p<0.01) and LLS (r=0.80; p<0.01). Strong correlations were also found
between peak flexion during forward flexion and stepping-up at ULS for all step heights (r=0.90-0.95; p<0.001) and at LLS for the highest step only (r=0.73; p=0.01).
Moreover, high correlations were demonstrated between the different step heights at ULS and LLS (r=0.84-0.97; p<0.01), as well as between STS and stepping-up at
ULS (r=0.84-0.87; p<0.01) and LLS (r=0.83-0.89; p<0.01).
Conclusion: There were strong correlations in peak flexion angles in different regions of the lumbar spine between forward flexion and various functional activities.
Specifically, CLBP patients with flexion deficit in one activity also showed deficits of similar magnitude in the other activities. Further research needs to evaluate the
effects of treatment on spinal movement deficits in patients with CLBP. Particularly, it is not known if kinematic improvement (such as increased lumbar flexion) in
one activity will also occur in other tasks.
Implications: This study suggested that patients whose motor behaviour consists of decreased lumbar flexion probably adopt this behaviour in many activities of daily
living. Therefore, therapeutic interventions for CLBP should integrate various functional activities in their programs.
Funding Acknowledgements: The study was not funded.
Ethics Approval: The research was approved by the Human Research Ethics Committee of the Canton of Vaud (CER-VD).
Keywords: Chronic low back pain, functional activities, kinematics

PO2-LB-041
INFLUENCE OF DUAL TASKING AND KINESIOPHOBIA ON SENSORIMOTOR CONTROL AND MUSCLE ACTIVITY PATTERNS IN PATIENTS WITH NONSPECIFIC CHRONIC
LBP COMPARED TO CONTROLS WITHOUT LBP
P. Vaes*, J. Van De Gucht 1, A. Loots 1, K. Vermeiren 1, S. Lagrin 1, S. Malone
1
Manual Therapy, Vrije Universiteit Brussel-Belgium, Brussels, Belgium
Background: Motor control often is impaired in chronic non specific low back pain patienst (CNSLBP). This impairment can increase during double tasks. This is
documented for motor control tasks but insufficiently for mental and stress related tasks.
Purpose: Sensorimotor control, superficial electromyography (sEMG) measures of the abdominal muscle activity, the effect of dual task and the influence of
kinesiophobia were compared between a CNSLBP group and a control group.
Methods: A comparison between a chronic nonspecific low back pain (CNSLBP) group and a control group without LBP was carried ot in a cross-sectional study
design.
Lateral flexion and rotation on Tergumed devices, to evaluate sensorimotor control, were used in combination with sEMG, to measure the activity of the internal
oblique muscle (IO) and the external oblique muscle (EO). During one of the performances a dual task was added. The Tampa scale was used to measure the
kinesiophobia.
Results: total of 44 CNSLBP patients and 30 controls not suffering from low back pain were included in this study. Both groups showed a significant decrease in
sensorimotor control as measured by changes in trunk pressure on Tergumed when a dual task was added. The CNSLBP group had a significant worse sensorimotor
control compared with the control group without LBP. For ratio 1 (left IO/left EO) we didnt find a significant result. For ratio 2 (right IO/right EO) we found that the
control group scores significantly worse. The CNSLBP group had significant more kinesiophobia. The CNSLBP group with kinesiophobia scored significantly worse
compared with the control group without LBP for ratio 2.
Conclusion: CNSLBP patients showed significantly decreased sensorimotor control compared with individuals without LBP. Sensorimotor control decreases further
when a dual task is added. For movements to the right we found that the CNSLBP group showed superior stabilization as measured by reproducing pressure curve on
Tergumed. CNSBLP patients show significantly increased kinesiophobia levels. CNSLBP patients show significantly more rigidity which could be seen as uncontrolled
stabilization compared to the individuals without LBP.
Implications: Manual therapy treatment strategy should take into account that motor control in low back pain patients is influenced by motor and mental dual tasks.
Funding Acknowledgements: Vrije Universiteit Brussels Physiotherapy and manual Therapy research group-Belgium
Ethics Approval: Vrije Univeiteit Brussels Academic Hospital Ethics committee approved the study protocol
Keywords: None

PO2-LB-042
POSTURAL EDUCATION. A STUDY INVESTIGATING THE INTRA- AND INTER-EXAMINER RELIABILITY OF POSITIONING SUBJECTS INTO NEUTRAL AND LORDOTIC
SITTING POSTURE.
V. Korakakis 1 2 3,*, V. Sideris 2, Y. Sotiralis 3, S. Karanasios 3, K. Sakellariou 3, A. Sideris 3, G. Giakas 2
1
Orthopaedic and sports medicine hospital, Aspetar, Doha, Qatar, 2Faculty of Physical Education and Sport Science, University of Thessaly, Trikala, 3Hellenic
Orthopaedic Manipulative Therapy Diploma, HOMTD, Athens, Greece
Background: Evidence suggests that patients with neck and low back pain display altered proprioceptive postural awareness. Postural education and repositioning are
commonly performed aspects of physiotherapy practice. In clinical practice physiotherapists will reposition patients into lordotic sitting posture (LSP) and neutral
sitting posture (NSP) during assessment and treatment procedures, especially with patients who are sensitized to flexion potentially painful end-range positions.
Research indicates that reliably and accurately assuming such postures may be difficult which questions its application in clinical practice. Both NSP and LSP have
been described qualitatively however a range of spinal curves in terms of angles meet the criteria of these descriptions. Intra- and inter-examiner reliability of
postural education has been described in the literature as very good (ICCs range from 0.8 to 0.94), but reliability data in the majority of research designs have been
narrowly defined to discrete segments of the spine (eg. only lumbar spine and head).
Purpose: The objective of the present study was to evaluate the intra- and inter-examiner reliability of positioning subjects into NSP and LSP, by assessing all spinal
components, specifically: the head, spine, and pelvis postural in the sagittal plane.
Methods: After a power analysis, 26 subjects were recruited, and 3 physiotherapists positioned the subjects 3 times randomly into LSP or NSP while recording 9
sagittal joint angles using Vicon 3D motion analysis system. Estimates of reliability (ICC) and precision (SEM) were calculated.
Results: The intra-examiner reliability was excellent for all measured angles with ICCs ranging from 0.91 to 0.99 for NSP and from 0.92 to 0.99 for LSP. Small and
clinically acceptable SEM was observed for all measurements ranging from 0.85 to 2.91 degrees for NSP and 0.8 to 2.65 degrees for LSP.
The inter-examiner reliability was also excellent for all measured angles with ICCs ranging from 0.91 to 0.96 for NSP and from 0.94 to 0.98 for LSP. Small and clinically
acceptable SEM was observed for all measurements ranging from 1.29 to 2.58 degrees for NSP and 0.94 to 2.83 degrees for LSP.
The lower limit of 95% confidence intervals was more than 0.81 in all ICCs.
Conclusion: Experienced physiotherapists are able to reliably and accurately position subjects into neutral and lordotic sitting postures.
Implications: Intervention trials using postural repositioning can be conducted in the knowledge that repositioning sitting postures is a reliable and valid method.
Ethics Approval: University of Thessaly ethics committee
Keywords: education, physiotherapy practice, sitting posture

PO2-LB-043
INDIVIDUALISED COGNITIVE FUNCTIONAL THERAPY COMPARED WITH A COMBINED EXERCISE AND PAIN EDUCATION CLASS FOR PATIENTS WITH NON-SPECIFIC
CHRONIC LOW BACK PAIN: A MULTICENTRE RANDOMISED CONTROLLED TRIAL
M. O'Keeffe 1,*, H. Purtill 2, N. Kennedy 1, P. O'Sullivan 3, W. Dankaerts 4, A. Tighe 5, L. Allworthy 6, L. Dolan 7, N. Bargary 2, 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, 5Ballina
Primary Care Centre, 6Physiotherapy Department, Mayo General Hospital, 7Claremorris Primary Care Centre , Mayo, Ireland
Background: Non-specific chronic low back pain (NSCLBP) is a costly musculoskeletal disorder associated with a complex interplay of biopsychosocial factors.
Cognitive functional therapy (CFT) represents a novel, patient-centred intervention which directly challenges pain-related behaviours in a cognitively integrated,
functionally specific and graduated manner. A recent randomised controlled trial (RCT) demonstrated the superiority of individualised CFT for NSCLBP compared to
manual therapy combined with exercise. However, several previous RCTs have suggested that class-based interventions are as effective as individualised
interventions. Therefore, it is important to examine whether an individualised intervention, such as CFT, demonstrates clinical effectiveness compared to a relatively
cheaper exercise and education class.
Purpose: The current study is comparing the clinical effectiveness of individualised CFT with a combined exercise and pain education class in people with NSCLBP.
Methods: This study is a multicentre RCT. 214 participants, aged 1875 years, with NSCLBP for at least 6 months are being randomised to one of two interventions
across three sites. The experimental group receive individualised CFT and the length of the intervention varies in a pragmatic manner based on the clinical
progression of participants. The control group attend six classes which are provided over a period of 68 weeks. Participants are assessed preintervention,
postintervention and after 6 and 12 months. The primary outcomes are functional disability and pain intensity. Non-specific predictors, moderators and mediators of
outcome will also be analysed.
Results: 6 month outcome data will be analysed in May 2016 and can be presented at the conference.
Conclusion: This is the first RCT to compare the clinical effectiveness of individualised CFT and a combined exercise and education class for people with NSCLBP. The
study results will provide valuable information about the role of these interventions and has the potential to inform the clinical management of NSCLBP.
Implications: The results of this study could lead to the more effective management of NSCLBP in clinical practice.
Ethics Approval: Ethical approval has been granted by the Mayo General Hospital Research Ethics Committee.
Keywords: cognitive functional therapy, non-specific chronic low back pain, randomised controlled trial

PO2-LB-047
CAN SPECIFIC MOTOR CONTROL EXERCISES FOR THE LUMBAR-PELVIC REGION IMPROVE MOTOR AND RESPIRATORY PERFORMANCE IN OBESE MEN? A PILOT
STUDY
E. Bezzoli 1, D. Andreotti 2,*, L. Pianta 1, S. Gibbons 3, A. Salvadori 4, L. Puricelli 5, M. Mascheroni 1, L. Piccino 1, P. Capodaglio 4
1
Physiotherapy, Istituto Auxologico Italiano, Piancavallo (VB), Italy, 2Physiotherapy, SMARTERehab, Gordola, Switzerland, 3Medicine, Memorial University of
Newfoundland, St. John's, Canada, 4Medicine, Istituto Auxologico Italiano, Piancavallo (VB), 5Physiotherapy, Universit degli Studi dellInsubria, Varese, Italy
Background: Obesity is associated with reduced postural stability, pulmonary function and increased prevalence of low back pain. There is evidence of altered
movement patterns of the trunk, a forward shift of the center of gravity and increased anterior pelvic tilt in standing. Posture has been shown to play an important
role in automatic trunk muscle activation and respiratory function has an important role in posture, spinal stabilization and functional movements. The lumbo-pelvic
musculature influences breathing, postural control and lumbar stability by enhancing intra-abdominal pressure.
Purpose: The purpose of the present study is to evaluate whether specific motor control exercises aimed at improving the perception and activation of the lumbarpelvic cylinder musculature are able to modify respiratory as well as lumbar-pelvic function in obese men greater than general exercise.
Methods: 20 obese male patients (BMI 46 7.6 kg / m2) (age 53 8.4 years) with FVC <80% and FEV1>80% were randomized into two groups. Five days per week for
three consecutive weeks both groups performed one session of endurance training using a bicycle ergometer and took part in a 30-minute group exercise session.
The experimental group, (SE), performed specific exercises aimed at increasing perception and activation of the lumbar-pelvic musculature. The control group, (CG),
performed strengthening exercises. All subjects were evaluated with: spirometry, 6MWT, chest wall circumference, MIP and MEP. The following questionnaires were
administered: Oxygen Cost Diagram (OCD), Visual Analogue Scale (VAS), Patient-Specific Functional Scale (PSFS).
The above parameters were computed for each participant and then their mean and standard deviation values were calculated for each group and in each session
(PRE and POST session). The parameters were normally distributed therefore parametric analysis was used. The comparison between the PRE sessions of the two
groups was performed using t-test (for two independent samples). In each group, PRE and POST session was compared with t-test (for two dependent samples), to
detect significant differences. Null hypotheses were rejected when probabilities were below 0.05. In addition, variation (expressed as percentage respect to PRE
value) was computed as (POST-PRE)/PRE*100.
Results: The SE had significant improvements in the following respiratory functions: MVV (11.9%), Motley index (11.8%) and FVC (5.2%). Also significant improvement
was reported in the 6MWT (15 %), chest wall circumference (92.5%), OCD (63,6 %), MEP (9,3 %) and PSFS (36.5%).
The CG showed improvement in 6MWT (11%) and OCD (47.2%). The MEP value worsened, albeit not statistically significantly, while the chest wall circumference
remained unchanged.
In the SE the VAS value for LBP improved in 60% of the patients, while 40% remained unchanged; in the CG, 30% improved, 10% remained unchanged and in 60% the
symptoms worsened
Conclusion: The study suggests that in obese men respiratory function as well as lumbar function may benefit from specific exercises. This study was a pilot study and
is limited by low numbers and a lack of power calculation for a primary outcome measure. Therefore the statistics should be interpreted with caution. The results
suggest a level 1 clinical trial is warranted.
Implications: Specific motor control exercises may help improve clinically relevant outcomes in obese males relating to respiratory function and low back pain. These
exercises are common in clinical practice and in text books. Clinicians can use these exercise aproaches with suitable patients.
Ethics Approval: Ethics approval was provided by the Ethical Committee of the Istituto Auxologico Italiano.
Keywords: motor control, obesity, respiratory system

PO2-LL-053
HIP RANGE OF MOTION IS ASSOCIATED TO HIP AND GROIN SYMPTOMS AND PREVIOUS INJURY, INDEPENDENT OF THE PRESENCE OF CAM DEFORMITIES.
I. Tak*, P. Glasgow 1, R. Langhout 2, A. Weir 3, G. Kerkhoffs 4, R. Agricola 5
1
Sports Medicine, Sports Institute of Northern Ireland, Belfast, United Kingdom, 2Manual therapy and sports rehabilitation, Physiotherapy Dukenburg, Nijmegen,
Netherlands, 3Sports Medicine, Aspetar Hospital, Doha, Qatar, 4Orthopaedics and Sports Traumatology, Academic Medical Centre Amsterdam, Amsterdam,
5
Orthopaedic Surgery, Erasmus Medical Centre, Rotterdam, Netherlands
Background: Footballers (soccer) often have hip or groin symptoms (HGS), even when they are not injured according to the time loss definition. Previous hip or groin
injury is a risk factor for a relapse. Decreased hip range of motion (HROM) has been related to both hip and groin pain and the presence of a cam deformity. How
these factors interact is unknown.
Purpose: The first aim was to study whether HGS are associated with HROM. The second aim was to study the association of the presence of a cam deformity with
HROM. Additionally the influence of a cam deformity on the relationship between hip and groin symptoms and HROM was examined.
Methods: Seasonal screening data of two professional football clubs were used. Variables for HGS were current hip or groin pain, the Hip And Groin Outcome Score
(HAGOS) and previous hip and groin related time loss injury (HGTI). HROM was determined for hip internal, external and total rotation in a supine position and for the
bent knee fall out test (BKFO). Cam deformity was defined by an alpha angle >60 on standardized antero-posterior pelvic and frog-leg lateral radiographs.
Associations were calculated with univariate linear regression analysis with generally estimating equations (GEEs) was performed. To adjust for the presence of cam
deformity, as a cam is associated with decreased HROM, when analysing associations between HROM and HGS, this was entered as an independent variable in the
multivariate linear regression model with GEEs. Interaction effects were calculated in a multivariate model.
Results: Sixty players (mean(sd) age=23.1(4.2) years) were included. All were non-injured at the time of screening. Current hip or groin pain was not associated
with hip ROM. Hips of players in the lowest HAGOS inter quartile range (thus most affected by complaints, n=12) showed less internal rotation (23.98.7 vs 28.97.8,
p=0.036) and total rotation (58.213.5 vs 65.611.8, p=0.047) than those in the highest (n=29). No such differences were found for BKFO (p=0.417). Hips of players
with a previous hip and groin related time loss injury showed less internal rotation (21.16.8 vs 28.38.9, p<0.001) and total rotation (56.08.2 vs 64.513.6, p<0.001)
than those without. This was independent of presence of a cam. BKFO did not differ between groups (p=0.983). Hips with a cam deformity showed less yet nonsignificant IR (25.510.3 vs 29.07.1, p=0.066) and TROM (p=0.062) and higher (17.13.4 vs 14.24.6, p=0.078) yet non-significant BKFO values than hips without.
There were no significant interaction (all p>0.11) effects for the presence / absence of cam deformity and the HGS variables HAGOS and HGTI on the associations with
HROM.
Conclusion: Decreased hip ROM in professional football players is associated with more hip and groin related symptoms and with previous injury history. This is
independent of the presence of a cam deformity. Whether decreased hip rotation is a cause or effect remains unclear by this cross sectional design.
Implications: This subgroup of athletes, with more symptoms and/or previous injury, may benefit from strategies to improve hip ROM but further studied should
confirm this.
Ethics Approval: Dutch Central Committee on Research on Human Subjects confirmed ethical approval wasnt needed (Dutch Medical Research Involving Human
Subjects Act).
Keywords: cam deformity, groin pain, range of motion

PO2-MT-056
TRANSVERSE OSCILLATORY PRESSURE (TOP) IN THE MANAGEMENT OF CERVICAL RADICULOPATHY USING VISUAL ANALOGUE SCALE AND NECK DISABILITY INDEX
AS OUTCOME MEASURES
A. O. Ojoawo*
Background: Cervical radiculopathy is an important subgroup of neck disorders causing severe pain and disability
Purpose: The study assessed the effect of transverse oscillatory pressure (TOP) on pain intensity and functional disability of patients with cervical radiculopathy.
Methods: Twenty six subjects with non-specific unilateral radiating neck pain were randomly selected in to Groups A and B with equal number. Subjects received
kneading massage, cryotherapy and active isometric exercises to the posterior paraspinal muscles, trapezuis and sternomastoid muscles. TOP was administered
to group A while group B served as control. Treatment was three times per week for four weeks. Visual analogue scale and neck disability index were used to assess
pain and neck disability respectively at baseline, two and four weeks. Data were analyzed using repeated measure ANOVA
Results: There was a significant improvement in the pain intensity and neck functional disability of patient between baseline and 4th week of treatment session in
group A and B (p<0.05). There was a significant reduction in pain intensity of Group A (f= 7.08, p < 0.05) at 2nd and fourth week than in Group B.
Conclusion: It can be concluded that TOP with active exercise, kneading massage and cryotherapy can reduce pain of patients with cervical radiculopathy faster
Implications: TOP is one of the physical therapy technique that is effective in amelorating cervical radicular pain
Funding Acknowledgements: Nil
Ethics Approval: Ethics and Reserach Comittee of Obafemi Awolowo University Teaching Hospitals approved the study
Keywords: Cervical Radiculopathy, Transverse Oscillatory Pressure , Pain intensity, Neck disability, Visual analogue scale

PO2-MT-057
DYNAMIC CLINICAL DECISION MAKING IN A PATIENT CENTERED MODEL CASE EXAMPLE IN PEDIATRIC ORTHOPAEDIC MANUAL THERAPY
C. Macdonald*
Background: OBJECTIVE: To describe the application of a patient centered dynamic clinical decision making process in orthopaedic manual therapy practice (OMPT)
with an impairment-based manual therapy approach post ankle fracture in a female pediatric patient.
BACKGROUND: Clinical decision making (CDM) in OMPT practice is diverse, and often founded in descriptive theory versus responsive to the individual patient. A
dynamic CDM process would ideally allow for evidence informed practice that is adaptive to patient response to care. For this case it is noted that a fracture of the
ankle is one of the most common lower extremity fractures and that evidence has been mounting for the support of early active ROM and protected weight bearing
versus surgical intervention or conservative management such as immobilization. However, there is limited and conflicting evidence for a manual therapy approach
to treatment of this condition in the pediatric patient population.
Purpose: CASE DESCRIPTION: A 7-year-old female presented 14 weeks after getting her foot trapped in an elliptical machine and suffering a distal fibular fracture.
Course of care prior to physical therapy interventions included six weeks of immobilization in a walking boot and protective bracing. Chief complaint was persistent
and chronic dorsal lateral ankle pain rated 10/10 on Numeric Pain Rating Scale (NPRS) during weight bearing activities. Scored 48/80 on the Lower Extremity
Functional Scale (LEFS). Gait observation noted limitation of dorsi-flexion from initial contact to terminal stance. Accessory motion testing revealed limitations at the
proximal and distal tibiofibular joints. Strength impairments were 4/5 for gastro soleus and tibialis anterior, tibialis posterior 4-/5 and peroneals 3+/5. Plantar flexion
ROM had an 8-degree bilateral difference, and dorsiflexion had aberrant movement towards an inverted position during testing on the affected side.
Methods: A dynamic CDM process was commenced. Interventions included graded non-thrust manipulation to distal tibiofibular joint, and a proximal tibiofibular
joint thrust-manipulation. Pain decreased to 4/10 on NPRS following the procedure with retest of ambulation. Fibular taping procedure with A/P spiral technique of
distal tibiofibular joint was then applied. Second visit pain was 4/10 pain with ambulation, A/P non-thrust manipulation was performed to distal tibiofibular joint, with
retest of ambulation producing 0/10 pain. The taping procedure was then reapplied and pain free strengthening and balance exercises were performed.
Results: OUTCOMES: The patient was seen for six visits over a 4-week period of time, with adjustment inter and intra-session based upon patient response to
interventions. At discontinuation patient presented with unrestricted sport participation, resolution of pain symptoms with ambulation and a LEFS score of 80/80.
From the clinician perspective, a novel approach to pediatric OMPT care post ankle fracture was identified that could guide future similar case presentation.
Conclusion: DISCUSSION: A dynamic CDM model supports developing individualized and informative treatment approaches for OMPT care. In this case a multimodel
treatment approach emphasizing impairment-based manual therapy may be beneficial in the treatment of chronic ankle pain in an pediatric female post fibular
fracture.
Implications: Educational approaches within OMPT which encourage a dynamic CDM process instead of the longitudinal application of a baseline theorem for OMPT
care may enhance patient care and also may help to develop innovative methods of treatment. Integrating therapist and patient vantage, recognizing that each
patient response to care is unique and not limiting potential treatment interventions due to a rigid baseline plan of care may each work to improve the quality of
OMPT care provided.
Ethics Approval: Single patient case, IRB submission not reuired, retrospective reporting on interventions on single case.
Keywords: clinical decision making, dynamic, Manual Therapy

PO2-MT-058
MANUAL THERAPY COMBINED WITH DRY NEEDLING FOR THE MANAGEMENT OF PATIENTS WITH PATELLOFEMORAL PAIN SYNDROME
A. I. de-la-Llave-Rincn 1, B. Loa-Barbero 1, M. Palacios-Cea 1,*, J. Salom-Moreno 1, R. Ortega-Santiago 1, S. Ambite-Quesada 1, J. L. Arias-Bura 2, C. Fernandez-De-LasPeas 1
1
Fisioterapia, Terapia Ocupacional, Rehabilitacin y Medicina Fsica, UNIVERSIDAD REY JUAN CARLOS, ALCORCON, 2Fisioterapia, Universidad Francisco de Vitoria,
Madrid, Spain
Background: Manual therapy and eccentric exercise programs directed at the quadriceps muscle have shown moderate evidence of effectiveness in patellofemoral
pain syndrome (PFPS). The presence of trigger points (TrPs) in the knee extensors may contribute to symptoms in PFPS. No previous study has investigated the
effectiveness of the inclusion of deep TrP-dry needling (TrP-DN) in the management of PFPS.
Purpose: To compare the effects of deep TrP-DN combined with manual therapy compared to superficial TrP-DN combined with manual therapy in pain, disability
and pressure pain sensitivity in PFPS.
Methods: Eight patients (5 men, 3 women, mean age: 255 years old) with PFPS were randomly assigned to either a control (superficial DN and manual therapy) or
experimental (deep TrP-DN and manual therapy) group. Both groups received 4 sessions at a frequency of once per week. The manual therapy program was the same
for both groups and included soft tissue interventions, stretching of the quadriceps and hamstring muscles, and an eccentric exercise program directed at the
quadriceps and hamstrings muscles. The control group received superficial DN on active TrPs reproducing the knee pain symptoms. Superficial DN consists of the
insertion of an acupuncture needle on the skin and twist the needle for 30 seconds. The experimental group received deep DN to those active TrPs reproducing knee
symptoms. In this case, the needle was inserted into the muscle, and the fast-in and fast-out technique was performed. Outcomes including self-reported knee pain
(numerical pain rate scale, NPRS, 0-10), disability (Knee injury and Osteoarthritis Outcome Score, KOOS, 0-100) and pressure pain thresholds (PPT) over vastus
medialis, rectus femoris and vastus lateralis muscles were assessed at baseline and 1w after the last session by an assessor blinded to the group allocation of
subjects.
Results: Significant Group * Time interactions were observed for knee pain intensity (F=4.690, P=0.045) and PPT over the vastus medialis (F=17.30, F=0.006): patients
receiving deep TrP-DN exhibited higher improvements in knee pain and pressure pain sensitivity over the vastus medialis than those receiving superficial DN. No
significant Group * Time interaction was observed for KOOS (F=2.253, P=0.184), and PPTs over vastus lateralis (F=0.802, P=0.405) or rectus femoris (F=2.403;
P=0.172): both groups showed similar changes in knee-related disability and pressure sensitivity on these points.
Conclusion: The inclusion of deep TrP-DN into a multimodal manual therapy approach was effective for reducing pain, pressure pain sensitivity on the vastus medialis
in patients with PFPS. No difference was observed on disability or pressure sensitivity on the vastus lateralis and rectus femoris.
Implications: Current results suggest that combination of manual therapy, exercises and TrP-DN may result in greater benefits for the management of subjects
with PFPS
Funding Acknowledgements: No funds were received for this study.
Ethics Approval: The current study was approved by Local Ethical Committee (URJC 2014-27)
Keywords: Dry needling, Manual Therapy, Patellofemoral pain

PO2-PA-064
CAN A STRATEGY FOR MOTOR IMAGERY RELEARNING USED IN LEARNING DIFFICULTIES BE USED FOR COMPLEX PAIN PRESENTATIONS? A CASE SERIES
S. Gibbons 1,*
1
Background: Motor imagery has been used in the rehabilitation of complex pain presentations and neurological disorders. A subgroup of patients lack the ability to
perform motor imagery. A remediation strategy is used in children with specific learning difficulties in which they are taken through a staged process to relearn
mental and motor imagery. This is an evidence based strategy in the special education field with MRI showing gray matter volume increases that correspond to the
intervention. This creates biological plausibility for the intervention in complex musculoskeltal pain presentations for patients who have poor motor imagery skills.
Purpose: The purpose of this paper was to report the use a motor imagery relearning strategy on patients who could not perform motor imagery and who had failed
other evidence based therapies.
Methods: The principles of the program used in children with learning difficulties was adapted for musculoskeletal pain patients in consultation with a special
education teacher. The intervention was used on subjects who scored 1 (no image) on subsections of the Kinesthetic and Visual Imagery Questionnaire (KVIQ). The
patient group consisted of; 2 patients with complex regional pain syndrome type 1 (CRPS); 1 patient with phantom limb pain (PLP) due to loss of a thumb; 12 subjects
with chronic low back pain (LBP); 6 subjects with whiplash associated disorders (WAD) of which 2 were acute; and 1 subject with chronic ankle pain post lateral
ligament sprain. Each subject attended 2 sessions per week for 30 minutes. Their home exercises were to practice the items on the KVIQ based upon the last
progression in the clinic. The primary outcome measure was the KVIQ. Secondary outcome measures included the Numerical Pain Rating Scale, (NPRS) and two point
discrimination (TPD).
Results: 18 of 22 subjects improved a mean of 2.4 on the visual imagery subscale (range 1-4) and 2.2 (range 1-3) on the kinesthetic imagery scale. The four subjects
who did not improve experienced acute flare ups of anxiety during the process of trying to perform motor imagery of the area of symptoms (HADS mean score 11.4
on the depression scale). In the 18 subjects that responded, pain decreased a mean of 3.4 (range 2-6). TPD improved a mean of 5.4cm (range 3.5-12.5).
Conclusion: A strategy to relearn motor imagery adapted from a treatment technique for children with specific learning difficulties may improve motor imagery and
other clinically relevant outcomes in subjects who do not experience high anxiety. The improved motor imagery can then used to facilitate other therapies which
require motor imagery. This case series provides justification for a level 1 clinical trial. Poor motor imagery and disrupted body image may be a cause of anxiety in a
subgroup of patients and should be investigated.
Implications: Relearning of motor imagery may be a viable treatment option for subjects who do not have the ability to perform motor imagery when this which is
related to their condition. Strategies can be used from existing textbooks. Further evidence is recommended before implementing into clinical practice.
Funding Acknowledgements: There was no funding
Ethics Approval: The Human Investigation Committee of Memorial University of Newfoundland deemed the project as program development since there is no
standard therapy in physiotherapy, therefore full ethics approval was not required. All subjects gave written consent for their results to be used.
Keywords: chronic pain, motor imagery, Rehabilitation

PO2-PA-065
EXPERIENCES OF SLEEP PROBLEMS IN PATIENTS WITH CHRONIC MUSCULOSKELETAL PAIN: AN EXPLORATIVE MIXED METHOD STUDY
L. Dhaese 1, F. Toye 2, K. Barker 2 3,*
1
Maastricht University, Maastricht, Netherlands, 2Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS FT, 3Nuffield
Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
Background: Sleep problems are highly prevalent in the chronic musculoskeletal pain population. They are associated with pain intensity, fatigue and mood disorders.
Current evidence is not supporting sleep hygiene education alone as effective in treating sleep problems. Subgroup identification is needed to determine the
effectiveness of sleep hygiene education alone in the chronic musculoskeletal pain population.
Purpose: To explore the experiences of sleep problems in patients with chronic musculoskeletal pain (1). To determine which subgroups of patients with chronic
musculoskeletal pain behave similarly regarding sleep hygiene (2) and benefit from a sleep hygiene intervention (3).
Methods: A total of 111 patients with chronic musculoskeletal pain were recruited from a secondary pain centre in Oxford (UK). All participants completed
questionnaires aimed at assessing sleep hygiene, sleep problems, pain, fatigue, depression and anxiety. A linear regression analysis was used to determine the bestfitting model to explain the variability in sleep hygiene scores. A single focus group session with six participants was carried out to explore the experiences of having
sleep problems. The verbatim transcript of this session was analysed using a two-step coding procedure.
Results: The analysis of the focus group session produced four themes: the difficulties of falling and staying asleep, my sleep problems affect my partner, I need a
break from constant pain, and the difficulties of breaking a habit. Depression scores, age and gender explained 26% of the variability in sleep hygiene scores (R2 = .26;
p < .001). A sleep hygiene intervention did not result in any significant improvement.
Conclusion: Sleep problems can affect the partner and have a negative influence on the patients quality of life. Sleep related habits are hard to break and need
specific treatment to change. Sleep hygiene intervention does not influence sleep hygiene scores. Younger males with mood disorders have worse sleep hygiene and
would be a subgroup to target with sleep hygiene intervention studies.
Implications: The results from this study highlight the need for addressing sleep problems in a CMP population. Sleep problems can have a serious impact on a
patients symptoms and life and need specific treatment to minimize these negative influences and reduce the secondary complaints of CMP. This study is the first to
identify a subgroup of patients with CMP that has poor sleep hygiene. Future high-quality studies should determine the efficacy of a sleep hygiene intervention in this
subgroup.
Funding Acknowledgements: The study was funded by the Nuffield Orthopaedic Centre Physiotherapy Research Unit bursary.
Ethics Approval: As the project was considered a service development, permission was at department level and external ethics review was not required.
Keywords: chronic pain, Mixed-method design, Sleep Problems

PO2-PA-066
UNDERSTANDING PAIN AMONG OLDER PERSONS: PART 1 THE DEVELOPMENT OF NOVEL PAIN PROFILES AND THEIR ASSOCIATION WITH DISABILITY AND
QUALITY OF LIFE
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 a range of variables are related to the impact of pain, most large population studies among older persons have simply examined the presence or
intensity of pain.
Purpose: To develop novel pain profiles based on a broad range of pain variables, and compare the discriminative ability of this approach to using pain intensity
ratings.
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. As well as pain variables, information on nine demographic and health variables were analysed. Two-step cluster
analysis was performed on those who reported being often troubled by pain using all self-reported pain variables, using the no pain profile as a comparison.
Results: Five profiles, four reporting being troubled by pain, emerged. 76% of the total population either reported that pain did not trouble them or did not impact
on their daily activities. All nine demographic and health variables differed significantly across the profiles (all p<0.05). All pain profiles reported significantly greater
disability and poorer quality of life than the no pain profile (p<0.05).
Conclusion: Simply categorising the impact of chronic pain among older persons by the presence, or intensity, of pain does not adequately reflect the variation in
disability and quality of life. Identifying those (i) with multisite pain, (ii) who take pain medications and/or (iii) whose pain affects daily activities better identifies those
with the highest levels of disability and poorest quality of life.
Implications: To better recognise, and address, the impact of chronic pain among older adults, some key characteristics linked to greater disability (e.g. multisite pain)
could be screened for, and used to direct subsequent management strategies.
Funding Acknowledgements: Not applicable.
Keywords: Chronic pain, cluster analysis, older adults

PO2-PA-068
CROSS CULTURAL ADAPTATION, RELIABILITY AND VALIDITY OF THE FRENCH VERSION OF THE CENTRAL SENSITIZATION INVENTORY
L. Pitance 1 2,*, E. Piraux 3, B. Lannoy 3, M. Meeus 3, A. Berquin 4, C. Eeckhout 5, V. Dethier 5, J. Robertson 6, M. Meeus 7, N. Roussel 7
1
Clinical research institute (IREC), Universit Catholique de Louvain, 2Oral and maxillo-facial Surgery Department, Cliniques Universitaires Saint-Luc, Brussels, 3Facult
des sciences de la motricit, Universit Catholique de Louvain, Louvain La Neuve, 4Institute of neurosciences, Universit Catholique de Louvain, Brussels, 5Faculty of
psychology, Universit Catholique de Louvain, Louvain La Neuve, Belgium, 6CHU Nantes, Nantes, France, 7University of Antwerpen, Antwerpen, Belgium
Background: Central sensitization has been proposed as a pathophysiological pain mechanism in which central nervous system neurons become hyperexcitable,
resulting in hypersensitivity to both noxious and non-noxious stimuli. The Central Sensitization Inventory (CSI) is a valid screening tool to help clinicians to identify
patients with central sensitization. To date, no French version exists.
Purpose: The aims of this study were to translate and cross-culturally adapt the CSI into French (CSI-Fr) and to investigate the main psychometric properties of the
CSI-Fr.
Methods: The CSI-Fr was developed using a standardized process of cross-cultural adaptation. Patients with chronic central sensitization pain (CS Fibromyalgia)
(n=40), patients with nociceptive pain (NP acute ankle sprain) (n=40) and healthy controls (HC) (n=40) completed the CSI-Fr and 4 other questionnaires (Pain
Catastrophizing Scale, Hospital Anxiety and Depression Scale, Brief Pain Inventory and SF-36). A confirmatory factor analysis was conducted based on the exploratory
factor analysis carried out by Mayer et al. (2013); five alternative models relating to the structure of the questionnaire were tested. The ability of the questionnaires
to discriminate between CS and HC was analysed and test-restest reliability for CS and HC was determined with a time interval of one week. The sensitivity and
specificity of the established cut-off score of 40 were also assessed. Concurrent Validity was calculated by correlating the CSI score with the scores from the 4 other
questionnaires
Results: The CFA demonstrated good fit indices for the 5 models (structural validity). There was a significant difference in CSI score between the patients with CP and
the other groups (p<0.001); sensitivity was found to be 95% and specificity 90% using the cut-off score of 40 (discriminant validity). The total CSI score correlated
with the scores of all the questionnaires (p<0.05) for CS, demonstrating good concurrent validity. Test-retest reliability was excellent for both CS (ICC = 0.94) and HC
(ICC = 0.91).
Conclusion: The French version of the CSI was shown to be a reliable and discriminant tool for the screening of central sensitization. The good concurrent validity
found supports the use of the CSI questionnaire for the assessment of patients with CS.
Implications: The French version of the CSI can be used in clinical practice by French speaking patients.
Ethics Approval: The study was approved by our regional Ethics Committee (Registration number: B403201421447)
Keywords: Central sensitization, Central Sensitization Inventory, chronic pain

PO2-SP-069
CLINICAL ASSESSMENT OF THORACIC AXIAL ROTATION: A CRITERION-RELATED VALIDITY STUDY OF A DIGITAL INCLINOMETER AND IPHONE
J. Bucke 1,*, S. Spencer 1, L. Fawcett 1, A. Rushton 2, N. Heneghan 2
1
English Institute of Sport, Lilleshall NSC, 2School of Sport, Exercise & Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
Background: Spinal axial rotation is required for many functional & sporting activities, with 80% of the motion coming from the thoracic spine. Limited thoracic
mobility may impair functional performance or predispose individuals to injury in anatomically related regions, such as the low back, neck or shoulder. Existing
measures of spinal axial rotation commonly involve technical equipment, in a seated position and include lumbar motion. A simple performance based outcome
measure (PBOM) would allow clinicians to measure isolated thoracic axial rotation, however no valid PBOM currently exists.
Purpose: To investigate PBOMs that can be used to assess isolated thoracic mobility in a clinical setting.
To explore the validity of a digital inclinometer and iPhone for measuring thoracic axial rotation using the four-point heel-sit position; a position that isolates mobility
to the thoracic spine by minimising movement at the lumbar spine, pelvis & hips.
Methods: From a power calculation, a convenience sample was recruited. Digital inclinometer (DI) (Acumar) & iPhone measurements of thoracic axial rotation in the
four point heel sit position were taken on asymptomatic participants (n=23), mean (SD) age of 25.82 years (4.28), mass 67.50 kg (9.46) and height 170.26 cm
(8.01). Measures were taken concurrently with Polhemus motion analysis alongside ultrasound imaging (reference standard) by an experienced researcher. This has
demonstrated face validity as it allows measurement of dynamic segmental movement & visualisation of the underlying bony tissue. Assessors were blinded to
results during testing.
Criterion validity of the DI and iPhone were assessed using Pearsons Product Moment Correlation Coefficient (r) (2 tailed), where p<0.05. Bland-Altman plots were
used to visually assess the mean difference and 95% limits of agreement between the DI, iPhone & reference standard.
Results: DI (r=0.882) & iPhone (r=0.875) demonstrated strong criterion validity for measuring thoracic axial rotation in the four-point heel-sit position.
Bland-Altman plots illustrate mean differences between the DI and iPhone to the reference standard of 5.82o (CI=14.55o) and 4.94o (CI=14.29o) respectively.
Conclusion: The DI & iPhone provide a valid PBOM of thoracic axial rotation in the four-point heel-sit position. Future research should include symptomatic samples &
sub-groups to improve the generalisability of findings.
Implications: DI and iPhone can be used in clinical practice to assess isolated thoracic axial rotation. This may be useful when assessing asymptomatic thoracic
dysfunction which may contribute to symptoms in an associated body region. This PBOM may also be useful to evaluate the effect of therapeutic interventions on
thoracic mobility.
Funding Acknowledgements: The study was carried out in association with the English Institute of Sport (EIS).
Ethics Approval: School of Sport, Exercise and Rehabilitation Sciences Research Committee, University of Birmingham, UK.
Keywords: Performance based outcome measure, Thoracic spine mobility, Validity

PO3-AP-002
PATIENT-THERAPIST INTERACTIONS IN MUSCULOSKELETAL PHYSIOTHERAPY: A QUALITATIVE SYSTEMATIC REVIEW AND META-SYNTHESIS.
M. O'Keeffe 1,*, P. Cullinane 1, J. Hurley 1, I. Leahy 1, S. Bunzli 2, P. O'Sullivan 2, K. O'Sullivan 1
1
Clinical Therapies, University of Limerick, Limerick, Ireland, 2School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia
Background: Musculoskeletal physiotherapy, including sports physiotherapy involves both specific and non-specific effects. Non-specific variables associated
with the patient, therapist and setting may influence clinical outcomes. Recent quantitative research has shown that non-specific factors including a positive
patient-therapist interaction can enhance treatment outcomes. It remains unclear however what factors influence patient-therapist interaction. No review to date
has been conducted on this topic. Qualitative research would be appropriate to achieve this.
Purpose: This qualitative systematic review and meta-synthesis investigated patient and physiotherapist perceptions of factors that influence patient-therapist
interaction.
Methods: Eleven databases were searched. Qualitative studies examining physiotherapists and/or patients perceptions of factors which influence patient-therapist
interaction in musculoskeletal settings were included. Two reviewers independently selected articles, assessed methodological quality using the Critical Appraisal
Skills Programme (CASP), and performed the analytical process which involved 3 stages; extraction of findings, grouping of findings (codes), abstraction of findings.
Results: 13 studies were included. Four themes were perceived to influence the patient-therapist interaction; (1) Physiotherapist interpersonal and communication
skills: the presence of skills such as listening, encouragement, confidence, being empathetic and friendly and non-verbal communication; (2) Physiotherapist practical
skills: physiotherapist expertise, level of training and ability to give good education; (3) Individualised patient-centred care: individualising the treatment to the
patient and taking patient opinions into account and (4) Organisational and environmental factors: time and flexibility with care and appointments.
Conclusion: A mix of interpersonal, clinical and organisational factors influence the patient-therapist interaction. Physiotherapist awareness of these factors could
enhance patient interaction and treatment outcomes. Mechanisms to best enhance these factors in clinical practice requires further study. Future research trials in
musculoskeletal pain should facilitate a good-therapist interaction and investigate its effects on pain and disability when added to other physiotherapy interventions.
Implications: Physiotherapists in clinical practice should harness the non-specific effects of treatment to increase the effectiveness of interventions they deliver to
patients.
Keywords: MUSCULOSKELETAL, patient-therapist interaction, qualitative systematic review

PO3-AP-006
OUTCOMES OF A 6 WEEK GROUP EXERCISE PROGRAMME FOR INDIVIDUALS WITH SEVERE OSTEOPOROSIS.
C. Tracey 1,*, H. Stevens 1, K. Barker 1
1
Physiotherapy Department, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS FT, Oxford, United Kingdom
Background: Worldwide an osteoporotic fracture is estimated to occur every 3 seconds, a vertebral fracture every 22 seconds. These have significant impact on an
individuals quality of life and represent a large economic burden for society. There is increasing evidence that physical therapies that address pain and physical
impairments may improve quality of life and reduce fracture risk in people with vertebral osteoporosis. Current evidence supports exercise prescription for
individuals with osteoporosis, but fewer studies have been completed in osteoporosis populations with vertebral fracture and only a small number of these use the
recommended guideline interventions that combine weight-bearing, strength and balance activities.
Purpose: To assess the effectiveness of a group exercise intervention for severe osteoporosis
Methods: Longitudinal cohort study of 30 consecutive patients attending an out-patient group exercise programme recruited from the out-patient physiotherapy
waiting list. Inclusion criteria of diagnosis of osteoporosis clinically or by DEXA, exclusion: cardiac screen failure.
Outcome data collected for height [cm], sagittal plane alignment tragus to wall [cm], shoulder flexion [degrees], ankle dorsiflexion [cm], Timed Load Stand Test [sec],
Timed single leg stand [sec], 6 minute walk, Perceived effort of walking CR10, VAS confidence to manage symptoms [cm].
Data collected at baseline and at 3 months after the 6 week programme. Baseline to 3 month changes were analysed using a Wilcoxon paired t test.
Results: Attendance rate was 95% for the 6 weeks of the class.
The mean age of participants was 78 years; with an average of 8 years since diagnosis, 2 previous vertebral fractures and a mean kyphosis Cobb angle of 57 degrees.
Height improved by a mean of 0.27 cm [unchanged in 6, decreased in 5, improved in 19 patients NS].
Tragus to wall improved by a mean of 2.5 cm [ improved in 26 , unchanged in 4 patients; p>0.001].
Shoulder flexion improved by 10 degrees [N.S.]; Ankle Dorsiflexion minimal changes only
Timed Load Stand Test improved by 8.1 seconds [ improved in 22, unchanged in 2, decreased in 6 p =0.02].
Single Leg Stance improved by 6.6 seconds [ improved 22, unchanged in 4, decreased in 4 p=0.002].
6 minute walk improved by a mean of 48 metres, improved in 28, unchanged and decreased in 1 each; with an improvement in the CR10 effort test of 0.8 p<0.001}.
Confidence to manage symptoms improved by 3 points on a 10 point scale [improved 29 p=0.05]
Conclusion: This was a simple observational study that successfully achieved changes in posture and function. The class had good adherence and improved the
confidence of the participants to manage their condition. The improvements were present 3 months after completing the class.
Implications: The results demonstrated that a group intervention for elderly, patients with severe osteoporosis could achieve demonstratbly effective results within
standard NHS resources.
Funding Acknowledgements: Unfunded.
Ethics Approval: Service evaluation therefore ethics approval not sought
Keywords: Osteoporosis, exercise

PO3-CS-008
THE INFLUENCE OF ANTERIO-POSTERIOR MOBILISATION AT THE CERVICAL SPINE ON VERTEBRAL ARTERY BLOOD FLOW
M. Lewis 1,*, C. Stapleton 2
1
Physiotherapy Department, Peterborough City Hospital, Peterborough, 2School of Health and Rehabilitation, Keele University, Keele, United Kingdom
Background: Joint mobilisations are passive low velocity rhythmic movements (Aquino et al., 2009), which can be used at the cervical spine to provide symptom relief
of neck pain and headaches (Gross et al., 2010). Such mobilisations may impact upon blood flow in the vertebral arteries (VAs) due to their course through the
foramen transversarium of the cervical vertebrae. Reduced blood flow may cause symptoms of cervical artery insufficiency (CAI) and, if collateral circulation fails, has
the potential to lead to more serious cerebrovascular events, such as stroke (Malo-Urris et al., 2012). It is important for physiotherapists to understand the effect
cervical spine joint mobilisations have on the blood supply to the brain in order to perform an appropriate riskbenefit analysis of their treatment (Thomas et al.,
2013). To the authors knowledge, there have not been investigations into the affects of Anterio-Posterior (AP) mobilisations on vertebral artery blood flow.
Purpose: The aim of this study was to determine the impact of an AP mobilisation of the cervical vertebra on peak systolic velocity (PSV) of the vertebral artery (VA)
determined by duplex ultrasound.
Methods: Following institutional ethical approval, 24 asymptomatic individuals (mean age 23yrs) were recruited and screened for known risk factors to CAI and
contraindications to cervical spine manual therapy. Participants underwent baseline measurement (pre AP) of peak systolic velocity (PSV) of the left VA, recorded
with Duplex Ultrasound. A bilateral AP mobilisation was applied to C4. Repeated measures of PSV were performed with the mobilisation force held (AP application)
and after release (post AP). PSV was determined from the mean of three consecutive peaks of the spectral waveform. Statistical analysis was performed using ANOVA
with pairwise comparisons with an alpha level of 0.05.
Results: A statistically significant reduction (p<0.05) in PSV was found when comparing the stages of application. Mean PSV at baseline (Pre AP) was 58.20cm/s (SD
17.55); during AP Application this decreased to 55.14cm/s (16.06), post AP application was 61.38cm/s (18.15).
Conclusion: Previous research does not advise on the magnitude of change in blood flow velocity at the vertebral artery required to be deemed clinically relevant.
However, with baseline measures of 58.20cm/s it seems unlikely that a drop of 3cm/s in blood flow velocity would be indicative of a clinically meaningful effect.
Therefore, it can be concluded that whilst, AP mobilisations at the cervical spine do impact on vertebral artery blood flow, the magnitude of this effect does not pose
any real threat to the cerebral circulation in a young, healthy, asymptomatic population. Clinical practice would benefit from future research into older and/or
symptomatic populations whose co-morbidities may increase the risk of CAI.
Funding Acknowledgements: This was an unfunded piece of work.
Ethics Approval: Approval granted from Keele Univeristy's School of Health and Rehabilitation's Student Project Ethics Committee.
Keywords: cervical spine, mobilisation, vertebral artery

PO3-CS-011
EXAMINING RADIAL NERVE EXCURSION DURING MOVEMENTS OF THE WRIST USING ULTRASOUND IMAGING
R. Ellis 1,*, B. Kasehagen 2, G. Mawston 1, S. Allen 3, W. Hing 2
1
Physiotherapy, AUT University, Auckland, New Zealand, 2Physiotherapy, Bond University, Gold Coast, Australia, 3Sound Experience, Auckland, New Zealand
Background: For several peripheral neuropathies (e.g. carpal tunnel syndrome) quantification of nerve movement or excursion is an important diagnostic
finding. Currently this is not the case for radial nerve neuropathies. For several clinical conditions (e.g. tennis elbow, radial tunnel syndrome etc.), impaired radial
nerve excursion is suspected. To ascertain whether impaired radial nerve excursion is indeed a factor, a method of real-time assessment is required. This study
utilised ultrasound imaging (USI) to quantify radial nerve excursion during wrist movements and to assess the reliability of this method. If shown to be reliable, USI
assessment of radial nerve excursion could be beneficial for the assessment of musculoskeletal disorders such as tennis elbow.
Purpose: The primary aim of this study was to quantify the amount of radial nerve excursion during active and passive movements of the wrist in different forearm
positions. The secondary aim was to assess the reliability of using USI to assess radial nerve excursion.
Methods: A controlled laboratory, cross-sectional study was conducted. Thirty healthy participants performed active and passive movements of the wrist (flexion and
ulnar deviation) to induce radial nerve excursion. These movements were performed with the elbow fully extended in both forearm supination and
pronation. Longitudinal radial nerve excursion was quantified using USI and frame-by-frame cross-correlation analysis for all test conditions along with the withinsession, intra-rater reliability. Electromyography was used to ensure no wrist muscle activity was present during passive tests. Wrist range of motion was measured
using an electrogoniometer.
Results: There was no statistically significant difference in mean radial nerve excursion between wrist flexion (1.29 0.05mm) and ulnar deviation (1.19 0.07mm)
(p=0.20). Forearm supination produced larger overall nerve excursion (1.41 0.32mm) when compared with forearm pronation (1.06 0.31mm) (p<0.01). Passive
wrist movements produced a mean 0.39 0.49mm greater (p<0.01) nerve excursion compared to those performed actively. Assessment of the reliability of
measuring longitudinal radial nerve excursion was moderate to high (ICC = 0.630.86, SEM 0.19-0.48mm).
Conclusion: There was no difference in radial nerve excursion when comparing wrist flexion to ulnar deviation. Radial nerve excursion is maximised with the forearm
supinated and with movements performed passively. USI is a reliable technique for assessing radial nerve excursion, in healthy people, during movements of the
wrist.
Implications: This study represents the first steps at ascertaining normative data for radial nerve excursion during the performance of different wrist
movements. From a clinical perspective placing the forearm in a supinated position combined with passive wrist flexion or ulnar deviation will maximise radial nerve
excursion. The technique developed in this study may provide a foundation for quantifying radial nerve excursion in the diagnosis and treatment of clinical conditions
such as tennis elbow and radial tunnel syndrome.
Ethics Approval: Ethics approval was provided by the Auckland University of Technology Ethics Committee (AUTEC) (application number 14/360).
Keywords: Radial Nerve, Reliability, Ultrasound Imaging

PO3-CS-013
MANAGEMENT OF HEADACHES BY PHYSIOTHERAPISTS IN IRELAND
A. Brady 1,*, J. Sugrue 2, C. Cunningham 3
1
Physiotherapy, Blackrock Clinic, 2Physiotherapy, Beaumont Hospital, 3School of Public Health, Physiotherapy and Sports Science, UCD, Dublin, Ireland
Background: Headaches are a prevalent condition with high personal and socioeconomic impacts (Wiendels et al., 2006). Physiotherapists aim to identify possible
cervical impairments contributing to or triggering headaches (Robertson and Morris, 2008). Research is limited on how physiotherapists assess and treat headaches
and how their practice complies with international guidelines on classification of headaches (International Headache Society (IHS), 2013), recognition of red flags
(NICE, 2012) and risk of cervical arterial dysfunction (International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT), 2012).
Purpose: The overall aim of this study was to determine the management of headaches by members of the Chartered Physiotherapists in Musculoskeletal Therapy
(CPMT) in Ireland, a specialist branch of the Irish Society of Chartered Physiotherapists (ISCP). More specifc objectives were to: 1.Explore knowledge of red flags
(NICE, 2012), volume of headache caseload and level of postgraduate education, 2.Establish use of IHS (2013) and IFOMPT (2012) guidelines and 3.Determine specific
outcome measures, assessment and treatment techniques utilised.
Methods: 448 CPMT members were surveyed in May 2014. The specifically designed 30-item anonymous cross-sectional survey comprised of five
sections: 1.Physiotherapist Profile, 2.Headache Undergraduate/Postgraduate Education, 3.Profile of Headache Patient Caseload, 4.Physiotherapy Assessment and
Diagnosis and 5.Physiotherapy Treatment Techniques. Data were analysed using descriptive statistics and chi square tests for subgroup analysis (Microsoft Excel
2011).
Results: A response rate of 26% (n=116) was achieved. Seventy-eight percent (n=91) of respondents reported managing headaches in their clinical practice with 74%
(n=65) treating three or less headache patients per month. Sixty-two percent (n=56) had completed a musculoskeletal postgraduate qualification. Of these, 88%
(n=49) stated that headache education formed part of the curriculum. Important red flags as identified by NICE (2012) were not recognised by all respondents (12%).
There were 7 red flags that less then 40% (n=48) of respondents recognised as red flags. When determining a headache type diagnosis 15% (n=12) of respondents
reported using IHS (2013) guidelines. The main types of headaches managed were cervicogenic, whiplash and tension-type headaches. IFOMPT (2012) recommended
objective tests such as cranial nerve examination, blood pressure measurement and handheld doppler ultrasound were reported to be performed by less than 19%
(n=15). The majority (66%) of respondents did not feel confident performing a cranial nerve examination. Frequent use (>80%) of upper cervical spine manual therapy
assessment techniques and a neurological examination was reported. Only half of respondents stated use of validated headache objective assessment tests such as
the flexion-rotation test and the craniocervical flexion test. Postural re-education, myofascial trigger point release, and deep neck flexor strengthening were the most
commonly used treatment techniques reported. Subjective (pain score and headache frequency/duration) rather than objective (headache diary, neck disability index
and headache disability questionnaire) outcome measures were predominantly used.
Conclusion: Due to low numbers of headache patients seen per month, physiotherapists may find it difficult to develop and maintain expertise in headache
management. Knowledge of red flags for the headache population was below expected standard. Further education on international guidelines, validated objective
assessments and outcome measures for the management of headaches is recommended. The questionannaire developed here could be utilised to capture
compartaive data in other jurisdictions.
Implications: This study has identified learning needs of physiotherapists in Ireland who manage patients with headaches which will inform future education.
Ethics Approval: An application was made to University College Dublin (UCD) Human Research Ethics Committee to exempt this study from ethical review and
exemption was granted. Permission was granted from the ISCP to email current members of the CPMT clinical interest group.
Keywords: Assessment, Headaches, Treatment

PO3-CS-014
CERVICAL PROPRIOCEPTION IN YOUNG ADULTS WITH AND WITHOUT NECK PAIN, WHO SPEND PROLONGED TIME ON MOBILE DEVICES: AN OBSERVATIONAL
STUDY.
S. Reid 1,*, A. Portelli 1
1
School of Physiotherapy, Australian Catholic University, North Sydney, Australia
Background: The use of mobile electronic devices (smartphones, tablets and laptops) has increased dramatically over the past few years. This has led to reports of
musculoskeletal symptoms such as neck pain, headaches and thumb pain. People with neck pain have been shown to have errors in proprioception, measured with
head repositioning accuracy (HRA) testing and this has been shown to improve with targeted treatment.
Purpose: Firstly, to survey Physiotherapy students about their mobile device usage and musculoskeletal symptoms. Secondly, to compare proprioception in young
adults with and without neck pain, who spend prolonged periods on mobile devices.
Methods: Physiotherapy students at Australian Catholic University, North Sydney were invited to complete a survey about the number of hours per day spent on
mobile devices such as smartphones, tablets and laptops and their musculoskeletal symptoms. Secondly, a two-group comparative observational study measuring
proprioception of 22 young adults with neck pain (60% female; mean age 21 3.5 years) and 22 without neck pain (68% female; aged 20.1 1.2 years), who spent
more than four hours a day on mobile devices was undertaken. Proprioception was measured with the HRA test during cervical flexion, extension, left and right
rotation. Intensity of neck pain was recorded with a visual analogue scale (VAS). T-tests were used to determine differences between groups and Pearsons bivariate
analysis was used to assess correlations.
Results: Ninety three students (65% female; mean age 21 years) completed the survey with 40% of students reporting they spent 2-3 hours, 28% 3-4 hours, and
27% >4 hours per day on mobile devices. Headaches were reported in 63%, neck pain in 43% and thumb pain in 24% of respondents. When participants who spend >
4 hours a day on mobile devices were assessed, those with neck pain were found to have significantly (p=0.02) poorer HRA (3.911.44) compared to asymptomatic
controls (2.951.17) during cervical flexion, but no difference between groups with other cervical spine movements. A moderate correlation (p<0.05) was found for
time spent on mobile devices and cervical spine pain intensity. Also, the greater the intensity of cervical pain, the greater were the deficits in head HRA during flexion.
Conclusion: University students are spending long periods of time on unsupported mobile devices and are reporting high levels of headache, neck and thumb pain.
These young people who spend long periods of time in sustained cervical flexion while on mobile devices exhibit poor proprioception into flexion which could indicate
that they have lost the ability to accurately determine where the normal straight ahead position is. The greater time spend on mobile devices, the greater the cervical
spine pain which lead to poorer proprioception in flexion.
Implications: The high proportion of young physiotherapy students with headache, neck and thumb pain could have implications on their working life as
physiotherapists. Students need to be educated in using the correct cervical spine position when on mobile devices. Interventions to retrain cervical proprioception
and cervical spine motor control may be required when treating patients who present with these problems.
Funding Acknowledgements: The Australian Catholic University
Ethics Approval: The ACU Human Research Ethics Committee (2013-334N).
Keywords: Cervical flexion, Neck pain, Proprioception

PO3-CS-015
DEVELOPMENT OF THE TAMPA SCALE FOR KINESIOPHOBIA FOR TEMPOROMANDIBULAR DISORDERS - JAPANESE EDITION: A PRELIMINARY STUDY
D. Uritani 1,*, T. Kawakami 2, N. Okazawa 2, T. Kirita 2
1
Department of Physical Therapy, Faculty of Health Science, Kio University, 2Department of Oral and Maxillofacial Surgery, Nara Medical University, Nara, Japan
Background: Musculoskeletal pain is influenced by psychosocial factors such as kinesiophobia, which is assessed by the Tampa Scale for Kinesiophobia (TSK).
Temporomandibular disorders (TMD) are also associated with kinesiophobia. Visscher et al. (2010) thus developed the TSK for Temporomandibular Disorders (TSKTMD). However, the TSK-TMD has not been validated in the Japanese population.
Purpose: This preliminary study aimed to investigate the validity and reliability of a Japanese version of the TSK-TMD.
Methods: There were 101 patients with TMD (84 women and 17 men, mean agestandard deviation (SD) 51.118.3 years) who visited dentists twice between
January 7 and June 2, 2015. We based the TSK-TMD Japanese First Edition (TSK-TMD-J) upon the original TSK-TMD translation and on the TSK Japanese version, with
permission from the original authors. The original author of the TSK-TMD also validated the quality of a reverse-translation of the TSK-TMD-J back into English.
Participants answered 12 items on the TSK-TMD-J. We calculated each participants total score, as well as mean, maximum, and minimum values of the total score.
We assessed the frequency distribution, because Terwee et al. (2007) suggested that a ceiling or a floor effect exists when more than 15% of all participants record
the maximum or the minimum score. We also calculated Cronbachs alpha to measure internal validity. At the second visit, patients gave a subjective account of
changes in their pathological condition, the patients global impression of change (PGIC), and an evaluation of subjective treatment effect (Farrar, et al. 2001). For
patients with no change in the subjective pathological condition (i.e. in stable condition) between visits, we assessed the test-retest reliability of the questionnaire by
calculating the intraclass correlation coefficient (ICC (1.1)). The statistical significance was set at p<0.05.
Results: The mean treatment period was 22.1 months. The meanSD total score of the TSK-TMD-J was 27.05.8. Maximum and minimum total scores were 43 and
13, respectively. Only one participant (1.0% of the study population) represented each maximum and minimum score. Cronbachs alpha was 0.86. The ICC (1.1) was
0.82 (95% confidential interval was from 0.70 to 0.90).
Conclusion: The TSK-TMD-J exhibits neither a ceiling nor a floor effect, as the maximum or the minimum score accounted for only 1.0% of the study population. The
results of this study also indicate that the TSK-TMD-J is an acceptable psychological scale since the calculated Cronbachs alpha of the questionnaire was more than
0.7 (Fayers, Machin 2005.). The test-retest reliability result of this study was high; the ICC (1.1) was 0.82. Landis and Koch (1977) demonstrated almost perfect
reliability when the ICC was between 0.8 and 1.0. Future studies will focus on the evaluation of construct validity of the TSK-TMD-J.
Implications: The results of this study indicate that the TSK-TMD-J is a useful questionnaire for assessing kinesiophobia of Japanese patients with TMD and help in
determining the value of a therapy in clinical practice. The results of this study should be useful in designing future studies and also will facilitate the comparison of
results across studies.
Funding Acknowledgements: This study was unfunded.
Ethics Approval: The Research Ethics Committee of Kio University (H27-01) and Nara Medical University (1019) approved the study.
Keywords: Kinesiophobia, questionnaire, temporomandibular disorders

PO3-CS-016
A VISUAL FEEDBACK SYSTEM OF THE BITE FORCE TO ASSESS JAWS MOTOR CONTROL IN UNILATERAL AND BILATERAL ISOMETRIC CONDITIONS
M. Testa 1,*, T. Geri 1, S. Roatta 2
1
Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Savona, 2Neuroscience, University of
Torino, Torino, Italy
Background: The assessment of the jaw function is usually based on measurements of quantitative variables like the range of movement and the maximal voluntary
contraction of elevator muscles and on evaluation of qualitative aspects like standard bolus comminution.
Although the precision and accuracy of the bite force delivery are relevant aspect of jaw motor control and possible outcomes supporting temporomandibular joint
rehabilitation, their assessment has received still too little attention.
Purpose: To develop a visual feedback system of the unilateral and bilateral bite force in order to assess the precision and accuracy of muscles motor control in
isometric condition and to construct rehabilitation exercises tailored on the patients impairments.
Methods: Two groups of seventeen and thirteen healthy volunteers participated in the study. They were respectively required to perform a unilateral and a bilateral
task biting over two force transducers positioned between the molar teeth. A training period was provided at the beginning of each task to improve familiarization
with the system.
The unilateral task consisted in a series of isometric unilateral biting lasting 5 seconds each to match 9 force targets.
The bilateral task consisted in coordinating right and left bite force in order to match 23 reference targets, representing symmetrical and asymmetrical jaw clenching.
Force targets and the level of the force delivered by the subjects were displayed on a pc screen as real time feed-back of the performance. Each exercise was
repeated three times in a first session and the two conditions were repeated in a second session the next day to evaluate reliability and learning effects.
The force performance was assessed with indices of accuracy (mean distance, MD and offset error, OE) and precision (standard deviation, SD).
The Intraclass Correlation Coefficient (ICC) was used to analyze the relative reliability of the indices while the Pearsons r was used to assess their concurrent validity.
An ANOVA for repeated measures was used to investigate any learning effect the day after.
Results: The proposed system was easily handled as the visual feedback was intuitively driven by the participants.
In the unilateral task, MD, OE and SD had ICC values of 0.74, 0.76 and 0.88, respectively. There were high correlations (all r > 0.7) between left and right sides,
between indices and intensity of contraction and among indices.
In the bilateral task, the ICCs of MD, OE and SD were, respectively, 0.78, 0.66 and 0.78. MD and OE were highly correlated (r = 0.97) while SD neither showed
correlation with MD (r = 0.7) nor OE (r = 0.15).
The repeated measures ANOVA revealed a dependence of indices on session (P < .05) for both the unilateral and bilateral conditions with all indices reduced in the
second session.
Conclusion: An innovative system is proposed which provides a visual feedback of the unilateral and bilateral biting force.
The motor performance is characterized using indices of accuracy (MD and OE) and precision (SD) which resulted to be sufficiently reliable.
The significant learning effect occurring in the second session could be attributed to the visual feedback that normally does not constitute a physiologic system of
control of clenching force.
Implications: The system may be used for the assessment and the rehabilitation of a variety of patients with clinical conditions affecting the jaws motor control.
Ethics Approval: This study received approval by the Ethics Committee of the University of Torino.
Keywords: bite force, motor control, temporomandibular joint

PO3-CS-018
AN INVESTIGATION INTO THE EFFECTS OF A TRIGGER POINT RELEASE TECHNIQUE TO TRAPEZIUS ON PERIPHERAL SYMPATHETIC NERVOUS SYSTEM ACTIVITY AND
PRESSURE PAIN THRESHOLDS IN THE UPPER LIMB.
J. Perry 1,*, H. Poel-Bonnett, E. Hutton, R. Dixey
1
Health Professions, Coventry University, Coventry, United Kingdom
Background: Myofascial trigger points (MFTrPs) significantly contribute to musculoskeletal dysfunction particularly in the neck & shoulder region. Ischaemic
Compression Technique (CT), a form of manual therapy, has been shown to be one of the most effective treatments of MFTrPs. Evidence suggests links between
joint-based manual therapy approaches & changes in sympathetic nervous system (SNS) activity & with mechanical hypoalgesia, as measured by pressure pain
threshold (PPT) algometry. However, research investigating these effects on myofascial structures & the treatments utilised to manage symptoms are lacking.
Furthermore, none have correlated SNS and PPT findings in MFTrP treatments which may provide valuable insight into the mechanisms of action of CT.
Purpose: To determine if ischaemic CT, to a latent MFTrP in upper fibres of trapezius (UFoT), produces a SNS response that correlates to changes in PPT.
Methods: A double-blind randomised controlled trial recruited 45 healthy volunteers (age 18-35yrs, 40% male) into one of 3 independent groups; control (no
treatment), placebo (light touch; 3 x 60 seconds) and intervention (CT; 3 x 60 seconds) applied to UFoT mid-belly. Outcome measures were taken from the ipsilateral
limb & included i) SNS recordings of skin conductance (SC) activity from pre- to peri- treatment periods (from index & middle fingers) and ii) mechanical PPT
algometry from pre- and post-treatment periods (applied at the 1st interosseous space). Data was transformed into percentage change for each outcome measure &
analysed using GLM (one-way ANOVA) & Pearsons correlation coefficient with significance levels set at 95%.
Results: The CT intervention group experienced a significant increase in SC (92.9%, p=<0.005; F=18.046; df 2) that was greater than placebo (7.8%, p<0.005) and
control (3.2%, p<0.005) conditions. Furthermore, a significant increase in PPT was observed following CT treatment (23.0%, p < 0.005; F=29.451; df = 2) compared to
the control condition (-4.5%, p < 0.005). Conversely a significant decrease in PPT occurred following the placebo condition (-22.1%, p<0.015). Correlation analyses
revealed a significant (p<0.005) moderate positive correlation (r=0.509) between SNS excitability & hypoalgesic responses following application of CT.
Conclusion: Results suggest CT applied to latent MFTrPs in UFoT result in sympathoexcitation & immediate mechanical hypoalgesia in the ipsilateral hand.
Furthermore, light touch (a low-threshold stimulus) may elicit a central sensitising effect. The findings provide a unique insight into the effects of myofascial therapy
approaches. Methodological limitations & further areas of research are discussed.
Implications: CT produces significant therapeutic hypoalgesia via the descending inhibitory pain modulation system. Care may be needed with low-threshold
stimulation techniques.
Funding Acknowledgements: unfunded
Ethics Approval: Ethical approval from Coventry University (Ref:P29208)
Keywords: Hypoalgesia, sympathetic nervous system activity, Trigger point ischaemic compression therapy

PO3-CS-020
DIFFERENCES IN TACTILE ACUITY AND WORKING BODY SCHEMA BETWEEN MUSICIANS AND NON-MUSICIANS
T. Amorim*, R. Silva , M. Thacker
Background: Performing music is a complex task that requires advanced and exceptional skills and extensive practice. Learning through experience and training is
accompanied by the development of multimodal sensory and motor skills. This induces neuroplasticity changes in the central nervous system at cortical and
subcortical levels. In addition, classical musicians with pain have been reported to have changes in quantitative sensory testing consistent with central sensitization
pain mechanisms and maladaptive cortical reorganization.
Purpose: The aim of this project was to examine whether classical musicians had different working body schema, painDETECT questionnaire (PD-Q) scores and twopoint discrimination (TPD) thresholds compared to non-musicians. This project also intended to examine the difference between symptomatic and asymptomatic
musicians and non-musicians.
Methods: Data was collected from twenty-five classical musicians and seventeen non-musicians. Motor imagery performance (MIP), TPD and PD-Q were used to
assess the different groups. Comparisons were made between musicians, non-musicians, symptomatic musicians and asymptomatic musicians. All participants
performed the MIP task ausing the software application Recognise (NOI, Australia). TPD was assessed using a mechanical sliding calliper (Digital Vernier 300mm). PDQ was included to screen for the presence of significant neuropathic component. Statistical analysis was performed using the SigmaPlot12.
Results: There were no differences in accuracy or reaction time of MIP between musicians and non-musicians (p>0.05). Musicians scored significantly higher on the
PD-Q compared to non-musicians (p<0.001). Symptomatic musicians also achieved significantly higher scores on the PD-Q compared to non-musicians (right
arm/hand pain p=0.002; left arm/hand pain p<0.001) and also to asymptomatic musicians (p=0.007). PD-Q score was positively correlated with the number of years
playing as a professional (r=0.046, p=0.034). Musicians had a significantly larger TPD threshold than non-musicians (p=0.035). Asymptomatic musicians
demonstrated less accuracy compared to non musicians(p=0.041), whereas no differences in TPD were found between symptomatic musicians and non-musicians
(p>0.05). Symptomatic musicians had lower TPD thresholds compared to asymptomatic musicians (p<0.05). A negative correlation was found between TPD
thresholds and the number of years playing (r=-0.523, p=0.007) and the numbers of hours of practice (r=-0.5, p=0.011).
Conclusion: Classical music performance and training might exert a negative effect on sensory discrimination acuity and and increase in PD-Q scores. However, no
changes were identified in the MIP task. The mechanisms that underline impairment of MIP have previously been attributed to a disrupted body schema. Therefore,
consideration should be given to peripheral and spinal cord mechanisms when assessing and treating this population.
Implications: A growing body of evidence suggests that the experience of pain may be associated with maladaptive cortical reorganization. However, this study shows
that in this population the mechanisms underlying their pain experience may be primarily related to peripheral and subcortical mechanisms. In view of these results it
is recommended that clinicians should consider the presence of underlying neuropathic pain mechanisms when assessing and treating classical musicians. It is
recommended to consider the use of appropriate and validated tools in order to assess the status of the peripheral and central nervous system. The use of
established classification systems and clinical reasoning models, accurate sensory testing and neuropathic pain screening questionnaires should also be considered. A
greater understanding of pain mechanisms underlying the experience of pain may lead to the development and the application of appropriate treatment strategies
strategies for classical musicians.
Funding Acknowledgements: This work was unfounded
Ethics Approval: Kings College London Ethics Committee RSC BDM/14/15-55
Keywords: body schema, two-point discrimination, tactile acuity, motor imagery performance, left/right judgment, musicians, painDETECT, neuropathic pain.

PO3-CS-021
INFLUENCE OF KINESIOPHOBIA AND SYMPTOMS OF CENTRAL SENSITIZATION ON MOTOR BEHAVIOUR IN PATIENTS WITH CHRONIC NECK PAIN.
R. De Pauw 1,*, I. Coppieters 1, L. Danneels 1, B. Cagnie 1
1
Rehabilitation Sciences and Physiotherapy, Ghent University, Ghent, Belgium
Background: Patients who suffer from neck pain often demonstrate deficits in their motor behaviour when compared to healthy controls (HC). Besides, some of these
patients show signs of kinesiophobia and central sensitization. Although tremendous evidence is available for these features, not many studies have focused on
differences between patients suffering from idiopathic neck pain (INP) and whiplash associated disorders (WAD).
Purpose: This study aims to demonstrate differences in motor control between HC, patients with chronic INP, and patients with chronic WAD and potential
associations between motor control and symptoms of central sensitization and kinesiophobia.
Methods: 29 HC, 37 patients with INP, and 34 patients with WAD were included in this study (female, mean age: 36.29). Inclusion criteria for patients were: suffering
from chronic neck pain for more than three months and Neck Disability Index (NDI) 10. Patients suffering from WAD were only included if they were classified as
WAD II following the Quebec Task Force criteria. Mobility (Algometer) and joint position error (JPE) were measured in all three groups. In addition, a force index was
computed by dividing every value by the average force found in the control group for each of the four force-components [side bending, flexion, and extension force
(Hand-held dynamometer)]. Kinesiophobia, central sensitization and disability were measured using the Tampa Scale (TSK), Central Sensitization Inventory (CSI) and
NDI respectively. An ANCOVA analysis controlling for age with post-hoc Tuckey-HSD correction was performed at the 5% significance level. Afterwards, multiple linear
regression was used to look for associations between TSK, CSI and motor behaviour.
Results: Both groups of patients seem to suffer from kinesiophobia and symptoms of central sensitization compared to HC. However, no differences were found
between both patient groups for kinesiophobia. In contrast, disability and symptoms of central sensitization seems to be worse in patients with chronic WAD. In
contrast, no significant differences were found for JPE between the three groups. Furthermore, patients suffering from chronic WAD seem to demonstrate greater
deficits in motor control then patients with chronic INP for force in all directions and mobility in the flexion-extension direction. Multiple regression analysis showed a
significant contribution of TSK (= - 0.01, p = 0.04) and CSI (= - 0.01, p < 0.001) to force. Every increase in points on the TSK or CSI corresponds with a decrease of 0.01
on the force-index. In contrast, only the CSI (= - 1.08, p < 0.001) seems to be associated with the flexion-extension mobility of patients. An increase in one unit on the
CSI corresponds with a decrease of 1.08 in mobility.
Conclusion: Overall, patients seem to demonstrate deficits in motor control and signs of kinesiophobia and central sensitization. However, patients with chronic WAD
show a higher degree of motor control dysfunction and more symptoms of central sensitization. Mobility was associated with kinesiophobia and symptoms of central
sensitization, whilst force was only associated with symptoms of central sensitization.
Implications: The presence of symptoms of central sensitization and kinesiophobia in chronic neck pain patients seems to be associated with mobility and force.
Therapists should try to address these features in their therapy program attempting to solve the patients complaints.
Funding Acknowledgements: No funding was received for this work.
Ethics Approval: Ethical approval was given by the ethical committee of the Ghent University Hospital.
Keywords: Kinesiophobia, motor skills, sensitization

PO3-CS-022
"INFLUENCE OF AN UPPER CERVICAL THRUST ON THE MOTOR CONTROL OF THE NECK: A SINGLE BLIND RANDOMIZED TRIAL"
R. Hage 1,*, F. Dierick 1, P. Thiry 1, S. Ahmadi 2
1
Unit de Recherche Forme & Fonctionnement Humain, Haute Ecole Louvain en Hainaut (HELHa), Montignies-sur-Sambre, Belgium, 2EA-3300: APERE Exercise
Physiology and Rehabilitation laboratory and 2IS department, Medical Faculty, Picardie Jules Verne University, Amiens, France
Background: Since 2009, we have undertaken research for the assessment of the neck motor control with a device called the Didren Laser (Hage R et al. Annals of
Physical and Rehabilitation Medicine 2009; 52:653-667). Because spinal manipulation is closely related to motor control of the cervical spine (Heikkila E et al. Manual
Therapy 2000; 5:151-157; Sterling M et al. Manual Therapy 2001; 6:7281), we wanted to assess the effect of a single thrust technique on motor control of head-neck
segment in the horizontal plane.
Purpose: The aim of this study was twofold:
(1) To assess the short-term effect of a manipulative thrust technique applied to C2, on the motor control of low-amplitude rotational head movements on 3 different
randomized groups of healthy subjects: treatment (T), control (C) and placebo/sham (P);
(2) To set up a preliminary study on healthy subjects before including neck pain patients.
Methods: We carried out a test,using the Didren laser device (Hage et al. 2009), in which a sequence of small amplitude rotational neck movements was timed
(head rotation of 30 to the left and to the right, alternately) by monitoring the laser beam targeting (fixed on a helmet) on 3 photodetectors placed at 90cm of the
subject (1 to the left, 1 to the right and 1 in front of the subject). The test was performed, before and after intervention, by 48 healthy under and post-graduate
students recruited from our physical therapy department. Volunteers were randomly divided into 3 groups (12 control, 12 placebo/sham and 24 treatment subjects)
by an experimented manual therapist who also performed the physical maneuver. Researchers assessing the outcomes were blinded to the participants' group
assignments.
Motor control outcome measures were based on the time-related performance of the subjects and included: the total time of the test, and the mean time on the left
and right sides.
Results: Groups were similar at baseline since no significant differences between groups were observed before intervention (one-way ANOVA). Significant differences
were observed after intervention in the 3 groups for the total time, the mean time on the left and the right sides of the test (two-way RM ANOVA [group x time]; total
time, F=11.58, P=0.001, Power= 0,907; mean time on right, F=7.04, P=0.011; Power= 0,675; mean time on left, F=12.48, P<0.001, Power= 0,929).
Conclusion: Our results showed that total and mean time on left and right sides were not influenced by the manipulative thrust technique applied to C2. In contrast, a
training effect has been observed for all subjects, whatever the group studied.
The experimental protocol and the kinematic outcome measures computed are sufficiently sensitive to highlight a short-term training component in healthy subjects.
Additional investigations will be required in neck pain patients. Furthermore, measures related to the quality of motor control of head-neck segment, such as the jerk,
must be implemented.
Implications: A better understanding of the motor control of head-neck segment in the horizontal plane and the effect of upper cervical thrust on it is of major
importance for the manual therapist in the management of the patients suffering from neck pain. The Didren Laser device seems to be a promising tool to assess
altered motor control of head-neck segment.
Ethics Approval: Participants gave a written informed consent before taking part of the study. No ethics committee was required since the experiment was
considered a normal part of physical therapy educational practice.
Keywords: Upper cervical, Thrust, Motor Control

PO3-CS-023
SCAPULOTHORACIC MUSCLE STRENGTH CHANGES FOLLOWING MANUAL THERPAY AND EXERCISE IN SUBJECTS WITH NECK PAIN
S. Petersen*, C. Cook, C. Wells, C. Postma, N. Domino
Background: Scapulothoracic muscle weakness has been associated with neck pain (NP). Little evidence exists regarding lower trapezius (LT), middle trapezius (MT)
and serratus anterior (SA) strength in this population. Improvements in LT strength have been observed following thoracic manipulation in healthy subjects, but
scapulothoracic strength changes following spinal manual therapy have not been examined in a NP population.
Purpose: The purpose of this study was to examine scapulothoracic muscle strength changes following manual therapy to the cervical spine and neck range of motion
(ROM) exercises in subjects with NP.
Methods: Twenty-two subjects with NP and 17 asymptomatic control (AC) subjects underwent strength testing of the LT, MT, and SA using a hand-held
dynamometer. Subjects with NP were treated with a single session of manual therapy to the cervical spine and were instructed in neck ROM exercises. The AC group
received no intervention. Strength testing was repeated after the manual therapy intervention, then 48 and 96 hours later. Change scores were calculated for
strength change over time. Independent t-tests were done for strength change between the NP group and AC group.
Results: There was a significant difference between the NP group and AC group for strength change over time in the LT (p<0.01); MT (p<0.01); and SA (p<0.01). In all
muscles examined, subjects in the NP group who received intervention showed significantly greater strength improvement over the 96-hour time period compared to
the AC group.
Conclusion: Scapulothoracic muscle strength improvements were observed following manual therapy and neck ROM exercises in subjects with NP. Strength
improvements lasted up to 96 hours, even though no strengthening exercises were prescribed.
Implications: Strength of the LT, MT, and SA muscles should be examined in patients with neck pain. Manual therapy and neck ROM exercises may contribute to
scapulothoracic muscle strength improvements in patients with NP. This combination of interventions should be considered as a component of a rehab program for
patients with NP and scapulothoracic muscle weakness.
Funding Acknowledgements: Cardon Rehabilitation Grant
Ethics Approval: This study was approved by the Des Moines University Institutional Review Board.
Keywords: axioscapular, manipulation, scapula

PO3-CS-024
THORACIC DYSFUNCTION IN WHIPLASH ASSOCIATED DISORDERS: A SYSTEMATIC REVIEW AND META-SYNTHESIS
N. Heneghan*, R. Smith 1, A. Rushton 1
1
School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
Background: WAD research has largely focused on the neck, yet symptoms often include other areas. The prevalence of acute thoracic spine pain is reported ~66%,
which is perhaps unsurprising given the mechanism of injury involves a forceful loading/eccentric contraction of posterior thoracic structures such as trapezius. Many
individuals with WAD experience disability & pain beyond normal tissue healing time, termed chronic WAD. With the thoracic spine contributing to neck mobility, and
23% of individuals complaining of thoracic pain one year post injury, it is time to look beyond the neck to fully understand anatomical dysfunction in WAD.
Purpose: An evidence synthesis is needed to examine dysfunction in the thoracic spine region in individuals with WAD. Knowledge of thoracic dysfunction (TD) may
be used to inform clinical practice and trials of interventions targeting TD in WAD.
Methods: A systematic review was designed using CRD guidelines, reported using PRISMA, MOOSE guidelines and registered with PROSPERO. A sensitive topic-based
search strategy was designed from inception to 1/09/15. Databases, grey literature & registers were searched using terms and key words derived from scoping
search. Two reviewers independently searched information sources, assessed studies for inclusion & extracted data. A third reviewer checked for accuracy. Extracted
data included summary data: sample size & characteristics, outcomes of interest, and timescales to reflect disorder state. Risk of bias was assessed using the
Newcastle-Ottawa Scale. Data was presented in tabulated form using qualitative meta-synthesis approach & grouped according to outcome, stage post injury and
severity. Strength of the overall body of evidence was assessed using GRADE.
Results: From searching 498 records were retrieved, with 14 studies (from case studies to large observational cohorts) being included in the evidence synthesis.
Thoracic pathologies and dysfunction reported in WAD include thoracic disc pathology, long thoracic & spinal accessory nerve injury, alteration in trunk sway,
trapezius myofascial-enthesal dysfunction, thoracic myofascial trigger points, alteration in activity of serratus anterior and several studies reporting thoracic outlet
syndrome (n=5). Most data related to chronic presentations and unclassified presentations, although some evidence exists for acute WAD and WADII. Quality of
included studies range from poor to good, often a consequence of poor reporting.
Conclusion: There is evidence, albeit low quality of TD in WAD involving structures including nerves, disc & muscles. Further research is required to fully describe TD
in WAD, including the effect of injury on thoracic joints/mobility; something that is a notable omission from the current evidence.
Implications: Anatomical dysfunction post WAD is not exclusive to the cervical spine and evidence of TD should be a consideration for clinicians examining patients
with WAD. Findings of this research support the need for further investigation of TD in WAD
Ethics Approval: Not required
Keywords: systematic review, thoracic dysfunction, whiplash, new directions,

PO3-CS-025
CRANIO-CERVICAL STABILITY OF CERVICAL FLEXOR MUSCLES IN HEALTHY ADULT MALES
K. Hazaki*, N. Kawano, N. Ogushi
Background: The longus colli (LC) is attached to the antero-external surface of the cervical vertebrae and it is thought to stabilize the cranio-cervical region. However,
the effects of the LC on cranio-cervical stability have not been investigated in detail.
Purpose: The present study aimed to determine the effect of the LC and sternocleidomastoideus (SCM) muscles on cranio-cervical stability by measuring muscle
thickness while external force was applied to the head.
Methods: The muscle thickness of the LC and SCM of 20 healthy males (mean age, 20.3 0.9 y) was measured on the right side using ultrasonography (US) with a 10MHz linear array probe placed parallel to the vertical axis running external to and 2 cm inferior from the thyroid cartilage and tilted 20 inward in the median sagittal
plane. External force was applied horizontally to the rear, 2-3 cm above the smooth part of the forehead above and between the eyebrows, and 20 degrees inside
the back of the right and left frontal eminence. The amount of applied external force strength measured using a hand dynamometer was none and 1, 2 and 3 kgw.
The participants were seated in a neutral position, with their hips and knees bent 90, with the arms lying along the sides of the body. The participants were asked to
hold their cranio-cervical region against each external force for at least five seconds while US images of the LC and SCM were acquired. The thickness of the LC and
SCM muscles was measured on US images using ImageJ image analysis software. All data were normalized as ratios of the baseline data without a load. Changes in
normalized muscle thickness in the three directions at four grades of force strength were evaluated by two-way repeated ANOVA and Scheff multiple comparison
tests.
Results: The normalized muscle thickness of the LC and SCM did not significantly differ in any direction at any force strength.The main effect of force strength
significantly differed (p < 0.001), whereas main effect of direction did not. The thickness of the LC and SCM muscles significantly differed between 1 and 2, 1 and 3,
and 2 and 3 kgw (all p < 0.001).
Conclusion: The LC and SCM stabilized the cranio-cervical region because the LC and SCM muscles thickened with increasing external force strength. Furthermore, the
right and left LC and SCM muscles seemed to contract to stabilize the cranio-cervical region because the direction of the external force did not alter stability.
Implications: The LC and SCM do not have the relationship of the intrinsic muscles and the extrinsic muscles, and both muscles appear to synergistically contract to
maintain cranio-cervical stability in healthy males.
Funding Acknowledgements: Nothing
Ethics Approval: This study is a part of the study that received the approval by the Ethical Committee about the study and the education for the organism in Osaka
Electro-Communication University ( No.14-007).
Keywords: longus colli, sternocleidomastoid, ultrasonography

PO3-CS-026
INTRAOPERATOR RELIABILITY OF MRI-BASED AREA MEASUREMENT OF INTERVERTEBRAL FORAMINA IN THE CERVICAL SPINE
H. Usa 1,*, H. Takei 2, M. Hata 2 3, H. Kamio 1, N. Shida 1, A. Senoo 4
1
Division of Physical Therapy, Faculty of Health Sciences, 2Department of Physical Therapy, Graduate School of Human Health Sciences, Tokyo Metropolitan
University, 3Senkawa-Shinoda Orthopedic Clinic, 4Department of Radiological Sciences, Graduate School of Human Health Sciences, Tokyo Metropolitan University,
Tokyo, Japan
Background: Nerve roots exist in intervertebral foramina in the spine. Compression of nerve roots and spinal nerves due to narrowing of the foraminal space often
causes various symptoms in spinal disease (e.g., a herniated disk and spondylosis deformans). Thus, it is important to measure the area of the intervertebral foramen
and to assess its changes. Magnetic resonance imaging (MRI) is often used for accurate area measurement of intervertebral foramina. However, to the best of our
knowledge, its reliability has not yet been tested in detail.
Purpose: This study aimed to investigate the intraoperator reliability of MRI-based area measurement of intervertebral foramina in the cervical spine.
Methods: Subjects were 11 young healthy adults without a past history of neck problems (mean age, 21.1 years; range, 1926 years). The mean value and standard
deviation (in brackets) for height was 162.9 (8.2) cm, and that for weight was 57.1 (7.9) kg. The operator was a physiotherapist with 12 years experience. An MRI
scanner (Achieva 3.0T, Philips Electronics Japan) was used to acquire images of the neck in the supine position with the neck positioned in its neutral position. Areas
of both the right and left intervertebral foramina from C2/3 to C7/T1 were measured using the 3D MPR function of the image analysis software OsiriX Lite 7.0.
Statistical analysis software IBM SPSS Statistics Ver. 20 was used to calculate the intraoperator intraclass correlation coefficient (ICC) of the areas of each
intervertebral foramen. The BlandAltman analysis was performed to examine the types of intraoperator errors. A 95% confidence interval for the minimal
detectable change (MDC95) was calculated to test limit values that represent true change in measurements of intervertebral foraminal areas.
Results: The mean areas and standard deviations (in brackets) of the first and second measurements (in cm2) of both sides of intervertebral foraminal areas were as
follows: 1.37 (0.18) and 1.40 (0.20) for the right, and 1.43 (0.19) and 1.43 (0.16) for the left at C2/3, respectively; 1.26 (0.19) and 1.29 (0.17) for the right, and 1.27
(0.12) and 1.26 (0.12) for the left at C3/4; 1.37 (0.20) and 1.31 (0.19) for the right, and 1.35 (0.20) and 1.40 (0.19) for the left at C4/5; 1.36 (0.27) and 1.33 (0.24) for
the right, and 1.32 (0.22) and 1.26 (0.22) for the left at C5/6; 1.37 (0.25) and 1.36 (0.23) for the right, and 1.22 (0.24) and 1.17 (0.24) for the left at C6/7; 1.17 (0.15)
and 1.16 (0.18) for the right, and 1.12 (0.20) and 1.13 (0.21) for the left at C7/T1, respectively. The ICCs (1, 1) were 0.840.91. The BlandAltman analysis revealed
that errors were of a random type. Respective MDC95 values (in cm2) for the right and left areas were: 0.17 and 0.20 at C2/3; 0.21 and 0.14 at C3/4; 0.16 and 0.17 at
C4/5; 0.21 and 0.16 at C5/6; 0.21 and 0.23 at C6/7; 0.18 and 0.18 at C7/T1.
Conclusion: The ICC, an index of relative reliability (agreement), was 0.8 or higher in the measurement of every intervertebral foramen, indicating that the method
shown in this study is reliable and can be used in the analysis of intervertebral foraminal areas. Errors of this method belong to the random type. Thus, with respect
to absolute reliability (accuracy), errors can be reduced by repeating the test under identical conditions, and by using the mean of test results as a representative
value. Furthermore, MDC95 results indicated that differences 0.2 cm2 were likely to be measurement errors.
Implications: The method measuring intervertebral foraminal areas, shown in this study, is highly reliable, and can be used in establishing scientific evidence for
therapeutic effect of joint mobilization in cervical spinal disease resulting from nerve root compression.
Funding Acknowledgements: This work was supported by Tokyo Metropolitan University.
Ethics Approval: The Research Safety and Ethics Committee of the Tokyo Metropolitan University, Arakawa Campus (approval number 13041).
Keywords: cervical spine, intervertebral foramina, MRI

PO3-LB-039
CORRELATION BETWEEN LUMBAR DYSFUNCTION AND FAT INFILTRATION IN LUMBAR MULTIFIDUS MUSCLES IN PATIENTS WITH LOW BACK PAIN
M. Hildebrandt 1,*, G. Fankhauser 1, A. Meichtry 1, H. Luomajoki 1
1
Institute of Physiotherapy, Zurich University of Applied Sciences, Winterthur, Switzerland
Background: Lumbar multifidus muscles (LMM) are important for spinal stability. Low back pain (LBP) is often associated with fat infiltration in LMM. Studies
investigating the association between low back dysfunction and fat infiltration plus their implication for physical rehabilitation are still sparse.
Purpose: The purpose of this study was to evaluate the relationship between the severity of lumbar dysfunction and the extent of fat infiltration of LMM and its
implications for exercise strategies of lumbar muscles in patients suffering from LBP. We hypothezised that increased fat infiltration of LMM is correlated with
impaired lumbar flexion (LF) and impaired movement and posture control.
Methods: In a cross-sectional study, 42 individuals with acute or chronic LBP were recruited. Their MRI findings were visually rated and graded using three criteria for
fat accumulation in LMM: Grade 0 (0-10% fat), Grade 1 (10-50% fat) and Grade 2 (>50% fat). Lumbar sagittal range of motion (Spinal Mouse), dynamic posture
control (Spinal Mouse), sagittal movement control (movement control tests), body awareness (two-point discrimination tests) and selfassessed functional disability
(Oswestry disability index) were measured to determine the subjects low back dysfunction. For each response a linear model was fitted to the data using fat, gender,
age, duration of LBP and body mass index as covariates. Pairwise contrasts between the fat-grades were estimated. We were interested in the covariate-adjusted
effect of fat on the outcomes.
Results: The main result was that increased severity of fat infiltration in the lumbar multifidus muscles correlated with decreased range of motion of lumbar flexion
(p=0.032). Pairwise contrasts between the fat-grades indicated a significant difference between Grade 1 and Grade 2 (12.42 degrees, 95% CI 0.513, 24.3). None of the
covariates (age, gender, body masss index and duration of LBP) were associated with impaired LF. No significant correlation was found between the severity of fat
infiltration in LMM and impaired movement control, posture control, body awareness or functional disability.
Conclusion: Fat infiltration of lumbar multifidus muscles correlates with reduced range of motion of lumbar flexion but not with impaired movement and posture
control. Whether asymptomatic subjects with decreased LF also demonstrate increased fat infiltration of LMM is unknown and has to be investigated.
Implications: This is the first study investigating the relationship between the severity of fat infiltration in LMM and the severity of lumbar dysfunction. The presented
findings could have implications for the treatment of LBP. There is evidence that exercise therapy is effective in treating chronic LBP. However, if patients with LBP
and fat infiltration of LMM demonstrate decreased lumbar flexion, exercise strategies that stimulate co-contraction of large trunk muscles may enhance stiffness and
therefore should perhaps not be chosen. Active and passive mobilisation of lumbar segmental stiffness and specific stabilizing exercises might be more efficient for
this subgroup. Further research is necessary to provide evidence whether these strategies are effective for the treatment of LBP and for the prevention of progressive
atrophy of LMM.
Funding Acknowledgements: Unfunded but supported by Zurich University of Applied Sciences, Switzerland.
Ethics Approval: Harmlessness of the study was approved by local ethic authorities.
Keywords: fat infiltration, low back pain , multifidus muscle

PO3-LB-042
RED FLAGS ASSOCIATED WITH THE EARLY DETECTION OF METASTATIC BONE DISEASE AS A CAUSE OF BACK PAIN
L. Finucane*
Background: The incidence of serious pathology causing back pain is around 1 in 100 patients in clinical practice, with one of the commonest being metastatic bone
disease (MBD). MBD is caused by a number of primary cancers but most commonly breast, prostate and lung cancers. The most commonly described symptom of
MBD is back pain which has a prevalence of 80% in the general population, which makes it difficult to diagnose clinically. Identification of MBD is supported by a
history of cancer, including the type of cancer and time since diagnosed, along with the presence of low back pain. Red flags which increase suspicion of serious
pathology are typically late stage manifestations of the disease (weight loss, unremitting pain, fever) when outcome is poor. Currently there is limited evidence of the
early signs of MBD.
Purpose: To identify the red flags associated with the early signs of MBD in people presenting with back pain with a history of a primary diagnosis of breast, prostate
and/or lung cancer.
Methods: A literature review was carried out to investigate whether the clinical presentation could be used to identify the early signs and symptoms of MBD arising
in breast, prostate and lung cancer.
Results: The literature review did not find any evidence of a clinical presentation that would help identify MBD. No combination of factors could be used reliably or
with sufficient sensitivity and specificity to be of value in identifying patients with MBD. Not all patients with a primary diagnosis of breast, prostate and lung cancer
will go on to develop metastatic disease and there was no evidence to support investigating all patients with back pain and a previous history of cancer. The risk
factors of developing MBD were identified as tumour size, nodal involvement, stage, and type of cancer at initial diagnosis.
Conclusion: Identifying patients with serious pathology is challenging for clinicians. Current red flags do not help to identify early signs of MBD in those patients with
a primary diagnosis of breast, prostate or lung cancer. Understanding how patients clinically present in the early stages could help in early diagnosis and improve
outcome for patients. Further research into patients experience of MBD would be useful to improve our knowledge of signs and symptoms that may help in
identifying MBD.
Implications: Knowing the risk factors associated with MBD may help clinicians make early and appropriate clinical decisions for further investigation for patients
presenting with low back pain and result in better patient outcomes.
Funding Acknowledgements: this work was unfunded
Ethics Approval: Ethis was not required
Keywords: Back pain, metastatic, Red flags

PO3-LB-043
EXPLORING CHRONIC LOW BACK PAIN (CLBP) BELIEFS AND LIVED EXPERIENCES IN A MULTI-ETHNIC POPULATION
G. Singh 1 2, C. Newton 1, K. O'Sullivan 3, A. Soundy 2, N. Heneghan 2,*
1
University Hospitals of Leicester, Leicester, 2University of Birmingham, Birmingham, United Kingdom, 3University of Limerick, Limerick, Ireland
Background: CLBP-related disability is associated with beliefs and experiences, which are influenced by culture, religion and interactions with healthcare practitioners
(HCPs). UK HCPs encounter people from many different cultures and ethnic backgrounds of which South Asian Indians (including Punjabis) form the largest ethnic
minority group. Resultantly, HCPs need to understand the beliefs and experiences of ethnic minorities, in order to facilitate efficacious management of CLBP within a
bio-psychosocial framework. To date, no studies have explored CLBP beliefs and experiences in UK Punjabi populations.
Purpose: To explore the CLBP beliefs and experiences of Punjabi and White British people living with CLBP.
Objectives
1) Investigate CLBP beliefs of English speaking Punjabi and White British people living with CLBP.
2) Explore how beliefs may influence the lived experience of CLBP.
3) Conduct cross-cultural comparisons between the two groups.
Methods: The methodological framework of interpretative description was used to conduct semi-structured interviews on a purposive sample of 10 participants with
CLBP (5 Punjabi and 5 White British) recruited from an NHS Physiotherapy waiting list. All interviews were audio-recorded and transcribed verbatim. Data was
analysed thematically using a constant-comparative approach to assist the identification of codes.
Results: Across both groups, most participants held negative biomedical CLBP beliefs, experienced unfulfilling HCP interactions and negative psychosocial effects of
CLBP. Common biomedical beliefs included "the spine is weak". While a perceived lack of support from HCPs resulted in weak therapeutic alliance. Most participants
catastrophised about their CLBP. However, some other negative psychosocial consequences were specific to Punjabi participants. These included disruption to
cultural-religious wellbeing for example, sitting on the floor to meditate and the perceived female role within the home, as well as a perceived lack of understanding
from the Punjabi community. In contrast to their White British counterparts, Punjabi participants initially preferred passive coping strategies, however all
demonstrated a transition in coping, instead favouring active strategies.
Conclusion: CLBP beliefs and experiences were primarily biomedically-orientated amongst both Punjabi and White British participants. Cross-cultural differences
related to the cultural-religious impact of CLBP on Punjabi participants, their coping styles and the negative community response to CLBP. Future research may
consider exploring the generalisability of these findings to other South Asian sub-groups. This could lead to the development of culturally appropriate training for
HCPs.
Implications: HCPs managing people with CLBP need to adopt a culturally-sensitive, bio-psychosocial approach which considers the individuals beliefs and
experiences, while addressing negative biomedical CLBP beliefs.
Funding Acknowledgements: NIHR funded studentship.
Ethics Approval: NRES Committee, London Riverside, 27/03/14.
Reference Number: 14/LO/0510.
Keywords: Beliefs and lived experiences , Chronic low back pain, Ethnic cultural

PO3-LB-047
SHORT-TERM EFFECT ON PAIN AND FUNCTION OF NEUROPHYSIOLOGICAL EDUCATION AND SENSORIMOTOR RETRAINING COMPARED TO USUAL PHYSIOTHERAPY
IN PATIENTS WITH CHRONIC OR RECURRENT NON-SPECIFIC LOW BACK PAIN, A PILOT RANDOMIZED CONTROLLED TRIAL
H. Luomajoki*, J. Kool 1, P. Wlti 2
1
Therapy Research, Klinik Valens, Valens, 2Physiotherapy Practice am Kohlplatz, Heiden, Switzerland
Background:
Non-specific chronic low back pain (NSCLBP) is a major health problem. Identification of subgroups and appropriate treatment regimen was proposed as a key priority
by the Cochrane Back Review Group. We developed a multimodal treatment (MMT) for patients with moderate to severe disability and medium risk of poor
outcome. MMT includes due to catastrophizing believes about the nature of NSCLBP, patients predominantly show poor sensory acuity of the trunk, and control of
the trunk.
Purpose:
A pilot study was conducted to investigate the feasibility of MMT, prior to a larger RCT, with focus on patients to usual physiotherapy patients adherence and the
evaluation of short-term effects on pain and disability of MMT when compared to usual physiotherapy.
Methods:
We conducted a randomised controlled trial (RCT) in a primary care physiotherapy centre in Switzerland. Outcome assessment was 12 weeks after baseline. Patients
with NSCLBP, considerable disability (five or more points on the Roland and Morris Disability Questionnaire (RMDQ) and medium or high risk of poor outcome on the
Keele Start Back Tool (KSBT) were randomly allocated to either MMT or usual physiotherapy treatment (UPT) by an independent research assistant. Treatment
included up to 16 sessions over 8 to 12 weeks. Both groups were given additional home training of 10 to 30 minutes to be performed five times per week. Adherence
to treatment was evaluated in order to assess the feasibility of the treatment. Assessments were conducted by an independent blinded person. The primary outcome
was pain (NRS 0-10) and the secondary outcome was disability (RMDQ). Between-group effects with Student the standardized mean difference of the primary
outcome were calculated. Students t-test or the Mann-Whitney U test and the standardized mean difference of the primary outcome were calculated.
Results:
Twenty-eight patients (46% male, mean age 41.5 years (SD 10.6)) were randomized to MMT (n = 14) or UPT (n = 14). Patients adherence to treatment was >80% in
both groups. Pain reduction (NRS; [95% CI]) Patients was 2.14 [1.0 to 3.5] in the MMT and 0.69 [-2.0 to 2.5.] in the UPT. The between-group difference was 1.45 [0.0
to 4.0] (p = 0.03), representing a moderate effect size of 0.66 [-0.1 to 1.5]. Reduction in disability on the RMDQ was 6.71 [4.2 to 9.3] in MMT and 4.69 [1.9 to 7.4] in
UPT, with a non-significant between-group difference of 2.02 [-1.5 to 5.6] (p = 0.25). The required sample size for a RCT with six months follow-up was estimated at
170 patients.
Conclusion:
MMT was found to be feasible and to significantly reduce pain in the short term when compared with UPT. A future RCT with a six-month follow-up would require
approximately 170 patients.
Implications: A multimodal treatment consisting of explain pain, sensory and motor exercises by chronic LBP patients is a good option in the treatment of chrnic LBP
patients in a private pphysiotherapy practice setting.
Funding Acknowledgements: No funding was received for this study
Ethics Approval:
The trial was approved by the local ethics committee (ethics committee of the canton Saint Gallen, Switzerland. Ethics committee trial identification number: EKSG
12/149/1B).

Keywords: chronic low back pain, patient education, sensory motor training, physical therapy, randomized controlled trial

PO3-LL-050
MYOFASCIAL TRIGGER POINT THERAPY FOR PLANTAR FASCIITIS: A FEASIBILITY STUDY
R. Grieve*, S. Palmer 1
1
Faculty of Health and Applied Sciences, Allied Health Professions, University of the West of England, Bristol, United Kingdom
Background: Recent evidence has identified tightness of the posterior leg muscles (calf and hamstring) and reduced ankle dorsiflexion as possible contributing factors
in plantar fasciitis (PF). Stretching is routinely advocated, but myofascial trigger point (MTrP) therapy has also been found to relieve calf tightness and increase ankle
dorsiflexion in non PF participants. A recently completed survey on usual physiotherapy practice for PF in adults found stretching exercises and self-management
more commonly used than MTrP or manual therapy.
Purpose: This study was conducted to inform a definitive randomised controlled trial (RCT). The main aims were to evaluate the feasibility and acceptability of
recruitment, randomisation, study procedures, treatment and outcome measures. Secondary aims were to ascertain if the addition of MTrP therapy to usual
physiotherapy practice might be effective in PF management.
Methods: Participants who met the diagnostic criteria for PF were included. Exclusion criteria: conditions or systemic diseases affecting the foot; recent
physiotherapy or MTrP therapy for PF. Participants were randomised to control (usual physiotherapy practice of advice and self-management) or intervention (usual
physiotherapy practice plus MTrP therapy). All participants were issued an advice booklet. Outcome measures included pain (Pressure Pain Threshold (PPT) and
verbal Numerical Rating Scale (NRS)); range of movement (ROM) (ankle dorsiflexion and knee extension); and function (Lower Extremity Functional Scale (LEFS)).
Palpation was used to identify MTrP prevalence. Participants in the intervention group attended three sessions approximately one week apart (with MTrP treatment
at each session and at home) and the control group attended two sessions approximately two weeks apart.
Results: Seven participants (6 men, 1 woman; mean age 42 years) with unilateral or bilateral PF were recruited. Mean pain NRS values improved by 4/10 for the
intervention group (n=3) and 3/10 for the control group (n=4). Mean ankle dorsiflexion ROM for the gastrocnemius increased by 3 and 10 for the intervention and
control groups respectively. For the soleus these figures were 5 and 2 respectively. Mean knee extension ROM (reflecting hamstring flexibility) was greater in the
control group (-18) than the intervention group (-25) following treatment. The LEFS improved by 10/80 points in the intervention group and by 4/80 in the control
group. Mean PPTs at all MTrP sites increased (representing reduced hyperalgesia) by 75kPa in the intervention group and by 37kPa in the control group. Both groups
reported a mean score of 2/5 (usually) for compliance with self-management stretching exercises and/or home MTrP therapy. All participants attended each session
with no attrition and no adverse reactions reported.
Conclusion: Overall participant compliance and acceptability of the assessment, treatment and outcome measures was good. There was a trend towards
improvements in pain, PPT and function in the intervention group, although changes in ROM were inconsistent between groups.
Implications: This feasibility study has indicated that a future RCT may be warranted to ascertain if MTrP therapy for PF would be a suitable adjunct to selfmanagement.
Funding Acknowledgements: Early Career Researcher Grant (SPUR 5) The University of the West of England, Faculty of Health & Applied Sciences.
Ethics Approval: Faculty of Health & Applied Sciences Ethics Subcommittee, University of the West of England, Bristol (HLS/13/08/108)

Keywords: Feasibility study, manual therapy, plantar fasciitis

PO3-LL-051
REAL-TIME SONOELASTOGRAPHY USING AN EXTERNAL REFERENCE MATERIAL: TESTRETEST RELIABILITY ON HEALTHY ACHILLES TENDON.
A. Schneebeli 1,*, F. Del Grande 2, G. Vincenzo 2, C. Cescon 1, R. Clijsen 3, F. Biordi 4, M. Barbero 1
1
Department of Business Economics, Health and Social Care, University of Applied Sciences and Arts of Southern Switzerland (SUPSI), Manno, 2Servizio di radiologia,
Ospedale Civico e Italiano, Ente Ospedaliero Cantonale (EOC), Lugano, 3Department of Business Economics, Health and Social Care, University of Applied Sciences and
Arts of Southern Switzerland (SUPSI), Landquart, Switzerland, 4ESAOTE, S.p.A, Genoa, Italy
Background: Real-time sonoelastography is a recent ultrasound-based technique which allows a qualitative assessment of tissue elasticity. Light and transverse tissue
compression with an ultrasound probe is applied to a surface producing a displacement within the tissue, which is less pronounced in harder than in softer materials.
Tissue displacement is calculated by comparing b-mode image pairs before and after the compression. Elasticity pattern are represented on the ultrasound monitor
as a colour scale superimposed on a B-mode image.
Purpose: To establish the testretest reliability of sonoelastography (SE) on healthy Achilles tendon in contracted and relaxed states using an external reference
system.
Methods: Forty-eight Achilles tendons from 24 healthy volunteers were assessed using ultrasound and real-time SE with an external reference material. Tendons
were analyzed under relaxed and contracted states. Strain ratios between tendons and reference material were calculated. The intraclass correlation coefficient
(ICC2.k) and Bland-Altman plot were used to assess testretest reliability.
Results: Reliability of SE measurements in relaxed state ranged from high to very high with an ICC2.k of 0.84 (95%CI: 0.640.92) for reference material, 0.91 (95%CI:
0.830.95) for Achilles tendon and 0.95 (95%CI: 0.910.97) for Kager fat pad (KFP). The ICC2.k value for skin was 0.30 (95%CI: 0.26 to 0.61). Reliability for
measurements in the contracted state ranged from high to very high with an ICC2.k of 0.93 (95%CI: 0.870.96) for reference material, 0.72 (95%CI: 0.500.84) for skin,
0.93 (95%CI: 0.870.96) for Achilles tendon and 0.81 (95%CI: 0.660.89) for KFP. Reliability of the strain ratio (Tendon/Reference) in the relaxed state was high with
an ICC2.k of 0.87 (95%CI: 0.750.93), and in the contracted state, it was very high with an ICC2.k of 0.94 (95%CI: 0.900.97).
Conclusion: SE using an external reference material is a reliable and simple technique for elasticity assessment of healthy Achilles tendon. The use of an external
material as a reference along with strain ratios could provide a quantitative measure of elasticity.
Implications: The use of sonoelstography with an external material as a reference along with strain ratios could provide a quantitative measure of the tendon
elasticity.
Funding Acknowledgements: We thank the Thim van der Laan Foundation, Landquart, Switzerland, for financial support.
Ethics Approval: The study was approved by the Ethics Committee of Canton Ticino, Switzerland.
Keywords: Achilles tendon, Sonoelastography, reliability

PO3-LL-053
THE IMMEDIATE EFFECTS OF TWO MANUAL THERAPY TECHNIQUES ON ANKLE MUSCULOARTICULAR STIFFNESS AND DORSIFLEXION RANGE OF MOTION IN PEOPLE
WITH CHRONIC ANKLE RIGIDITY
B. Hidalgo 1,*, T. Hall 2, C. Detrembleur 3
1
Physiotherapy / Manual Therapy, Faculty of Motor Sciences / Parnasse ISEI, Bruxelles, Belgium, 2School of Physiotherapy and Exercise Science, Curtin University,
Perth, Western Australia, Australia, 3Physiotherapy, Faculty of Motor Sciences , Bruxelles, Belgium
Background: Increased musculo-articular-stiffness (MAS) of the talocrural joint is a frequently encountered problem, identified during evaluation of weight-bearing
ankle dorsiflexion. Such stiffness may follow ankle injury such as ankle sprain, but asymmetric rigidity does not necessarily always follow ankle sprain.
Purpose: Our objective was to compare the efficacy of Mulligan Mobilization with Movement (MWM) and Osteopathic Mobilization (OM) for improving ankle
dorsiflexion ROM and MAS.
Methods: 40 men (18-40 years), presenting with chronic non-specific and unilateral ankle mobility deficit during weight-bearing ankle dorsiflexion were randomly
allocated to single session (3x10 reps) of either MWM (n=20) or OM (n=20). Outcome measures comprised 3 quantitative measures of MAS (viscous, elastic and total
stiffness) with an electromechanical device (passive oscillation technique in dorsiflexion) and 2 clinical measures of weight-bearing ankle dorsiflexion (WBDF) ROM;
toe-wall distance and angular ROM.
Results: A two-way ANOVA revealed a non-significant interaction between both techniques (MWM vs. OM) and time (pre and post intervention) on ankle dorsiflexion
for all outcome measures. For measures of MAS: elastic stiffness ( p=0.37), viscous stiffness ( p=0.83), total stiffness (p=0.58). For WBDF ROM : toe-wall distance
(p=.58) and angular ROM (p=0.68). Small effect sizes between groups were determined for all outcome measures with Cohens d ranging from 0.05 to 0.29. One-way
ANOVA demonstrated similar results with non-significant difference and small to moderate effects sizes (Cohens d=0.003 - 0.58) before and after interventions
within both groups. A second two-way ANOVA analysed the effect of each intervention on the sample categorized according to injury history status (injury vs. no
injury). These results revealed a significant interaction between groups and time but only for viscous stiffness (p=0.04, Cohens d=-0.55).
Conclusion: A single session of MWM and OM failed to improve measures of WBDF-ROM and MAS of the ankle, in subjects with chronic ankle dorsiflexion stiffness.
Despite this, there was an increase in viscous stiffness in people with history of ankle injury following both manual techniques, the value of which remains unclear.
Implications: There is no superiority of efficacy between both techniques to improve ROM during WBDF or ankle MAS with instrumented measures. Conversely, both
techniques induced significant increased of viscous stiffness at the ankle joint only in subjects with a previous history of ankle injury. However, this might be
potentially helpful to prevent or protect future ankle sprain in people with history of ankle injury.
Ethics Approval: The subjects provide signed informed consent, and ethical approval for this study was provided by the Commission dEthique Biomdicale
Hospitalo-facultaire (CEBFH) of the Universit Catholique de Louvain.
Keywords: Mobilisation with movement, musculoarticular stiffness, Osteopathic mobilisation

PO3-LL-055
TWO POINT DISCRIMINATION IN LOWER LIMBS IN HEALTHY PEOPLE: AVERAGE VALUES AND INFLUENCE OF GENDER, DOMINANCE, HEIGHT AND BMI
G. Valagussa 1 2, R. Meroni 1, F. Cantarelli 3,*, L. Molteni, L. Galbiati, C. Cerri 1
1
School of Medicine and Surgery, University of Milano Bicocca, Milan, 2SMARTERehab, Besana Brianza, 3SMARTERehab, Mantova, Italy
Background: There is evidence of alterations in two point discrimination (TPD) in some chronic pain conditions such as complex regional pain syndrome, phantom
limb pain and chronic low back pain. There is evidence that TPD training may influence pain and function. To be able to determine if an alteration of TPD exists it is
important to know normal values in healthy subjects. A literature search of normative values of TPD in the lower limb of healthy subjects was conducted. The current
literature has evaluated only the dominant side, only a segment of the limb or only a single point in a segment. To our knowledge no studies have assessed the
influence of gender, dominance, height and body mass index (BMI). There is a need to further understand TPD in the normal population.
Purpose: The main purpose of this study was to assess TPD values of thigh, lower leg and foot in both lower limbs in a healthy cohort. Secondary purposes were to
assess the correlation between each segment of both lower limbs and whether if these values are influenced by gender, dominance, height and body mass index
(BMI).
Methods: The study included forty-five healthy subjects (21 males, 24 females; mean age 30.42 years SD 11.41 years). A trained therapist performed the TPD
assessment for a total of forty-eight points, in a randomized order, using a previously described plastic calipers. The TPD was assessed in all three segments (thigh,
lower leg and foot), each segment divided in four areas (anterior, posterior, medial and lateral) and two points were assessed for each area. The same assessment
was carried out for both lower limbs.
Results: Overall, the mean value of the eight points for each of the following segments was: right thigh 3.15 cm (1.26 SD), left thigh 3.13 cm (1.24 SD); right lower leg
3.04 cm (1.30 SD), left lower leg 2.98 cm (1.24 SD); right foot 2.06 cm (0.72 SD), left foot 2.16 cm (0.73 SD). TPD values of each segment of both lower limbs in each
subject were analyzed and a good correlation (Pearsons coefficient 0.829) was found between the right and the left sides. Statistical analysis of our data found that
TPD values were not influenced by gender or dominance. No correlation between TPD values and height or BMI was found.
Conclusion: This study provides TPD mean values for each segment of lower limbs in healthy subjects. TPD mean values show a good correlation between the left and
right side in all three segments of the lower limb. TPD mean values are not influenced by gender, dominance, height and BMI in healthy subjects.
Implications: Knowing the TPD mean values of the lower limbs in healthy people could help in the assessment of TPD in chronic pain patients with lower limb
symptoms. This may be immediately translated into clinical practice by participants using a plastic calipers.
Keywords: healthy subjects, lower limb, Two point discrimination

PO3-MT-060
STRAIN COUNTER STRAIN TECHNIQUE VERSUS KINESIO TAPE IN TREATING PATIENTS WITH MYOFASCIAL NECK PAIN SYNDROME
A. Abdelfattah*
Background: Myofascial pain syndrome (MPS) is one of the most common examples of musculoskeletal pain; an accumulating body of evidence suggests that unique
hypersensitive loci, named Myofascial trigger points. Strain counter strain is an indirect osteopathic technique where the dysfunctional joints and muscles moves
away from restrictive barriers. Kinesio tape is frequently applied for pathologies in the musculoskeletal system
Purpose: The purpose of this study was to compare the effects of strain counter strain technique and kinesio tape on Myofascial neck pain syndrome.
Methods: SUBJECTS: Forty five patients with myofascial neck pain syndrome assigned randomly into: strain counter stain technique group (n=15), kinesio tape group
(n=15) and control group (n=15).
METHODS AND MATERIALS: The strain counter stain technique was applied for two weeks (3 sessions/ week-20 minutes per session). kinesio tape was applied for
upper Trapezius muscle for two weeks (3days on and one day off). Pressure algometry, Visual analogue scale (VAS) and Neck disability index (NDI) were used to
evaluate participants before and after the corresponding interventions.
ANALYSES: Analysis of variance test (ANOVA) was used to determine differences between groups for all measured parameters. Paired t-test was used to compare
between the pre- and post-treatment values within groups.
Results: For the 45 study participants (33 women and 12 men; mean age=44.17 years) statistical analysis revealed that Subjects in strain counter strain technique
and kinesio tape groups experienced significant increase in pressure pain threshold, decrease in neck disability scale and pain level than those in the control group in
favor of strain counter strain technique group (p>0.05)
Conclusion: This study might assists in the understanding of the comparing efficacy between the strain counter strain technique and kinesio tape technique on neck
myofascial pain syndrome. Both Strain counter strain and kinesio tape techniques for patients with MPS have a strong positive impact on pain severity, pain threshold
and functional levels in comparing to control group in favor of strain counter strain which more effective to MPS patients. Follow up measurement revealed stable
improvement in all measured variables.
Implications: These observed effects should be of value to clinicians and health professionals involved in the treatment of neck myofascial pain syndrome.
Funding Acknowledgements: unfunded work
Ethics Approval: every research done in cairo university must be approved by the ethical committee focal point in it , so my research was approved
Keywords: Kinesio tape , Myofascial pain syndrome, Strain counter strain

PO3-MT-061
IMMEDIATE EFFECTS OF A PASSIVE SHOULDER ELEVATION IN NEUROGENIC CERVICAL RIB
S. Khatri 1, N. Desai*, A. Agarwal 2
1
Physiotherapy, Pravara Institute of Medical Sciences , Loni, 2Physiotherapy, Physiocare Clinic, Tinsukia, India
Background: Cervical rib is an important cause of neurovascular compression at the thoracic outlet. Previous studies have shown the prevalence of cervical ribs to be
between 0.05 and 3%, depending on the sex and race of the population studied. Conservative treatment in the form of physiotherapy for cervical rib is found to be
complex and challenging. Effects of a passive shoulder elevation technique in cervical rib patients yet left to unveil.
Purpose: To determine the immediate effects of a passive shoulder elevation technique on pain, Active Cervical Range of Motion (ACROM) and Pressure Pain
Threshold (PPT) in patients with cervical rib.
Methods: In this quasi experimental study, radiologically and clinically confirmed twenty four symptomatic cases of cervical rib were allocated into study and control
group. Visual Analog Scale (VAS) score, ACROM and PPT were assessed before and after the intervention. The study group was given passive shoulder elevation
technique with painful and/or restricted active cervical movement, in addition to conventional physiotherapy where as control group received only conventional
physiotherapy.
Results: No differences were found in baseline measures between groups. There were significant improvements in intensity of pain (P < .01), ACROM (P < .01) and
PPT (P < .01) immediately after passive shoulder elevation and conventional physiotherapy compared to conventional physiotherapy alone.
Conclusion: These results provide evidence for the efficacy of the passive shoulder elevation technique in the management of individuals with neurogenic cervical rib.
This study has provided justifications and directions for future research exploring long term effects of passive shoulder elevation technique in neurogenic cervical rib.
Implications: Passive shoulder elevation technique is one of the most effective treatment tools to achieve immediate hypoalgesic effect in individuals with
neurogenic cervical rib.
Funding Acknowledgements: No funding sources were reported for this study.
Ethics Approval: Human Ethics Committee, Maliba Pharmacy College.
Keywords: Cervical rib, Hypoalgesic, Neurogenic

PO3-MT-063
EFFECT OF KALTENBORN LUMBAR MOBILIZATION WITH AND WITHOUT PIRIFORMIS STRETCHING ON CHRONIC MECHANICAL LOW BACK PAIN
S. Hussain*
Background: . Low back pain extensively affects the population. Person is unable to stand straight and reduced range of motion and flexibility is also seen.
[1]
Mechanical low backache imposes a significant burden on the society. 50-80% population is affected by mechanical low back pain. [2] Pain resulting from any type
of stress or strain on structures of vertebral column is generally referred as mechanical pain. It is very common medical problem. A great number of patients see the
physicians and physiotherapist due to low back pain. [3] Severity of mechanical low back pain can vary. It can be caused by twisting ones back or may be caused by
motor vehicle accident. Absenteeism from work and direct cost of medical care due to backache are huge. [4]
Purpose: This project was a research study carried out for partial fulfillment of M.S.O.M.P.T degree. Other objectives of the research were to determine the effect of
Kaltenborn lumbar mobilization with and without Piriformis stretching on pain, function and quality of life.
Methods: This interventional study was conducted at Physical Therapy Clinic of Women Institute of Rehabilitation Sciences Abbottabad, from 7th February 2015 to 7th
November 2015.
Patients ranging from 30-60 years from both genders with chronicity of at least six months were included. A total of 50 patients were screen out as per inclusion
criteria and 30 patients were selected and randomly placed into two groups A and B, where 15 were male and 15 females. Group A = Kaltenborn lumbar mobilization
with Piriformis stretching. Group B = Kaltenborn lumbar mobilization alone.
The Numeric Pain Rating Scale (NPRS), Oswestry Disability Index (ODI), Short Form (SF)-36 Questionnaire and Range of Motion of Lumbar spine were used as outcome
measures. All the patients were assessed at baseline before intervention and at the completion of 6 weeks intervention plan.
Results: The mean Oswestry disability index score for Group A improved from a baseline score of 49.46 to 15.73 indicating a significant improvement in the functional
capacity of the patients while the mean Oswestry disability index score for Group B improved from a baseline score of 31.06 to 26.80 indicating improvement in the
functional capacity of patients, but as compared to Group A it shows less improvement in functional capacity. The paired t-test value for both Group A & Group B
showed a significant improvement in pain reduction measured on Numeric Pain Rating Scale, Group A showed greater reduction in pain than the Group B. Group A
showed more improvement in mean lumbar flexion range of motion i.e from 38.66 Degree to 54.40 Degree as compared to Group B which showed less improvement
i.e from 37.66 Degree to 46.33 Degree. Similarly mean extension range of motion in Group A improved from 19.66 Degree to 30.66 Degree and mean lumbar
extension ROM for Group B has increased from a baseline score of 18.66 Degree to 28.66 Degree. Group A showed more improvement in mean lumbar side bending.
Right and left side bending for Group A improved from 19.66 Degree to 29.33 Degree. Group B showed improvement of 19.66 Degree to 29.33 Degree in right side
bending and improvement of 18.33 Degree to 25.66 Degree in left side bending.
Conclusion: It is concluded that if patients of chronic mechanical low back pain treated with Piriformis stretching along with Kaltenborn lumbar mobilization
technique will manage pain, function and quality of life more effectively as compared with Kaltenborn lumbar mobilization technique alone.
Implications: Accurate physical therapy evaluation and exercise prescription along with lumbar mobilization is an effective treatment for patients suffering from
chronic low back pain. This research will be a baseline for researchers to carry put further researches.
Ethics Approval: The study was approved by Riphah Ethical Review Committee and Physical Therapy Clinical Setting of WIRS was taken. The informed consent was
taken from all patients.
Keywords: Pain, mobilization, Piriformis, backache, lumbar, intervertebral disc.

PO3-PA-065
EVALUATION OF A COMBINED EXERCISE AND ACCEPTANCE AND COMMITMENT THERAPY GROUP BASED PROGRAMME FOR CHRONIC PAIN. A PILOT STUDY.
M.-B. Casey*, D. Lowry 1, C. Hearty 2, R. Neary 3, C. Doody 3
1
Psychology Department, Mater Misericordiae University Hospital, 2Department of Pain Medicine, Mater Misericordiae University Hosptial, 3School of Public Health,
Physiotherapy and Sports Science, University College Dublin , Dublin, Ireland
Background: The multidimensional nature of chronic pain presents significant challenges for healthcare professionals and guidelines recommend referral to
multidisciplinary pain management programmes (PMPs). The effectiveness of exercise for the treatment of chronic pain is well established and there is emerging
evidence to suggest that Acceptance and Commitment Therapy (ACT) is an effective psychological approach. However further research is needed to investigate the
effects of combining exercise and ACT as an intervention for chronic pain.
Purpose: The aim of this pilot study was to evaluate the impact of a combined exercise and ACT group based PMP for people with chronic pain.
Methods: 46 people with chronic pain consented to participate in this study which was set in a hospital Pain Medicine Clinic in Ireland. Participants mean age was 51
years (SD 8.33 years) and mean duration of symptoms was 9.6 years (SD 8.6 years). Participants attended the multidisciplinary PMP one day each week for eight
weeks. Each day began with a two-hour ACT psychology session delivered by a Senior Psychologist. This was followed by supervised aquatic or gym based exercise of
one hour duration led by a Senior Physiotherapist. Educational talks were also provided each week covering topics such as medication management, pacing and sleep
hygiene. Participants completed a series of validated outcome measures at baseline and on completion of the programme (N=36), at four month follow up (N=21)
and at one year follow up (N=14). Two participants were excluded as they attended less than fifty percent of the programme and eight participants failed to return
questionnaires post intervention. In addition to completion of questionnaires, participants wore pedometers for the duration of the programme which recorded daily
step count. Data were analysed using descriptive statistics, paired t tests and ANOVA using SPSS v 20.
Results: Significant improvements were seen between baseline and post intervention measures in the Brief Pain Inventory (BPI) pain interference subscale, Chronic
Pain Acceptance Questionnaire (CPAQ) total and activity engagement (AE) subscale, Pain Catastrophizing Scale (PCS) total, PCS Rumination subscale, PCS Helplessness
subscale, Pain Self Efficacy Questionnaire (PSEQ) and Kessler 10 (K10) psychological distress scale. There were no significant changes in average daily step counts over
the duration of the programme. Significant improvements were seen between baseline and four month follow up in the BPI interference subscale, PCS total, PCS
rumination subscale, PCS helplessness subscale, K-10 and Fear Avoidance Beliefs Questionnaire (FABQ) work subscale. Significant improvements were seen between
four month follow up and 1 year follow up in the Chronic Pain Values Inventory (CPVI) mean success rating and mean discrepancy rating, PCS helplessness subscale
and K10.
Conclusion: The results of this pilot study are encouraging and suggest that a combined exercise and ACT PMP is a promising intervention for chronic pain. The
findings also suggest that many of these effects may be maintained in the medium term or long term. However the results should be interpreted in light of the lack of
a control group and the small numbers in this pilot study, particularly in relation to the longer term follow up data. Further high quality randomised controlled trials
are necessary, specifically trials incorporating physical activity measurement, cost-effectiveness analysis and long term follow up.
Implications: This pilot study provides justification for further research to investigate the effectiveness of combining exercise and ACT as a treatment for chronic pain.
If found to be effective this intervention could be recommended for wider implementation to enhance patient outcomes and aid in reducing the significant
healthcare costs related to the management of chronic pain conditions.
Ethics Approval: Mater Misericordiae University Hospital Ethics Committee
Keywords: Acceptance and Commitment Therapy, Chronic Pain, Exercise

PO3-PA-066
VASCULAR FLOW LIMITATIONS MISDIAGNOSED AND MISMANAGED AS CHRONIC MUSCULOSKELETAL PAIN: A CASE SERIES
A. Taylor*
Background: Vascular pathologies are well documented yet rare causes of distal limb symptoms (Peach, Schep, Palfreeyman et al., 2012). Patients with distal lower
limb symptoms may complain of concomitant low back pain and as such, may be misdiagnosed and mismanaged as musculoskeletal cases.
Purpose: This case series, documents 3 such cases, a 5 year, 15 year and 34 year delay to appropriate management and considers how delays to diagnosis may be
avoided in the future.
Methods: All three cases were analysed in detail, using root cause analysis. The aim was to identify reasons for delays to appropriate diagnosis and management and
to suggest key areas for improvement for clinicians.
Results: All three subjects were young male (mean age 21.6) competitive cyclists at the time of presentation of symptoms. All three complained of vague, non-specific
lower limb symptoms of pain/discomfort, tingling/paraesthesia and limb fatigue during exercise or effort. All three had been diagnosed as having symptoms of
lumbosacral origin despite normal MRI scans. Each case had been seen by a variety of specialists and managed unsuccessfully by a series of manual and physical
therapists for prolonged and protracted courses of treatment. One of the subjects had developed low back pain during the course of their physical therapy
management.
2 had been offered exploratory lumbar spinal surgery which they declined. 1 underwent unsuccessful surgical thigh fasciotomies. 3/3 had been labelled as chronic
pain cases and managed via pain clinics and offered a series of options, from drug therapies to CBT and pain management programmes.
All three were eventually routed for routine vascular examination (including exercise stress testing and ankle to brachial pressure index testing) which revealed the
(by now) advanced ischaemic source of their symptoms.
The mean delay to diagnosis and appropriate management was 18 years.
Conclusion: This case series illustrates that clinicians need to be cognisant that young fit athletes may present with lower limb symptoms of vascular origin. The
presenting symptoms may be vague and non-specific and present distally as non-dermatomal pain/discomfort, tingling/paraesthesia commonly experienced during
exercise or effort. A sound knowledge of vascular pathology as a source of such symptoms in the younger sporting population may reduce the delays to diagnosis
described in this case series. Long courses of unsuccessful physical therapies are inappropriate for this population. Furthermore, pain management may be another
source of delay to appropriate management of these cases. Clinicians should focus on the patients complaint of exercise induced symptoms and clinically reason
and investigate appropriately. Simple vascular examination is not beyond the skill set of all good physical therapists. Delays to appropriate triage and management of
this magnitude, can be avoided in the future.
Implications: Key Findings: Young fit athletes may present with lower limb symptoms of vascular origin.
Exercise induced symptoms, should raise the index of suspicion of a vascular source of symptoms.
Long protracted courses of physical therapies or pain management are entirely inappropriate for this population.
Vague and non-specific symptoms presenting distally as non-dermatomal pain/discomfort, tingling/paraesthesia commonly experienced during exercise or effort, are
an indication for vascular examination.
Future delays to diagnosis/management may be avoided in the future via diligent clinical reasoning.
Funding Acknowledgements: N/A
Ethics Approval: N/A
Keywords: chronic pain, exercise, vascular, examination, musculoskeletal, pain management

PO3-PA-067
THE VALIDITY OF THE DUTCH PAINDETECT AND THE DN4 QUESTIONNAIRE FOR NEUROPATHIC PAIN IN PATIENTS WITH SUSPECTED CERVICAL OR LUMBAR
RADICULOPATHY: A DIAGNOSTIC ACCURACY STUDY
W. Scholten-Peeters 1,*, R. Epping 2, S. Rooker 3, A. Verhagen 4
1
Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, 2Department of Physical
Therapy, Research group Diagnostics, University of Applied Sciences, Breda, 3Department of Neurosurgery and Orthopaedics, Kliniek ViaSana, Mill, 4Department of
General Practice, Erasmus MC -University Medical Center, Rotterdam, Netherlands
Background: Patients with neuropathic pain experience higher levels of disability and pain compared to non-neuropathic pain patients. It is important to identify
neuropathic pain early, preferably in primary care settings, to guide treatment decisions and prevent chronicity. There is lack of evidence whether the Dutch
painDETECT questionnaire ) and Douleure Neuropathique en 4 questions (DN4DLV) can adequately assess neuropathic pain in patients with neck-arm pain and backleg pain suspected of radiculopathy.
Purpose: The purpose of this study was to evaluate the diagnostic accuracy and the test-retest reliability of the PDQDLV and DN4DLV compared to a consensus
reference test diagnosis based on the grading system in patients with neck-arm pain or back-leg pain suspected of radiculopathy.
Methods: Patients with neck-arm pain and back-leg pain suspected of cervical or lumbar radiculopathy referred from primary care, were eligible for inclusion. The
painDETECT and DN4 screening lists were considered as the index tests. The reference test was the expert consensus diagnosis for neuropathic pain between a
medical specialist and a physiotherapist by using the international accepted grading system. Diagnostic accuracy was determined by calculating the sensitivity,
specificity, positive predictive values, negative predictive values, likely hood ratios and diagnostic odds ratios. Test-retest reliability for the index tests was assessed
using intraclass correlation coefficients.
Results: A total of 180 patients were included. Fifty-nine patients (33%) had neuropathic pain according to the reference test. Both the painDETECT and DN4 had
moderate sensitivity of respectively 75% (95% CI: 61.6-85.0) and 76% (95% CI: 63.4-86.4) and poor specificity of respectively 51% (95% CI: 42.0-60.4) and 42% (95%
CI: 33.2-51.5). A negative score on both screening lists increased the sensitivity up to 83% (95% CI: 71.0-91.6).
Conclusion: Both the painDETECT) and the DN4 screening lists are not suitable in primary care to rule in or rule out neuropathic pain in patients with suspected
cervical or lumbar radiculopathy. A combination of both screening lists seems to be somewhat better to rule out a neuropathic pain component, however the
percentage false negative test-scores is still about 20%.
Implications: The use of both the PDQ(DLV) and the DN4(DLV) in patients with suspected radiculopathy in a primary care setting should not be recommended yet.
Funding Acknowledgements: This study was funded by the Scientific College of Physiotherapy of the Royal Dutch Society for Physical Therapy.
Ethics Approval: The local ethical committee of the Elisabeth hospital in Noord-Brabant, The Netherlands, approved the study.
Keywords: DN4, neuropathic pain, PainDetect

PO3-SP-069
IS THORACIC SPINE POSTURE ASSOCIATED WITH SHOULDER PAIN, RANGE OF MOTION AND FUNCTION? A SYSTEMATIC REVIEW.
E. Barrett 1,*, M. O' Keeffe 2, K. O' Sullivan 1, K. McCreesh 1, J. Lewis 3
1
Department of Clinical Therapies, Univeristy of Limerick, 2Department of Clinical Therapies, University of Limerick, Limerick, Ireland, 3University of Hertfordshire,
Hertfordshire, United Kingdom
Background: Shoulder pain is a common musculoskeletal condition. Excessive thoracic kyphosis is considered a predisposing factor for subacromial impingement
syndrome (SIS). Postural assessment and treatment is a common component of the physiotherapy management of SIS. At present there is still uncertainty about the
nature of the relationship between SIS and thoracic spine posture. A systematic review is required to establish the evidence base supporting the consideration of
posture in people with shoulder pain.
Purpose: The purpose of this systematic review was to investigate the relationship between thoracic kyphosis and shoulder pain, range of motion (ROM) and
function.
Methods: This review was registered with PROSPERO (number CRD42015024834). Two reviewers independently searched 8 electronic databases in July 2015 and
identified relevant studies by applying strict eligibility criteria. Sources of bias were assessed independently by two reviewers with a standardised tool previously
validated for use in observational studies (Ijaz et al 2013). Data were synthesized using a level of evidence approach (van Tulder et al 2003).
Results: 9 studies were eligible for inclusion. Eight studies were rated as high quality. There is a strong level of evidence that maximum shoulder ROM is greater in
erect postures compared to slouched postures (p<.001), in patients with and without SIS. There is a strong level of evidence that no significant difference in thoracic
kyphosis exists in groups with and without SIS (p>0.05). One trial demonstrated significantly less mobility of the thoracic spine in patients with SIS (p<0.05).
Conclusion: This review concludes that an increase in thoracic kyphosis creates an immediate limitation in shoulder ROM. However, no definitive relationship exists
between thoracic kyphosis and shoulder pain. Interestingly, a restriction in thoracic spine mobility may be of importance in people with SIS. There is a need for
further research in the form of prospective cohort studies to investigate any potential relationships between thoracic hyperkyphosis and shoulder pain as well as
studies examining the specific value of thoracic postural rehabilitation in populations with painful shoulders.
Implications: An increased thoracic kyphosis may not be a predominant feature in patients with shoulder pain. Clinicians who choose to assess and modify resting
thoracic posture as part of a shoulder pain treatment programme should be aware of the lack of evidence supporting this approach. Clinicians should assess thoracic
posture on an individual basis as a one size fits all description may not exist.
Funding Acknowledgements: The work was not funded.
Ethics Approval: Ethical approval was not required for this systematic review.
Keywords: Posture, Shoulder pain, thoracic dysfunction

PO3-SP-071
MANIPULATION AND MOBILISATION FOR NECK PAIN CONTRASTED AGAINST AN INACTIVE CONTROL OR ANOTHER ACTIVE TREATMENT: UPDATE OF A COCHRANE
REVIEW
P. Langevin 1,*, A. Gross 2, S. Burnie 3, M.-S. Bdard-Brochu 4
1
Radaptation, Programme de physiothrapie, Universit Laval / Physio Interactive, Qubec, 2School of Rehabilitation Science&Department of Clinical Epidemiology
and Biostatistics, McMaster University, Ha, 3Department of Clinical Education, Canadian Memorial Chiropractic College, North York, 4Physiothrapie, Physio
Interactive, Qubec, Canada
Background: Manipulation and mobilisation are commonly used to treat neck pain (NP). This is an update of a Cochrane review published in 2003, and updated in
2010.
Purpose: To assess the effects of manipulation or mobilisation alone compared with those of an inactive control or another active treatment on pain, function,
disability, patient satisfaction, quality of life(QoL) and global perceived effect(GPE) in adults experiencing NP with or without radicular symptoms and cervicogenic
headache (CGH) at immediate- to long-term follow-up.
Methods: Computerized databases updated to May 2014 were used as a search strategy. Randomised clinical trials (RCT) assessing if manipulation improves clinical
outcomes for adults with acute/subacute/chronic NP were included without language restriction. At least two review authors independently selected studies,
abstracted data, calculated GRADE, and assessed risk of bias. Pooled relative risk and standardised mean differences (SMD) were calculated.
Results: We included 51 RCT (2920 participants, 18 RCT of manipulation/mobilisation versus control; 34 RCT of manipulation/mobilisation versus another treatment).
Cervical manipulation: For subacute/chronic NP, a single manipulation (3 RCT, 154 participants, low to very low quality) relieved pain at immediate-term follow-up.
For acute to chronic NP, multiple sessions of cervical manipulation (2 RCT, 446 participants, moderate to high quality) produced similar changes in pain, function, QoL,
GPE and patient satisfaction when compared to mobilisations at immediate/short/intermediate-term follow-up. For acute to chronic NP, multiple sessions of cervical
manipulation were more effective than medications to improve pain and function at immediate-term (2 RCT, 216 participants, moderate quality), intermediate-term
(1 trial, 182 participants, moderate quality) and long-term follow-up (2 RCT, 223 participants, moderate quality). For chronic CGH, multiple sessions of cervical
manipulation (2 RCT, 125 participants, low quality) may be more effective than massage to improve pain and function at short/intermediate-term follow-up.
Thoracic manipulation: A single session of thoracic manipulation improved pain at (5 RCT, 346 participants, moderate quality) and function (4 RCT, 258 participants)
short-term follow-up and pain/function/QoL at intermediate follow-up (1 trial, 111 participants, low quality) in acute/subacute NP patients. Data analysis suggested
publication bias.
Cervical Mobilisation: For acute and subacute NP, anterior-posterior mobilisation (one trial, 95 participants, very low quality) may favour pain reduction over rotatory
or transverse mobilisations at immediate-term follow-up. Mobilisation as a stand-alone intervention may not reduce pain more than ultrasound, TENS, acupuncture
and massage for subacute and chronic NP at immediate- and intermediate-term follow-up (ranged from low to very low quality).
Conclusion: Although support can be found for use of thoracic manipulation versus control for NP, function and QoL, results for cervical manipulation and
mobilisation versus control are few and diverse. Cervical manipulation and mobilisation present similar results for every outcome at immediate/short/intermediateterm follow-up. Multiple cervical manipulation sessions provided better pain and functional improvement than medications. Research protecting against various
biases is needed and further high quality researches comparing manipulation or mobilisation over other treatment are needed to help clinicians in treatment choice.
Implications: Cervical manipulation and mobilisation demonstrate similar effect on pain and function for acute to chronic neck pain patient. Thoracic and cervical
manipulation may improved neck pain. Cervical manipulation may be more effective than medication and massage for neck pain and cervicogenic headache.
Publication bias cannot be ruled out.
Funding Acknowledgements: Internal sources
McMaster University, Department of Clinical Epidemiology and Biostatistics; School of Rehabilitation Sciences; Occupational Health Program, Canada.
Centric Health, Lifemark Physiotherapy, Canada.
Vrije Universiteit Amsterdam, Academic Medical Centre, Coronel Institute of Occupational Health, Netherlands.
Sunnybrook & Womens College Health Sciences Centre, Physiotherapy Department, Canada.
LAMP Occupational Health Program, Canada.
Northwestern Health Sciences University, Minnesota, USA.
Royal Canadian Chiropractic College, Canada.
Ethics Approval: Ethics approval not required
Keywords: manipulation, mobilisation, neck pain

PO4-CS-008
THE EFFECTS OF FUNCTIONAL POSTURAL TRAINING VERSUS CERVICO-SCAPULAR MUSCLE TRAINING IN VIOLINISTS WITH CHRONIC NECK PAIN
K.-N. Park 1,*, S.-H. Kim 2
1
Physical therapy, Jeonju University, 2Physical therapy, Human movement center, Jeonju, Korea, Republic Of
Background: Motor control training of the deep cervical flexor and scapular muscle is often recommended in supine position as one of the treatment plan in violinists
with neck pain. However, supine position is not functional and it is unknown to transfer the training effects to pain reduction during playing violin. Thus, deep cervical
flexor training in functional position is necessary for violinist with neck pain.
Purpose: The purpose of this study was to compare the effectiveness of 6-week functional postural training (FPT) versus cervico-scapular muscle training (CSMT) on
pain intensity, pain sensitivity and disability of the neck in violinists with chronic neck pain.
Methods: Twenty-six violinists with chronic neck pain (age; 21.22.2 years, pain duration; 7.32.9 years) were recruited and randomly allocated into FPT group (n=13)
and CSMT group (n=13) after baseline measurement. Intensity of neck pain with visual analogue scale (VAS) after playing violin, pressure pain threshold (PPT) with
digital algometry over the most symptomatic segment of cervical spine, and disability with neck disability index (NDI) were evaluated before and after each exercise.
Participants in each group attended an exercise program during for three days each week over a 6week period. FPT was performed in erect sitting as follows:
Imagine your head is helium balloon and head is lifting toward the ceiling, effortless during playing. A neutral posture of scapula was taught as follows: Spreading
your chest horizontally. For CSMT, deep neck flexion exercise, serratus anterior exercise in supine, and lower and middle trapezius exercises in prone were
performed. 2-way analyses of variance with a bonferroni adjustment was used for intergroup and intragroup comparisons of VAS, PPT and NDI values. Significance set
as P<.05.
Results: Both FPT and CSMT produced significant reduction in VAS and NDI and increase in PPT at most painful area of cervical spine (P<.05). FPT showed superior
improvement of VAS, NDI and PPT than CSMT (P<.05).
Conclusion: Both FPT and CSMT resulted the improvement of neck pain after playing violin, pain sensitivity and neck disability in violinists with chronic neck pain. In
this study, FPT was superior to CSMT for the measured variables associated with chronic neck pain in violinists. These results highlight the value of functional training
in the management of violinist with neck pain for pain relief.
Implications: 1) Both functional exercise in sitting and clinical training in supine during 6-week are effective methods to reduce the neck pain in violinists. 2)
Functional training in sitting is more effective to transfer the training effects into performing activity of violinists, resulting reduction of neck pain than supine
position. 3) A local hypoalgesic effect was gained from the functional training.
Ethics Approval: Ethics approval was obtained from the Jeonju University Ethics Committee for Human Investigations.
Keywords: functional exercise, neck pain, violinist

PO4-CS-010
RELIABILITY OF PERFORMANCE-BASED CLINICAL MEASUREMENTS TO ASSESS SHOULDER GIRDLE KINEMATICS AND POSITIONING. A SYSTEMATIC REVIEW
N. D'hondt 1 2,*, J. Pool 1, S. Hacquebord 1, H. Kiers 1, C. Terwee 3, D. Veeger 2
1
Institute of Human Movement Studies, HU University of Applied Sciences Utrecht, Utrecht, 2Faculty of Human Movement Sciences, VU University Amsterdam,
3
Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, Netherlands
Background: Deviant shoulder girdle movement is often suggested as an eminent factor in the aetiology of shoulder pain. Knowledge of the reliability of
measurements of shoulder girdle kinematics and positioning is needed to determine which tests are clinically suitable.
Purpose: To evaluate reliability, measurement error and internal consistency of measurements with performance based clinical tests to assess shoulder girdle
kinematics and positioning in patients with shoulder pain.
Methods: This study was conducted according to the COSMIN guidelines for systematic reviews. We searched Medline, Embase, CINAHL and SPORTDiscus from
inception up to August 2015. Original articles published in Dutch, English or German language were included when these involved the evaluation of at least one of the
measurement properties of interest of the target tests. Two reviewers independently evaluated the methodological quality per studied measurement property with
the 4-point-rating scale of the COSMIN checklist, extracted data of each study and assessed the adequacy of the measurement properties. For each measurement
method a best evidence synthesis (BES) was performed .
Results: Forty studies were included. These comprehended more than 30 different tests. Measurements were grouped into three main categories: 1) positional
measurements; 2) measurements of dynamic characteristics; 3) tests to diagnose shoulder girdle impairment. Methodological quality ratings varied from good
(12/60) to fair (23/60) and poor (25/60). We refrained from meta-analysis due to heterogeneity across the studies. BES yielded high quality evidence for positive
within-tester reliability of a gravity-referenced measurements for scapula rotation in a neutral position and for negative between-tester reliability of the Modified
Scapular Assistance test (M-SAT). The quality of evidence of the remaining measurements was either moderate, low, conflicting or absent.
Conclusion: Current evidence is insufficient to recommend a particular performance-based clinical test for reliable clinical measurements of shoulder girdle
kinematics and positions. Within-tester reliability of inclinometrical measurements of scapula rotation in a resting position seems to suffice. Data on between-tester
reliability are lacking. Therefore its clinical applicability remains unclear. The M-SAT for symptom alteration does not seem to be reliable for clinical use. Evidence of
other measurements is inadequate.
Implications: The huge variety in performance, description and interpretation of tests hampers the synthesis of research evidence and does not benefit clinical
applicability. For future research we suggest that authors should stick to the original test description when evaluating an existent tests measurement properties.
When a modification of the initial test seems to be more valid, the test should be renamed.
Funding Acknowledgements: None.
Ethics Approval: No ethics approval required
Keywords: measurement, scapula, systematic review

PO4-CS-014
THE EFFECTS OF TEXTING ON BALANCE AND GAIT IN YOUNG ADULTS WITH AND WITHOUT NECK PAIN: AN OBSERVATIONAL STUDY
R. Fraser 1,*, S. Reid 1
1
School of Physiotherapy, Australian Catholic University, North Sydney, Australia
Background: Texting has become an integral part of daily life. It has been shown that texting leads to deficits in standing balance and gait in people without neck pain.
Excessive mobile phone use such as texting, emailing and browsing the Internet has been associated with neck pain. Although balance and gait impairments have
been identified in people with neck pain, no research has examined the effects of texting on balance and gait in people with neck pain.
Purpose: 1) To investigate the effects of texting on balance and gait in young adults with and without neck pain. 2) To compare balance and gait in young adults with
and without neck pain when texting.
Methods: An observational study of fifty young adults (21.62.3 years) with neck pain (n=25) and without neck pain (n=25). Participants performed a series of balance
tests while texting on different types of surfaces and in different stance positions. Centre of pressure (COP) sway velocity and sway length were measured with the
Humac Balance system. Participants completed gait tests while texting at different paces. Spatiotemporal characteristics of gait were evaluated using the GAITRite
system.
Results: Texting led to significantly increased COP sway velocity and sway length in the neck pain group in all balance tests compared to non-texting conditions
(p<0.05). Those without neck pain had significantly increased COP sway velocity and path length when texting compared to the non-texting condition only during the
single leg stance condition (p=0.016). There was significantly increased COP sway velocity and sway length for the neck pain group compared to the non-neck pain
group in all balance tests (p<0.05). For gait, both those with and without neck pain had significantly decreased gait speed and cadence when texting compared to not
texting when walking at a self-selected speed and at maximal walking speed (p<0.05). A total of 60% of participants reported experiencing an accident while texting
and walking such as tripping over or walking into an object.
Conclusion: Texting leads to deficits in balance and gait in young adults with and without neck pain. These impairments tend to be greater in those with neck pain
compared to those without pain. Further research is required to examine the effects of texting on balance and gait in people with neck pain in older populations.
Implications: This study suggests the need to educate young adults on the effects texting has on balance and gait to minimise the risk of accidents such as tripping
over while texting. Clinicians should assess balance and gait in young adults with neck pain to identify any potential deficits.
Funding Acknowledgements: No external funding was provided for this study.
Ethics Approval: Approved by the ACU Human Research Ethics Committee (2014344N).
Keywords: balance, gait, neck pain

PO4-CS-016
CLINICAL FEATURES AND RISK FACTORS FOR CERVICAL ARTERIAL DISSECTION: AND INVESTIGATION OF FINDINGS IN A HEADACHE AND NECK PAIN POPULATION.
L. Thomas*, L. Eide 1, S. Roenaas 1, P. Hingorani 1, C. Gray
1
School of Health and Rehabilitation Sciences, University of Queensland, St Lucia, Australia
Background: Manual therapy of the cervical spine has in rare cases been associated with adverse neurovascular events, the most serious of which is cervical arterial
dissection (CAD). Recognizing CAD is difficult as it may mimic a musculoskeletal presentation. Current screening practices are under review in light of suggestions that
they may not adequately identify those at risk of neurovascular compromise or with an ischaemic event already in progress and some frameworks have been
suggested which may lack clinical utility. There is a need for a succinct protocol which can be conducted quickly within a normal clinical encounter on patients of
concern.
Purpose: To evaluate the clinical utility of a proposed screening tool in individuals with neck pain and/or headache. Additionally, to determine how frequently key
features of cervical artery dissection occur and how well these features are matched with physical findings.
Methods: This was an observational cohort study. Twenty participants with neck pain and headaches were screened for key features of cervical artery dissection
using a structured interview, and physical examination for signs of vestibular and somatosensory, cardiovascular and neurological dysfunction.
Results: 20 participants (9 males) with a mean age of 27.25 years (SD = 6.08; age range 20-39) were included in the study. Sixteen (80%) participants had at least one
feature of cervical arterial dissection in either the structured interview or the physical examination. It was rare to have three or more key features, with only 15% of
participants presenting with this many. There was poor correlation between reported subjective symptoms and objective signs. Most physical examination findings
could be accounted for by more benign causes.
Conclusion: In a patient group with neck pain and headache without cervical arterial dissection there are likely to be less than three features suggestive of this
condition and these can usually be accounted for by a benign cause. The proposed screening tool is comprehensive, structured and has good clinical utility.
Implications: There is a need for a succinct protocol which can be conducted quickly within a normal clinical encounter on patients of concern. The proposed
screening tool may form the basis for the development of such a protocol.
Funding Acknowledgements: The study was unfunded
Ethics Approval: Ethical approval was granted by the Medical Research Ethics Committee of the University of Queensland
Keywords: None

PO4-CS-018
PRESENCE OF CENTRAL SENSITISATION AND SENSORY DEFICITS IN PATIENTS WITH ATRAUMATIC SHOULDER INSTABILITY
B. Hughes 1,*, A. Jaggi 1, H. Cox 2, S. Alexander 1, H. Cohen 3
1
Shoulder and Elbow Unit, 2Royal National Orthopaedic Hospital, London, United Kingdom, 3Rheumatology , Royal National Orthopaedic Hospital, London, United
Kingdom
Background: Pain is a feature associated with atraumatic shoulder instability. Character of pain varies in nature not always directly related to episodes of
subluxation. Pain can be widespread with sensory disturbances often associated with minor or no intrarticular structural damage . Central sensitisation has been
found to be evident in other upper limb disorders such as shoulder impingement (Gwilym et al 2011) . Early detection and understanding of the pain presentation
may guide improved management and avoid inappropriate interventions.
Purpose: Prospective cohort study to investigate 1. Prevalence of neuropathic pain in atraumatic shoulder instability, 2. Differences in sensory perception compared
to asymptomatic controls.
Methods: 32 patients (28 females, mean age 26) with atraumatic shoulder instability completed the subjective PainDETECT questionnaire. Duration of symptoms and
previous interventions were recorded. Sensory perception was tested in the affected limb with 1. Pressure algometer, 2. Monofilament for static sensation 3. Brush
for dynamic sensation. The dominant arm was tested in 75 asymptomatic subjects (53 females, mean age 32) as a control group.
Results: 33% patients demonstrated neuropathic pain (scores > 19 on PainDETECT). 31% patients had allodynia (exaggerated pain response to normal stimuli).
Patients demonstrated an increased pain response to pressure compared to controls (p= <0.001) (95% CI -2.51 to -3.00). Patients with neuropathic pain experienced
increased pain in response to pressure compared to patients without (p= <0.021) (95% CI -0.75 to -0.95).
Conclusion:
A third of patients with atraumatic shoulder instability presented with neuropathic pain and sensory deficits irrespective of duration of symptoms or previous
interventions. In these patients, light pressure could cause unbearable pain. These findings are synonymous with the characteristics observed in patients with
central sensitisation. A multidisciplinary approach including a biopsychosocial model and appropriate pharmacological agents to manage the pain effectively should
be considered prior to considering surgical interventions. It is still unclear if these abnormal sensory changes are a result of the GHjt instability or the pre-cursor to
developing abnormal motor function resulting in instability. Further studies are needed to better understand the development of pain in this cohort and the effect
minor trauma has on the neurological system as well as the most effective treatments to manage it.
Implications: Shoulder instability associated with constant and widespread pain should be assessed for central sensitisation to avoid inappropriate surgery and poor
outcome. The PainDETECT questionnaire may be useful in screening for the presence of central sensitisation in this cohort of patients. Early detection and referral to
appropriate pain services from primary care may help improve outcomes for these patients.
Ethics Approval: Ethics approval not required. Permission granted by the Research and Development Dept. to undertake evaluation of assessment.
Keywords: complex pain, sensory deficits, shoulder instability

PO4-CS-020
VERTEBRAL ARTERY LOOP: A RARE CAUSE OF CERVICAL RADICULOPATHY.
L. Wood*, M. Czyz 1, B. Boszczyk 1
1
Spinal, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
Background: Although a vertebral artery loop causing cervical radiculopathy is a rare condition, practitioners should be mindful of this as a differential diagnosis in
order to ensure patients receive the most appropriate care timeously.
Purpose: To present two cases of a vertebral artery loop compressing cervical nerve roots as a rare but important differential diagnosis to be considered in cervical
radiculopathy.
Methods: A literature search of Medline, Cinahl, Pubmed and Web of Science over one month by both authors was conducted to find articles regarding vertebral
artery loops and vertebral artery anomalies. Two single retrospective case studies are reported with regard to the evidence.
Results: Six case reports are reported in the literature regarding vertebral artery loops causing cervical radiculopathy, with one updated literature review. A variety of
cervical levels are reported, with higher prevalence noted at C4/5, followed by C3/4 and C5/6. Salient identifying features include widening of the intervertebral
foramen. This is not always reported radiographically and therefore an awareness of this condition is important to ensure it is not missed. Two cases of a vertebral
artery loop compressing cervical nerve roots were diagnosed based on clinical findings, neuroimaging and pain relief achieved after fluoro-guided nerve root block.
Both of them were listed for surgical decompression of the vertebral artery.
Conclusion: Vertebral artery loops are a rare condition that may have implications for patients with persistent radicular pain in the absence of degeneration or disc
prolapse. Many of the patients were successfully managed conservatively with physiotherapy, but surgical decompression should be considered should conservative
measures be unsuccessful.
Implications: This is an important differential diagnosis for those working in an extended scope role, especially in a spinal secondary care setting. Early recognition
and management can ensure appropriate care for improved patient outcomes.
Ethics Approval: No ethics approval. Patients remained anonymous at all times adn there was no mention of patient identifiable information.
Keywords: anomaly, Cervical radiculopathy, vertebral artery

PO4-CS-021
A CADAVERIC ASSESSMENT OF THE ALAR LIGAMENT
S. Karas 1,*, K. Rabey 2, H. McIntyre 1, B. Babb 3, E. M. Williams-Hatala 1
1
Chatham University, Pittsburgh, 2Midwestern University, Downers Grove IL, 3Chatham University, Pitstburgh, United States
Background: The alar ligament is an essential component of upper cervical stabiltiy and may be injured in whiplash associated mechanisms. It has been advised that
the integrity of the alar ligament be tested prior to manual therapy to the cervical spine, although the tests utilized lack validity and reliability. While MRI assessment
allows for visualization of the alar ligament, it also produces poor interobserver agreement.
Purpose: The purpose of this study was to assess the origin, insertion, and characteristics of the alar ligament in cadaveric models and document observed variations.
Methods: The alar ligaments of cadaveric models were exposed and the models positioned prone with the cervical spine in neutral. A series of high quality photos
were taken at various positions and angles so that the entire ligament could be visualized.
Results: The angle the ligmaent traveled from the dens to the occiput ranged from 41.8 to 69.1 degrees. Additional variations were noted in thickness and location of
insertions into the occiput also varied.
Conclusion: Manual stress testing of the alar ligament may not be reliable due to anatomical variations in the angle of placement of the alar ligament, as well as
variations in its insertion into the occiput. These same variations may explain the differences in MRI interpretations.
Implications: Clinicians should rely on patients subjective signs and symptoms as well as clinical presentation to determine possible alar ligament pathology. Manual
stress testing and MRI reports should be interpretted knowing that their reliability have not been established.
Funding Acknowledgements: No funding was required.
Ethics Approval: No ethics approval was needed.
Keywords: alar ligament, cervical spine anatomy, Upper cervical spine

PO4-CS-023
THE EFFECT OF CERVICAL PHYSICAL THERAPY IN PATIENTS WITH CERVICOGENIC SOMATIC TINNITUS
S. Michiels 1 2,*, W. De Hertogh 2, S. Truijen 2 3, P. Van de Heyning 1 3 4
1
Department of Otorhinolaryngology, Antwerp University Hospital, Edegem, 2Department of Rehabilitation Sciences and Physiotherapy, 3Multidisciplinary Motor
Centre Antwerp, 4Department of Translational Neurosciences, University of Antwerp, Wilrijk, Belgium
Background: Tinnitus can be related to many different aetiologies such as hearing loss or a noise trauma, but it can also be related to the somatosensory system of
the cervical spine, called cervicogenic somatic tinnitus (CST). Patiens with CST may benefit from cervical spine treatment, but it is hard to predict the treatment
outcome.
Purpose: The objective of this study was to investigate the effect of a standardized physical therapy treatment protocol on cervicogenic somatic tinnitus (CST) and to
identify prognostic indicators that can predict a positive outcome of this physical therapy treatment.
Methods: Patients with severe subjective tinnitus (Tinnitus Functional Index(TFI) 25 - 90 points), in combination with neck complaints (Neck Bournemouth
Questionnaire(NBQ) > 14 points) were included. Exclusion criteria: tinnitus with clear otological aetiologies, severe depression, traumatic cervical spine injury, tumors,
cervical spine surgery or conditions in which physical therapy is contra-indicated. Patients were randomized in an immediate-start therapy group and a group with a
delayed start of therapy by 6 weeks to create a control group.
The immediate-start and delayed-start patients received a physical therapy treatment directed to the cervical spine of 12 sessions of 30 minutes during six weeks.
TFI, NBQ and global perceived effect (GPE) were collected at baseline, after six weeks wait-and-see in the delayed-start group, immediately after the last treatment
session and 6 weeks after the last treatment session. A set of cervical biomechanical and sensorimotor tests was performed at baseline and 6 weeks after the last
treatment session.
Results: In total, 40 patients were included in the study. Immediately after treatment, the average TFI-score decreased significantly (p=0.04) but increased again six
weeks after the last treatment session. The NBQ-score decreased significantly directly after treatment (p<0.001) and maintained after 6 weeks follow-up (p=0.001). In
week 6 of the study, a substantial improvement of the tinnitus was present in 58% of the immediate-start group compared to no improvement in the delayed-start
group.
Patients suffering from low-pitched tinnitus are significantly more likely to benefit from the applied treatment than patients suffering from high-pitched tinnitus (87%
versus 48%) (p=0.04). When combining the low-pitched tinnitus with the increase of tinnitus during inadequate postures during rest, walking, working or sleeping, a
group of patients could be identified that all experienced substantial improvement of their tinnitus immediately after treatment and after 6 weeks follow-up.
Co-variation of tinnitus and neck complaints was present in 49% of the study population. The co-varying group had significantly lower TFI-scores after treatment
(p=0.001) and after 6 weeks follow-up (p=0.03).
Conclusion: Patients who experience a tinnitus decrease from cervical physical therapy are those with covarying tinnitus and neck complaints and those with a
combination of low-pitched tinnitus and increasing tinnitus during inadequate cervical spine postures. To prove the efficacy of cervical physical therapy in these
patients, the study needs to be repeated to include only the described subgroup.
Implications: Cervical physical therapy can be an effective treatment in some tinnitus patients. Physical therapists can consequently have a supportive role in the
multidisciplinary treatment of CST, given their specific skills in cervical spine evaluation and treatment.
Funding Acknowledgements: This study was funded by a research grant and TOP BOF from the University of Antwerp.
This study was performed at the Multidisciplinary Motor Centre Antwerp (M2OCEAN) that was established by means of a Hercules Grant type 2 for medium sized
research infrastructure from the Flemish Research Council (AUHA/09/006).
Ethics Approval: The Antwerp University Hospital Ethics Committee(s) approved this study (reference number: B300201421113).
Keywords: cervical spine, Tinnitus, treatment

PO4-CS024
NECK-SPECIFIC EXERCISES REDUCE DISABILITY AND IMPROVE HEALTH-RELATED QUALITY OF LIFE IN INDIVIDUALS WITH CHRONIC WHIPLASH-ASSOCIATED
DISORDERS COMPARED TO BEING ON A WAITING LIST FOR PHYSIOTHERAPY
A. Peolsson*, M. Landn Ludvigsson 1 2, G. Peterson 1 3
1
Medical and Health Sciences, Physiotherapy, Linkping University, Linkping, 2Rehab Vst, County council of stergtland, Motala, 3Centre for Clinical Research
Srmland, Uppsala University, Eskilstuna, Sweden
Background: Neck-specific exercises are superior to prescribed general physical activity in reducing pain and disability in individuals with chronic whiplash-associated
disorders (WAD). However, there is scarce information on the effects of neck-specific exercises compared to no intervention.
Purpose: To investigate whether 3 months of neck-specific exercises (NSE) would better reduce pain and disability and improve health-related quality of life in
individuals with chronic grade 2 or 3 WADs compared to being on a waiting list for physiotherapy treatment.
Methods: In a prospective, randomized, controlled study, 41 individuals (31 women, 10 men; mean age of 38 years, standard deviation [SD] 11.2) with chronic (6 to
36 months) grades 2 (verified to emanate from the neck in a clinical examination) and 3 (radiculopathy and neurological findings emanating from the neck) WAD were
randomized to NSE or no treatment while on a waiting list for 3 months. Outcome measures used were neck-specific disability (Neck Disability Index; NDI), neck pain
intensity (Visual Analogue Scale; VAS), general pain-related disability (Pain Disability Index; PDI), one's belief in one's own ability to complete tasks and reach goals
(Self-Efficacy Scale; SES), and health-related quality of life (EuroQol five dimensions; EQ-5D).
Results: The NSE group had a significantly (p<0.01) greater improvement compared with no treatment in NDI, SES, and EQ-5D. The NSE group improved over time in
all outcome variables (p<0.0001). Except for the PDI, individuals not receiving treatment scored significantly worse (p<0.01) on all assessments over time.
Conclusion: NSEs provided benefit to individuals with chronic WAD compared with no intervention.
Implications: This is the first prospective, randomized investigation of an intervention in patients with chronic WAD compared to being on a waiting list for
physiotherapy treatment. The positive findings of NSEs show the possibility of treating individuals with chronic WAD.
Funding Acknowledgements: Linkping University and the county councils stergtland and Srmland.
Ethics Approval: Approved by the Regional Ethics Review Board, Linkping, Sweden.
Keywords: Whiplash injury, spine, rehabilitation

PO4-CS-026
DIFFERENCES IN REPORTED SEVERITY OF PAIN AND THE LOCATION OF PAIN IN PATIENTS WITH RECURRENT STRUCTURAL AND NON-STRUCTURAL SHOULDER
INSTABILITY
A. Gasson 1,*, A. Jaggi 2, S. Alexander 2, M. Thacker 3
1
Physiotherapy Department, Imperial College Healthcare NHS Trust, 2Shoulder and Elbow Unit, Royal National Orthopaedic Hospital, 3Centre for Human and
Aerospace Physiological Sciences, King's College London, London, United Kingdom
Background: Recurrent shoulder instability (RShI) has a complex and multifactorial pathogenesis. It often presents difficulties for clinicians to classify and
manage. Many classification systems have been proposed to identify different types of RShI and to guide surgical or conservative treatment. These systems are
based on a wide range of factors but none take into account the pain presentation of the patient. Experiential evidence suggests there is a difference in how pain
presents subjectively in patients with a non-structural versus a structural cause for their RShI.
Purpose: The primary purpose of this study was to assess if aspects of subjective pain presentation would be able to contribute towards differentiating between
individuals with or without a structural lesion associated with their RShI.
Methods: A retrospective population based cohort design was used. Physiotherapy pain assessments were collected from the notes of 51 patients at a tertiary
referral shoulder rehabilitation service. All patients included met strict inclusion and exclusion criteria. Each patient had undergone a diagnostic arthroscopy to
determine the presence or absence of structural gleno-humeral joint (GHJ) intra-articular pathology underlying their RShI. Appropriate analysis compared the severity
of reported continuous pain (Numerical Rating Scale {NRS}) and pain location (scored from a body chart) between those with structural pathology and those without.
Results: Patients with recurrent shoulder instability and no intra-articular GHJ pathology were likely to have significantly higher levels of continuous pain (Mann
Whitney U= 150.0, p=0.004). The Median NRS for patients with no intra-articular pathology was 5 [95% CI 3.76-5.81] compared to a median NRS of 2 [95% CI 1.423.62] in patients with pathology.
92% of patients with no intra-articular pathology also had a diffuse non-anatomical distribution of pain involving the whole upper quadrant ( = 16.05, p = <0.001)
whilst 62.5% of patients with pathology had pain specifically localised over the GHJ.
Conclusion: Patients with RShI but no intra-articular GHJ pathology were likely to report significantly higher levels of continuous pain. This is counter intuitive as it
would be expected that those with pathology would have reports of greater pain. There are several mechanisms with the potential to explain this finding including
central sensitisation; where increased excitability of the central nervous system is amplified and maintained beyond the initial nociceptive processing. It is known that
pain is not a direct measure of the condition of an individual's tissue and it can be experienced without any nociceptive input at all. The presence of wide spread pain
in patients with no pathology could be explained by heterosynaptic facilitation and alterations in the receptive fields of central nervous system neurons.
Implications: Understanding the variation in the pain profile of patients with RShI may have diagnostic importance and guide treatment. Recognition of more
centrally driven pain mechanisms may warrant treatment targeted at these systems in combination with the periphery. The results from this study will used to
inform future research.
Ethics Approval: Approval for the study was sought from the Research and Development department at the hospital and confirmed under the remit of a service
evaluation (Reg Number SE.14.010).
Keywords: Central sensitization, Pain, shoulder instability

PO4-CS-027
CHANGES IN SYMPTOMS AND RESTING POSITION OF JAW, ATLAS AND AXIS IN PATIENTS WITH TMJ DYSFUNCTION FOLLOWING GLOBAL POSTURAL REEDUCATION
L. Henriquez 1,*, L. Palomer 2, J. Leppe 2, N. Tuttle 3
1
Physical Therapy, Universidad San Sebastian, 2Physical Therapy, Universidad del Desarrollo, Santiago, Chile, 3Physiotherapy, School of Allied Health Sciences, Griffith
University, Gold Coast, Australia
Background: Head on neck posture influences both the resting position and functional movement of the jaw. Altered head on neck posture is therefore thought to be
a possible contributor to the development of temporomandibular joint (TMJ) symptoms. Global Postural Re-education (GPR)is a method based on an integrated idea
that the muscular system consisting of muscle chains, which can shorten from constitutional, behavioural, and psychological factors. To date the effect of GPR on
symptoms or 3D segmental posture has not been investigated in patients with TMJ symptoms.
Purpose: To determine whether pain or clicking with active movements or 3D resting posture of the jaw and upper two vertebrae change following treatment using
GPR.
Methods: Thirteen volunteer university students with disc displacement with reduction (DDR) completed the study. Initial assessment included 1) Clicking and pain
while performing a series of ten active jaw movements. Clicking was recorded by the investigator and pain was rated by the participant on a analogue visual scale. 2)
The Hospital Anxiety and Depression Scale Spanish version(HADS) was used to evaluate anxiety and depression. 3) CT scans were taken with the head in a repeatable
position. All participants received six weekly GPR treatments. Location of the skull, jaw, C1 and C2 were determined in 3D using a semi-automated segmentation
system (Mimics) with the operator blinded to the condition (pre/post treatment). Intra-operator limits of agreement for reprocessing the same scan was 0.13 mm for
translation and 0.38 for rotation across all axes. Changes in position of the jaw, C1 and C2 in relation to the skull were calculated for rotations and translations in each
of the three cardinal axes (flexion/extension, rotation and lateral flexion). Wilcoxon Sign Rank test was used to determine pre/post differences. Means and 95%
confidence intervals (CI) for all measures were calculated. Differences were considered significant if the CIs did not include zero.
Results: Following treatment, there was a reduction in the incidence of clicking. Scores in the HADS improved by 3.23 (CI 1.59 4.87), particularly in the depression
scale (2.69, CI 1.20 - 4.18). The jaw was 0.24mm lower (CI 0.09 - 0.39) and 0.39 more flexed (CI 0.14-0.65); C1 was 2.59 more flexed (1.02 4.14) and 0.55 more
rotated to the left (CI 0.22 - 0.87 degrees; and C2 was 2.01 (CI 0.95 3.07) more flexed and 2.6 (CI 1.29 2.63)more rotated to the left.
Conclusion: In this case series, there was a reduction in clicking and anxiety as well as alterations in posture following a six week GPR treatment program.
Implications: This study provides pilot data suggesting that a specific exercise program may be able to alter resting posture and reduce some symptoms of DDR.
Further studies including a control group would be necessary before any clear conclusions can be drawn about the presence of a possible relationship between
posture and symptoms in patients with DDR.
Funding Acknowledgements: The study was supported by internal funds of Universidad San Sebastian (number 5006 ) .
Ethics Approval: The project was supported by the physiotherapy school of San Sebastian University, all subjects gave written informed consent to participate,
however, when the study was implemented there was no obligation to submit the study to an ethics committee.
Keywords: Global Postural Reeducation, Temporomandibular Joint, Upper cervical spine

PO4-ED-028
CONSENT IN OSTEOPATHIC PRACTICE - A QUALITATIVE OBSERVATIONAL STUDY
S. Vogel 1,*, A. Hooper 2, L. Hazel 2
1
Research Centre, 2The British School of Osteopathy, London, United Kingdom
Background: Concerns about communication and consent are sources of complaints to regulatory bodies. Risk of safety events concerning treatment of the neck have
been reported in the literature and have been a focus of concern. This is reflected in anxieties about gaining consent when treating the neck. Gaining informed
consent is a professional requirement across manual therapies. Previous work in the field of manual therapy has used cross sectional survey reports of practitioner
consent practice and patients' report of their experience of information receipt. These data may be subject to recall bias and the influences of social desirability.
Therefore there is a need for observational studies of practice in action.
Purpose: This study aimed to investigate the verbal consent process between osteopaths and new patients.
Methods: Cross sectional observational qualitative study of new patient consultations with osteopaths. Consecutive new patients attending a single practice were
given information about the study and gave written consent to take part. Consultations were audio recorded and transcribed verbatim. Thematic analysis was
undertaken drawing on both inductive and deductive approaches and using constant comparative coding, categorising and thematic analysis. Trustworthiness
strategies to enhnace the analysis included: memo writing, immersion, consensus review, debriefing, triangulation, and insider positioning.
Results: Seven practitioners agreed to take part. Twenty new patient consultations were included in the analysis. Three mains styles of consent behaviour were
identified: Directing, explaining and educating. Strategies varied between practitioners and within consultations. Permission to act gained by practitioners varied from
being explicit to implied or assumed with patients receiving varying degrees of information prior to practitioners taking action. Giving of information happened
throughout the consultation often as a running commentary. Summarising and checking of understanding happened towards the end of the consultation. Limited
information about risks and alternative treatment options were given whereas information about the nature and likely benefits of treatment were most common.
Conclusion: The process of receiving consent is a dynamic, complex and continuous process throughout the consultation. There are challenges in mapping
practitioner patient interactions clearly to requirements expected by regulatory standards of practice. There are opportunities for practitioners to further structure
consultations in order to better work in partnership with patients in receiving consent and adhering to stautory requirements. Further study should explore the role
of CPD in enhancing the structure of the consultation and making consent more explicit. Similar data would benefit from discourse and linguistic ethnographic
analytic approaches to further explore the use and meaning of consent realted language within the consultation.
Implications: The study identifies opportunities within the consultation to enhance the receipt of consent. This should be contextualised within a partnership model
of practice which enhances the therapeutic alliance in addition to adhering to regulatory standards of practice. There are opportunities to provide clearer structure
and content to enhance the receiving of consent from patients.
Ethics Approval: The British School of Osteopathy Research Ethics Committee
Keywords: Communication, Consent, Information exchange

PO4-LB-035
REDUCED NON-DOMINANT LUMBAR MULTIFIDI CROSS-SECTIONAL AREA IS A PRECURSOR OF LOW BACK INJURY: A PROSPECTIVE COHORT STUDY
B. Olivier*, N. Gillion 1, A. Stewart 1, W. McKinon 2
1
Physiotherapy, 2School of Physiology, University of the Witwatersrand, Johannesburg, South Africa
Background: The lumbar multifidi muscle (LM) is classified as a stabilizer of the lumbar spine it anticipates movement and stabilizes the lumbar spine prior to
movement. Various cross-sectional studies have found that LM cross-sectional area (CSA) is lower in the presence of low back pain and that asymmetry in LM CSA is
associated with low back injury. None of these studies investigated LM CSA asymmetry as a precursor or predictor of injury. If a difference in left vs right LM CSA is
found to be associated with future incidence of low back injury, the measurement of LM CSA can be included in low back injury prevention programs.
Purpose: The aim of this study was to investigate the symmetry of the CSA of LM at L3, L4 and L5, in the context of simultaneous injury monitoring.
Methods: This prospective cohort study took place in the indoor cricket nets of the associated tertiary institution. Injury free, male, right-handed cricket fast bowlers
playing at a non-professional level participated in this study. LM CSA at L3, L4 and L5 vertebral levels was measured through the use of rehabilitative ultrasound
imaging in a resting position in prone. The primary outcome measure (dependent variable) of the study was the incidence of an injury during the cricket season.
Results: Twenty-six fast bowlers (aged 21.8 1.8 years) participated. No difference was found between the left and the right LM CSA amongst injury free bowlers. In
bowlers who sustained a low back injury during the cricket season, the left CSA at L3 (p=0.04) and L5 (p=0.04) is smaller compared to the right.
Conclusion: The LM CSA found in this study compares well to findings from previous studies. No difference between LM CSA in this group of injury free fast bowlers
was found as measured at the start of the cricket season. Bowlers who sustained a lower back injury during the season had smaller L3 and L5 LM CSAs on the left. As
none of the bowlers who sustained a lower back injury during the season, had a previous lower back injury, these findings may indicate that the difference in LM CSA
may be a precursor of injury. Future research is needed to investigate the potential of LM CSA asymmetry to be a predictor of injury in various populations.
Implications: Left/right difference in size of lumbar multifidi may be a precursor to low back injury even in the absence of previous low back injury.
Funding Acknowledgements: Funding was received from the National Research Foundation, the Carnegie Foundation of New York and the local Society of
Physiotherapy.
Ethics Approval: Ethical clearance was obtained from the Human Research Ethics Committee of the University of the Witwatersrand (reference M10430).
Keywords: low back pain, Multifidus, rehabilitative ultrasound imaging

PO4-LB-037
TEST-RETEST RELIABILITY AND MINIMAL DETECTABLE CHANGE OF THREE-DIMENSIONAL GAIT ANALYSIS IN CHRONIC LOW BACK PAIN PATIENTS AND HEALTHY
INDIVIDUALS
R. Fernandes*, P. Armada-da-Silva, A. Pool-Goudaazward, V. Moniz-Pereira, A. P. Veloso
Background: Three-dimensional gait analysis (3DGA) is a valuable assessment method used in clinical and in research settings to support clinical functional diagnoses
and decision-making. Repeated gait measurements can also be useful to evaluate the outcome of therapeutic interventions, although the observed variability
between pre and post intervention measurements may be due to treatment effects or measurement variation, or a combination of both (McGinley et al., 2009). Thus,
knowledge about the error magnitude can minimise the risk of over-interpreting small differences as meaningful (Schwartz et al., 2004) and can contribute to the
certainty that a measured intervention effect exceeds the measurement error. Data on reliability and measurement error of 3DGA in CLBP patients is lacking,
although evidence that clinically acceptable errors are possible in 3DGA in patients with cerebral palsy or stroke (McGinley et al., 2009).
Purpose: The aim of this study is to investigate test-retest reliability and minimal detectable change of 3DGA in a sample of CLBP patients and healthy individuals.
Methods: A test-retest study was conducted with a sample of 14 CLBP patients and 14 healthy individuals that underwent two biomechanical gait assessments with
an interval of 7.61.8 days. Data collection was carried out using a 13-camera opto-electronic system (Oqus 300, Qualisys AB, Gothenburg, Sweden) at 200Hz.
Participants were instructed to walk during a few minutes at their preferred velocity and 10 gait cycles were selected to be processed in Visual 3D software (v5.01.10,
C-Motion, Inc). A GCVSPL filter was applied to kinematic data. The marker set selection was based on previous reports (Seay et al., 2008) and a 9 segments model
(feet, shanks, thighs, pelvis, lumbar and thoracic spine) was built and optimized through global optimization (Lu et al., 1999). Anthropometric and time-distance
parameters, as well as peak values for lower limb and trunk joint angles and moments, were computed. Intraclass Correlation Coefficient (ICC3,k) and their 95%
confidence intervals were calculated. Standard error of measurement (SEM), minimal detectable change (MDC) and limits of agreement (LOA) were also estimated.
Results: The obtained ICC values demonstrate varied test-retest reliability indices for joint angles and a SEM <2.5 for CLBP and 4 for healthy individuals. Although
joint moments showed lower reliability than joint angles, the majority of the ICCs were above 0.7 and the SEM and MDC values were low (0.06 Nm/kg and 0.18
Nm/kg for CLBP; 0.2 Nm/kg and 0.6 Nm/kg for healthy individuals). Bland-Altman plots with 95% LOA revealed a good agreement and time-distance parameters
were all highly repeatable (ICCs > 0.86).
Conclusion: The results of this study show high test-retest reliability on 3DGA parameters in CLBP and an acceptable level in healthy individuals. For the majority of
the parameters, ICCs were higher in the CLBP group, which may be related with higher movement variability in the healthy group. The SEM and MDC values were
generally higher in transverse plane parameters, which is of extremely importance since changes in pelvis and thorax rotations in CLBP patients are frequently
reported both in clinical and research context.
Implications: The results of this study supports the reliability of 3DGA in the assessment of CLBP patients gait patterns and emphasize its potential use for clinical
reasoning and decision making when dealing with CLBP patients.
Funding Acknowledgements: This study was supported by the Instituto Politcnico de Setbal (PhD Grant reference SFRH/PROTEC/67505/2010).
Ethics Approval: The Ethics Committee of the University of Lisbon approved the study. All the participants were informed of the procedures and risks of the study and
signed an informed consent.
Keywords: Gait Analysis, Measurement error, Reliability

PO4-LB-039
A PRAGMATIC STUDY ADDRESSING FASCIAL ACCESS POINTS IN THICKENED CONNECTIVE TISSUE ON THOSE WITH LOW BACK PAIN: PRELIMINARY DATA
B. Harper 1, L. Steinbeck 2, A. Aron 1, C. Heldman 3,*
1
Physical Therapy, Radford University, Roanoke, VA, 2Atlanta Falcons Physical Therapy Centre, Jasper, GA, 3Radford university, Roanoke, United States
Background: Physiotherapists and orthopedic manual therapists (OMT) focus on local joints, discs, nerves, and muscles when treating patients with low back pain.
Treatments are typically directed to the lumbar and thoracic spine, pelvis, and hips. Joint interventions include mobilizations, thrust manipulations, and pelvic
traction. Muscle treatments include soft tissue mobilization (STM) and myofascial trigger points (MTrPs). Neurodynamic interventions address nerve dysfunctions.
Prescribed exercises range from general fitness to core stabilization programs or motor control routines. The Fascial Manipulation (FM) method addresses the fascial
system through regional interdependence in a biomechanical, holistic, and systematic fashion. The addition of this unique perspective may expand OMT practitioners
ability to address another system to effect outcomes in low back pain patients.
Purpose: To determine the benefit of adding FM to patient treatment for low back pain. Outcomes measured with the validated metrics of subjective pain, patient
experience, and disability.
Methods: A pragmatic experimental time series between two outpatient convenience samples. Patients were referred to physical therapy by a medical physician and
were randomized into standard physical therapy (SPT) without FM and SPT with FM. Diagnoses ranged from low back pain/lumbago or post-surgical to failed back
syndrome. Interventions for SPT without FM included thermal and/or electrical modality, general STM, and general therapeutic exercises in combination with
mobilization, manipulation and/or traction. For the SPT with FM group, a certified instructor of the Fascial Manipulation Association, provided FM interventions in
addition to thermal and/or electrical modality and general therapeutic exercise. Participants completed the Oswestry Disability Index (ODI), Numeric pain Rating Scale
(NPRS) and Global Rating of Change (GROC) at initial evaluation and discharge.
Results: SPT group (n=28) had 9.24.8 visits compared to 7.73.5 visits for the FM group (n=43) (p=0.1). The ODI decreased by at least one category in 45% of SPT
cases and had no change in 55%. This was similar to FM group with 62% decreased and 38% with no change (Pearson chi-square: p=0.1). Fifty percent of SPT group
had GROC values of 5, 6, or 7 at discharge compared with 93% of FM group (Pearson chi-square: p=0.0001). Discharge FM group NPRS was double compared to SPT
counterparts (-4.32.2 to -1.52.5, p=0.0001). Overall, 95% of subjects in FM group had at least a 2 point decrease in NPRS compared to 57% of SPT group (Pearson
chi-square: p=0.0001). When data was analyzed with an NPRS change of at least 4 points, 61% of FM patients experienced the decrease compared to just 14% of SPT
group (Pearson chi-square: p=0.0001).
Conclusion: Data analysis revealed strongly statistically significant differences between SPT group and FM group in NPRS and GROC, making the differences unlikely
due to chance. The application of FM to physical therapy clients with low back symptoms results in a significant reduction in pain and significantly positive perceived
benefit from treatment. The mechanism of effectiveness could originate from the applied mechanical stimuli, which improves sliding of the fascia thereby normalizing
biomechanical length tensions and axis of arthrokinematic motion segments within the connective tissue spatial planes as expressed by the constructs of
biotensegrity and regional interdependence. This study should be replicated with larger sample sizes more tightly controlled, but still pragmatic in application.
Implications: The FM method allows a systematic approach to addressing the fascial system in patients, including those with low back pain. The ability to
biomechanically assess and treat fascia provides OMT practitioners a systematic methodology to compliment clinical paradigms involving arthology, myology, and
neurodynamics.
Funding Acknowledgements: Partially funded by a Radford University grant from the Waldron College of Health & Human Services by special initiative of the dean.
Ethics Approval: Approved by the Radford University IRB.
Disclosure of Interest: B. Harper Conflict with: Partially funded by a Radford University grant from the Waldron College of Health & Human Services by special
initiative of the dean., L. Steinbeck Conflict with: Partially funded by a Radford University grant from the Waldron College of Health & Human Services by special
initiative of the dean., A. Aron Conflict with: Partially funded by a Radford University grant from the Waldron College of Health & Human Services by special initiative
of the dean., C. Heldman: None Declared
Keywords: Fascia, Biomechanics, Pragmatic

PO4-LB-041
PAIN PROVOCATION FOLLOWING REPEATED MOVEMENTS IN PEOPLE WITH CHRONIC LOW BACK PAIN: SUBGROUPING AND MULTIDIMENSIONAL PROFILES
M. Rabey*, A. Smith 1, D. Beales 1, H. Slater 1, P. O'Sullivan 1
1
Curtin University, Perth, Australia
Background: Clinicians evaluate pain responses to repeated forward/backward spinal bending in people with chronic low back pain (CLBP). While directional patterns
of pain amelioration and provocation with repeated movement have been reported this has been based upon clinical judgement rather than standardised protocols,
possibly introducing bias. Pain responses to movement reflect complex sensorimotor interactions influenced by multiple dimensions (e.g. psychosocial). It is not
known whether pain responses to movement are associated with different multidimensional profiles.
Purpose: To derive subgroups in people with CLBP (n=294) based upon valid/reliable pain responses to a standardised repeated spinal bending protocol. To
determine whether subgroups have differing multidimensional profiles.
Methods: Subgroups were derived based upon clinically-important (2-points, 11-point numeric rating scale) changes in pain intensity following repeated forward
and backward bending and profiled on demographics, pain characteristics, protective behaviours, pain sensitivity (pressure/heat/cold pain thresholds, temporal
summation), psychological, health and lifestyle factors.
Results: Four subgroups were derived: one had no clinically-important increased pain in either direction (49.0%), another had increased pain with repeated forward
bending only (28.2%), another was provoked by repeated backward bending only (9.9%). The fourth had increased pain bending both directions (12.9%). The first
subgroup appeared normal for pain sensitivity, depression, anxiety, stress and catastrophising; but had elevated fear-avoidance and distorted body perception
compared to normative data. Those provoked by forward bending had elevated disability and catastrophising, slower movement, and low self-efficacy compared to
other subgroups; and elevated depression, fear-avoidance and distorted body perception compared to normative data. Those provoked by backward bending had
elevated fear-avoidance and distorted body perception compared to normative data. The fourth subgroup had higher pain intensity, catastrophising and lower selfefficacy than other subgroups; and elevated lumbar pressure and cold pain sensitivity, depression, fear-avoidance and distortion of body perception compared to
normative data. Those demonstrating a clinically-significant amelioration of pain when moving in the opposite direction to that which was provocative was captured.
Conclusion: Pain provocation following repeated movements in CLBP appears heterogeneous. Mechanisms relating to pain provocation following repeated bending
are postulated. Clinically-significant amelioration of pain when moving in the opposite direction to that which was provocative appears less common than reported.
Implications: This subgrouping is easily incorporated in clinic and may trigger examination of multidimensional presentations associated with differing subgroups.
Funding Acknowledgements: Martin Rabey was supported: Musculoskeletal Association of Chartered Physiotherapists Doctoral Award, Chartered Society of
Physiotherapy Charitable Trust, Curtin University Postgraduate Scholarship, Australian Postgraduate Award. Darren Beales was supported by: National Health and
Medical Research Council of Australia Early Career Research Fellowship.
Ethics Approval: Human Research Ethics Committees of Curtin University, Royal Perth Hospital and Sir Charles Gairdner Hospital in Perth, Australia.
Disclosure of Interest: M. Rabey Conflict with: Musculoskeletal Association of Chartered Physiotherapists Doctoral Award, Chartered Society of Physiotherapy
Charitable Trust, Curtin University Postgraduate Scholarship, Australian Postgraduate Award., A. Smith: None Declared, D. Beales Conflict with: National Health and
Medical Research Council of Australia Early Career Research Fellowship, H. Slater: None Declared, P. O'Sullivan: None Declared
Keywords: repeated movement, Chronic low back pain, subgrouping

PO4-LB-047
EFFECTIVENESS OF MAINTAINED RESONANT OSCILLATIONS IN THE TREATMENT OF ACUTE LUMBAR DISC HERNIA. A NEW MANUAL THERAPY APPROACH
J. Lpez*
Background: Lumbar disc hernia (LDH) is a common cause of low back pain and radicular leg pain. The lumbosacral radicular syndrome (LSRS), caused by a herniated
lumbar disc, is one of the most expensive disorders for society in terms of work absenteeism and disability.
The most appropriate treatment for LDH, whether surgical or conservative, remains controversial due to the disparity of results in the short, medium and long term.
The effectiveness of manual therapy in the conservative treatment of LDH is known. Current studies suggest that conservative treatments that have proven effective
are: stabilization exercises and physical therapy consisting of mild stretching and pain relief modalities such as ultrasound, whirlpool, ice and heat pack therapy,
electrical stimulation, and/or massage.
In the usual conservative treatment of acute LDH, the intervention with active manual therapy is under-represented and the results may be different if more active
and interventionist manual therapies were used (Jull, 2012).
Purpose: This study analyses the efficacy of manual oscillatory therapy, following the POLD technique, for acute LDH and compares it to usual evidence based
treatment.
"POLD" Method (Pulsation Oscillation Long Duration) is a novel conservative treatment, performed with an evolution of rhythmic oscillating mobilization.
Methods: A randomised, controlled, triple-blind pilot clinical trial. The sample of 30 patients was divided into two homogeneous groups to receive usual treatment
(control) or treatment with the POLD technique. We analysed range of motion and subjective variables such as the severity (visual analogue pain scale (VAS) and
extension of the pain (centralization).
Results: With the application of POLD therapy, patients presented significant changes on range of motion (forward flexion with p < 0.05) at completion of the trial in
comparison with the control group. They showed a significant reduction in the severity of pain with a mean VAS scale for lumbar, gluteus and thigh pain, which
improved from 5.09 to 0.79, 5.07 to 0.97 and 4.43 to 0.49 respectively (p<0.05), and also when compared to usual treatment (p<0.05) for all body regions. Moreover,
we observed a reduction in pain extension (centralization phenomena) (p<0.001) in comparison with usual treatment.
Conclusion: In view of the results obtained in this trial we conclude that for acute LDH pathology it is evident that treatment with POLD technique, characterized by a
maintained resonant oscillatory mobilization (hands on), is more effective in increasing range of lumbar flexion, reducing the subjective severity of pain and causing
a rapid centralization when compared with standard physiotherapy treatment (hands off) recommended by current evidence.
Implications: Our findings suggest that clinicians should consider the POLD Method for the treatment of acute LDH in their clinical decision-making.
Funding Acknowledgements: We would like to thank Omphis Foundation for letting us use their clinical infrastructures to conduct the treatment sessions.
Ethics Approval: The trial was supervised and received the ethical approval by the Department of Cell Biology, Physiology and Immunology of the Institute of
Neuroscience at the Autonomous University of Barcelona, as part of the Neuroscience doctorate study program.
Keywords: ACUTE DISC HERNIA, POLD MANUAL THERAPY, RESONANT OSCILLATION

PO4-LL-049
MUSCLE MAPPING AFTER ACUTE MUSCLE INJURY IN ELITE ATHLETES: A CASE STUDY USING HIGH SURFACE AREA, LOW DENSITY, ELECTROMYOGRAPHY
D. Morrissey 1, C. Daly 1,*, R. Woledge 1
1
SEM, QMUL, London, United Kingdom
Background: Persistent neuromuscular inhibition is thought to manifest following sprint related hamstring muscle injury in sport and may underlie persistently high
re-injury rates (Mendiguchia et al 2012, Fyfe et al 2013). Recent research has demonstrated localized intramuscular activation deficits in athletes with prior
hamstring injury using functional magnetic resonance imaging (fMRI) (Bourne et al 2015).
Purpose: Our study is a research project under the topic Integrating research into practice. This project is the first to employ multichannel surface
electromyography (sEMG) to explore temporo-spatial activation patterns in the hamstring muscle group following acute injury, a potential means of detecting
persistent, post-injury muscle activity alterations during muscle testing
Methods: Four longitudinally-aligned eight-channel arrays of unipolar sEMG electrodes were attached to the skin overlying the hamstring muscle group in a world
class female sprinter with a history of right-sided proximal biceps femoris injury struggling to fully rehabilitate. The skin was prepared and the arrays were placed
either side of a line drawn along the centre of the biceps femoris and medial hamstring muscle groups of both legs. The central electrode pairs of each array were
placed either side of the muscle belly midpoint) and the remaining twelve electrodes extended along the muscle belly in a cephalo-caudad orientation at 20mm
intervals. Each posterior thigh therefore had an array of 32 channels corresponding to the biceps femoris laterally and semitendinosis / semimembranosis medially.
The subject performed maximal effort concentric and eccentric contractions at varying speeds on an isokinetic dynamometer, while s-EMG signals were collected
using a REFA 64 channel device (TMSi Enschede, Netherlands). Force data was collected simultaneously using an Isocom Isokinetic Dynomometer (Eurokinetics
Limited, UK). We wished to analyze regional contributions to overall maximal myoelectric activity within the hamstring muscle group. We defined the maxima as the
period of time when the total amplitude across 32 channels (i.e. one leg) exceeded 80% of the maximum signal during each contraction. We calculated the
contribution of each channel to overall knee flexor activity by expressing the mean amplitude of individual signals, as a ratio of the overall mean activity during this
peak activation period thus enabling the identification of areas of greater and lesser relative activity across all knee flexors.
Results: Recruitment patterns were asymmetric between injured and uninjured sides. Increased contributions to overall peak knee flexor activation were observed in
the region of prior injury (proximal right biceps femoris). This was associated with relative under-activity in the medial hamstring muscles on this side. The activation
patterns were reversed on the uninjured side, with lower levels of activity seen in the lateral hamstrings and increased levels seen in the medial muscle bellies.
Conclusion: Areas of relative over-activity in the previous injury region were associated with under-activity in the adjacent medial hamstring muscle. As these signals
were collected during maximal effort contractions, this may indicate inefficiency in activation, with maximal force generation associated with over-recruitment of
muscle fibers in the region of previous injury. Such myoelectric imbalance may partly explain the persistently high re-injury rates seen in sprint related hamstring
injury. If confirmed by studies with higher subject numbers, this method may offer valuable rehabilitation advances should the restoration of normal recruitment
patterns be associated with a reduction in re-injury risk.
Implications: This method appears to offer an innovative means of detecting persistent, post-injury muscle activity alterations during muscle testing
Funding Acknowledgements: Dr Morrissey is partly funded by the NIHR/HEE Senior Clinical Lecturer scheme. This abstract presents independent research funded by
the National Institute for Health Research (NIHR). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of
Health.
Ethics Approval: Ethics approval was granted Queen Mary University of London REC
Keywords: hamstring, multichannel sEMG, Neuromucular inhibition

PO4-LL-051
THE EFFECTS AND MECHANISMS OF RUNNING GAIT RETRAINING IN THE MANAGEMENT OF PATELLOFEMORAL PAIN: A FEASIBILITY TRIAL
D. Morrissey 1, B. Neal 1,*, C. Barton 1
1
SEM, QMUL, London, United Kingdom
Background: Patellofemoral pain (PFP) is the most prevalent running-related injury, and is thought to be associated with numerous biomechanical deficits.
Runners with PFP are thought to be a subgroup that only achieves partial success with multimodal Physiotherapy. Observational studies have reported that two
weeks of gait retraining to reduce peak hip adduction reduces pain and improves function at three months follow up in runners with PFP. However, this research
was limited to females and PFP patients possessing excessive peak hip adduction (> 20) at baseline, limiting clinical applicability. Significant reductions in
patellofemoral joint stress using cues to increase cadence have also been reported in female runners with PFP, although evaluation of symptom changes were not
reported in this research.
Purpose: This study aims to (i) determine the feasibility of a simple gait retraining intervention (increasing cadence) in a mixed sex UK population; and (ii) inform
upon potential biomechanical mechanisms.
Methods: Male and female runners with PFP of minimum three months duration are being recruited, aged 18-45, currently/recently running a minimum of
10KM/week, and with PFP scored at a minimum of 3/10 on a VAS scale. Lower-limb kinematics and electromyography are sampled during a 3KM treadmill run
before and after a six-week gait retraining intervention. External metronome feedback to increase baseline cadence by 7.5%, applied using a faded-feedback
design adopted from published work, forms the intervention.
Results: In five participants recruited to date, increasing cadence has significantly reduced worst (38mm) pain (p=0.01). Electromyography data identified an 11.11%
reduction in Gluteus Medius average activation (mean of amplitude from onset to offset), alongside increased activation duration for both Gluteus Maximus (140ms)
and Medius (100ms). Kinematic changes to date have been negligible. Full data will be available in the next three months.
Conclusion: Preliminary data suggests that a simple gait retraining intervention of increasing cadence by 7.5 % reduces pain in runners with PFP in a mixed sex UK
cohort, with emergent biomechanical mechanisms identified which may partially explain the observed effects.
Implications: Gait retraining is emerging as an effective intervention for runners with PFP, with a 7.5% increase in cadence appearing to be an effective intervention
and worthy of consideration in clinical practice. Future work should focus on establishing efficacy via randomized trials and investigating the most effective form of
feedback.
Funding Acknowledgements: Mr. Neal is partially supported by an early researcher grant from the Private Physiotherapy Education Fund and by his primary
employer, Pure Sports Medicine. Dr. Morrissey is part-funded by the National Institute of Health Research (NIHR) Senior Clinical Lecturer Scheme.
Ethics Approval: Ethical approval was granted by the Queen Mary Ethics of Research Panel (QMREC2014/63) on 22/09/2014.
Keywords: Biomechanics, Patellofemoral pain, Running

PO4-LL-052
A MANUAL MUSCLE MANIPULATION AND EARLY RETURN TO SPORTS IN FOOTBALLERS WITH LONG-STANDING ADDUCTOR-RELATED GROIN PAIN; A PROSPECTIVE
CASE SERIES.
I. Tak*, B. Bertrand 1, R. Langhout 2, A. Weir 3, M. Barendrecht 4, J. Stubbe 5, G. Kerkhoffs 6
1
Fysio Valkenburg, Valkenburg, 2Manual therapy and sports rehabilitation, Physiotherapy Dukenburg, Nijmegen, Netherlands, 3Sports Medicine, Aspetar Hospital,
Doha, Qatar, 4Dutch Centre for Allied Health Care, Amersfoort, 5Sports Medicine, University of Applied Sciences, 6Orthopaedics and Sports Traumatology, Academic
Medical Centre Amsterdam, Amsterdam, Netherlands
Background: A manual manipulation of the adductors in combinagtion with a structured return to running program and exercise regime results in reduction of
complaints in athletes with long-standing adductor-related groin pain (LARGP). This manipulation is common practice in a few private clinics and early return to sports
is then allowed. No data on the course of complaints during this progressive return to sports are available.
Purpose: The objective was to assess effects of manual muscle manipulation of the adductors when combined with early progressive return to sport (RTS) in
footballers with longstanding adductor related groin pain in terms of pain, function and patient satisfaction.
Methods: This was a prospective case series. Treatment was a manual manipulative stretch of the adductors in transverse and longitudinal proximal direction. RTS
allowance was immediately after treatment. Follow-up was at 2, 6 and 12 weeks assessing pain levels with numeric pain rating scale (NPRS), daily report of sports
activity, Hip And Groin Outcome Score (HAGOS) and global perceived effect (GPE) for treatment and patient satisfaction on a 7 point Likert scale.
Results: Thirty-four footballers with a median pre-injury Tegner score of 9 (IQR: 9-9) were willing to participate in the pre and post treatment assessments. Within
two weeks 82% returned to pre-injury playing level at an average of 5.3 (1-14) days. At twelve weeks this was 88%. Pain reduction was significant (p<0.001) from
NPRS 7 (IQR 6-8) to 1 (IQR 0.2-3) during sports and from NPRS 8 (IQR 6-8) to 1 (IQR 0.8-3) after sports. Significant (p<0.001) improvement was observed on all HAGOS
subscales. Clinical relevant improvement was reported by 85% and 82% was satisfied. This treatment did not prove to be succesful for 4 players and 3 of them did not
return to sport. Despite this no clinical relevant worsening was observed.
Conclusion: The manual muscle manipulation of the adductors and progressive return to play seems a worthwhile treatment in footballers with long-standing
adductor-related groin pain. This leads to short time for return to sports in the majority of injured footballers. It is not a solution for all injured players but in those
not showing improvement no aggravation of complaints was noted. Comparative studies with both short term and longer follow-up times are needed to get more
insight in the course and effects of interventions regarding return to sports. Effects of this treatment should be established in a randomized controlled trial focussing
on early return to play.
Implications: This treatment can be considered for athletes where there is pressure for early return to sports. Based on these findings it is not recommended to
consider this a substitute for exercise regimes in longstanding adductor related groin pain. It may be considered as an add-on. This suits the 'Doha agreement on
terminilogy and definitions in groin pain in athletes' (Weir et al., BJSM 2015)
Funding Acknowledgements: This study was not funded
Subjects Act).
Keywords: adductor, groin pain, return to play

PO4-MT-057
AGREEMENT OF MYOFASCIAL TRIGGERPOINT PRESENCE IDENTIFIED THROUGH PALPATION AND ULTRASOUND IMAGING
P. Blanpied*, M. Kineke 1, M. Deardorff 1, J. Fitzsimmons 1, J. Smith 1
1
Physical Therapy, University of Rhode Island, Kingston, United States
Background: Myofascial triggerpoints are thought to be a source of myogenic pain. Typically determined clinically by palpation, triggerpoints on the upper trapezius
muscle have also been identified by doppler ultrasound imaging using externally applied vibration. The agreement between triggerpoint identification between
palpation and ultrasonic imaging is unknown.
Purpose: The purpose of this study was to determine the level of agreement between identifying the presence or absence of myofascial triggerpoints in the upper
trapezius muscle using palpation versus doppler ultrasonic imaging.
Methods: 34 subjects (age 21-80 years) participated in this study. Subjects were positioned prone on a raised mat table with the skin overlying their upper trapezius
muscle exposed. An examiner attempted to locate a myofascial triggerpoint in the upper trapezius muscle by palpation, typically using a pincer grasp. If a triggerpoint
was located, the skin directly over the triggerpoint was marked. If a triggerpoint was not found, the skin was similarly marked but over an area without an underlying
triggerpoint. Another examiner, blind to the results from palpation, investigated the area marked by the first examiner using vibration (100Hz) and doppler ultrasonic
imaging (esaote MyLab25 Gold), and recorded either the presence or absence of a triggerpoint defined by a hypoechoic area in the muscle, surrounded by doppler
colored signal. Agreement of the presence or absence was determined using a Kappa coefficient. Because of problems with prevalence and bias, the prevalence
adjusted, bias adjusted Kappa coefficient (PABAK) was also computed.
Results: Presence of a triggerpoint in the upper trapezius muscle was highly prevalent using both methods. Agreement determined by the Kappa coefficient was .31.
Using the PABAK improved the Kappa coefficient to .48. Positive agreement was 82%; negative agreement was 53%.
Conclusion: When one method found a triggerpoint, there was a high likelihood the other method also found a triggerpoint. Agreement on the absence of a
triggerpoint was less strong. It is unknown if the agreement rate between palpation and ultrasonic imaging depends on active versus latent triggerpoints, or if the
agreement rate differs across muscles.
Implications: There is currently no gold standard for objectively determining the presence and location of a triggerpoint. Ultrasound imaging using vibration appears
to have potential for objectively documenting the presence of a myofascial triggerpoint.
Ethics Approval: This study was approved by the Human Subjects Institutional Board at the University of Rhode Island.
Keywords: Triggerpoint, Ultrasound Imaging

PO4-MT-060
DO BELIEFS AND KNOWLEDGE ABOUT SPINAL HIGH-VELOCITY LOW-AMPLITUDE (HVLA) MANIPULATIONS DIFFER BETWEEN INDIVIDUALS WITH OR WITHOUT A
HISTORY OF SPINAL HVLA MANIPULATION(S) ?
C. Demoulin 1 2,*, D. Baeri 1, G. Toussaint 2, M. Tomasella 1 2, Y. Depas 1, S. Grosdent 1 2, A. Beernaert 3, B. Cagnie 3, J.-M. Crielaard 1 2, M. Vanderthommen 1 2
1
Department of Sport and Rehabilitation Sciences, University of Liege, 2Department of Physical Medecine and Rehabilitation, Liege University Hospital Center, Liege,
3
Department of Rehabilitation Sciences and Physiotherapy, University of Ghent, Ghent, Belgium
Background: Spinal High-Velocity Low-Amplitude (HVLA) manipulations have been used for years in the management of patients with spinal pain. Despite the miles of
paper on the topic, they generally remain enigmatic for the general population. Furthermore, although strong evidence exists regarding the influence of patients
(mis)beliefs, little is known regarding individuals knowledge and beliefs about spinal HVLA manipulations.
Purpose: The aims of the present work were to investigate individuals knowledge and beliefs regarding spinal HVLA manipulations and to compare them in
participants with or without a history of such manipulations.
Methods: Sixty participants (no-HVLA group) without a history of spinal HVLA manipulations (i.e., 20 asymptomatic without history of spinal pain, 20 asymptomatic
with a history of spinal pain and 20 with present spinal pain) and 40 (HVLA group) with a history of spinal HVLA manipulation(s) (i.e., 20 asymptomatic with a history
of spinal pain and 20 with present spinal pain) were included in the present study. They all attended an individual session during which they were interviewed by
means of a standard questionnaire with open questions about their present (or history of) spinal pain as well as about their experience, beliefs and knowledge (e.g.,
effects, indications, contraindications, risks, the source of the cracking or popping noise commonly reported, etc.) regarding spinal HVLA manipulations.
Results: The study population (57 females and 43 males) had a mean age of 43.5 15.4 years old. The participants reporting present spinal pain (70% of low back
pain in both groups) had a mean duration of pain of 13.8 11.2 years old. 77.5% of the participants of the HVLA group received more than one manipulation; 87%
received the manipulation(s) by an osteopath. No significant differences were observed between the no-HVLA and the HVLA groups regarding the demographic
statistics. Most participants in both groups held a positive opinion of the spinal HVLA manipulations: 77.5% and 91.7% of participants in the HVLA and no-HVLA
groups reported to be ready to receive them (again) in case it is needed. The knowledge and beliefs about the HVLA manipulations were also similar in both groups:
most participants had a wrong or very limited knowledge of the clinical effects, the contraindications, the risks of spinal HVLA manipulations and of the source of the
cracking/popping noise (>70% participants evoking vertebras put back into place or a friction between two vertebras), etc. More than 25% of participants in both
groups also reported that patients with long lasting spinal pain could be treated only with spinal HVLA manipulations.
Conclusion: The present study points out the positive view of the general population regarding spinal HVLA manipulations but also a lack of knowledge and some
misbeliefs about them which might have negative impacts in case of spinal pain. Surprisingly, no differences were observed between individuals who have or have
not received manipulations in the past.
Implications: Clinicians, especially those performing spinal HVLA manipulations, should be aware of patients lack of knowledge and misbeliefs related to the
manipulations. They should better address these misbeliefs because they might favor kinesiophobia and prevent patients to take an active role in their own
treatment.
Ethics Approval: This study was approved by the Ethical Committee of the Liege University Hospital Center
Keywords: low back pain, manipulative therapy, neck pain

PO4-MT-061
EFFICACY OF NEUROARTICULAR MANUAL THERAPY TECHNIQUES IN TREATMENT OF PEOPLE WITH CERVICOBRACHIAL PAIN SYNDROME- A RANDOMIZED CLINICAL
TRIAL
N. Rani 1,*, S. P. Kumar 2
1
Physiotherapy, Fortis Superspecialty Hospital, Phase-VIII, Mohali, Punjab, India, Mohali, 2Physiotherapy, M.M Institute of Physiotherapy and Rehabilitation, M.M
University, , Mullana-Ambala, India
Background: Cervicobrachial pain syndrome (CBPS) is a non-specific neuromusculoskeletal disorder which characteristically present with cervical spine hypomobility
and neural mechanosensitivity in people with mechanical neck pain. According to impairment-based clinical reasoning, it was necessary to evaluate the efficacy of
neuroarticular manual therapy (NAMT) addressing neural and articular impairments in CBPS.
Purpose: To evaluate the efficacy of neuroarticular manual therapy (NAMT) comprising of cervical lateral glide (CLG) and peripheral nerve slider (PNS) techniques in
treatment of people with CBPS.
Methods: The study was a randomized clinical trial with concealed treatment allocation performed on sixteen referred patients with CBPS who were purposively
sampled and recruited upon written informed consent as per approval of Institutional Research Ethics Committee of MMIPR. The participants were randomly
assigned to receive either a combination of CLG and PNS depending upon manual palpation, spinal mobility testing and upper extremity neurodynamic testing (in
addition to standard care) or standard physical therapy treatment (local application of moist heat and interferential therapy). The treatment sessions were of 50 mins
duration and were administered daily for five consecutive days. The outcome measurements included pain intensity (10cm visual analogue scale- VAS), range of
motion- ROM (universal goniometer), neurodynamic mobility (NDROM), and functional disability using neck disability index (NDI).
Results: There were statistically significant (p<.001) changes in all outcome measures with all change scores for between-group comparisons better for the NAMT
group compared to control group, with improvements noted in both groups. All observed effects were beyond minimum clinically important difference for all the
outcomes.
Conclusion: The combined NAMT comprising of CLG and PNS given in addition to standard care was more effective than standard care alone to reduce pain intensity,
improve neck rotation mobility, increase neurodynamic mobility and improve self-reported function in people with CBPS.
Implications: CBPS patients who present with neural mechanosensitivity and cervical spinal hypomobility could be effectively managed with a combined treatment
approach comprising of conventional PT treatment and NAMT techniques.
Funding Acknowledgements: Funded by Post-graduate research grant of Academy of Orthopaedic Manual Physical Therapists (AOMPT Inc., India) under grant Ref.no:
AOMPT-PGRF/2013/OMT-10
Ethics Approval: The study protocol was approved by Institutional Research Ethics Committee of M.M Institute of Physiotherapy and Rehabilitation, M.M University,
Mullana-Ambala, India under approval letter Ref.No: MMIPR-IREC/2013/MPT-7
Keywords: Cervical radiculopathy, cervicobrachial pain syndrome, non-specific neck-arm pain

PO4-PA-062
PRELIMINARY DEVELOPMENT OF ITEMS TO IDENTIFY A NEURO-IMMUNE-AUTONOMIC-ENDOCRINE INVOLVEMENT IN COMPLEX PAIN PRESENTATIONS
S. Gibbons 1,*
1
Background: The neuro-immune, endocrine and sympathetic/autonomic (NISE) systems have traditionally been considered as separate entities however
contemporary research shows considerable bi-directional inter-relations between the systems. Molecular biology highlights potential pathways by which NISE dysregulation may cause pain and / or sensory hypersensitivity. Autonomic symptoms are associated with fibromyalgia and patients with medically unexplained
symptoms. Related interventions such as vitamin D supplementation and testosterone gel have shown to be clinically beneficial in specific populations. There is a
need to identify patients who may have a pain mechanism due to NISE dysregulation. A screening tool provides a cheaper alternative than laboratory equipment.
Purpose: The purpose of the project was to identify symptom based items that can be used to identify patients that are likely to have a NISE involvement in a pain
mechanism, which may be used to develop a screening tool.
Methods: For face validity, a literature review identified 227 relevant symptoms which were organized based on a review of symptoms in a questionnaire format. For
content validity, the items were reviewed for appropriateness and ranked for importance by 3 experienced therapists. As well, a sample of 8 patients underwent a
semi-structured interview after completing the pilot item questionnaire. The COMPASS 31 is an existing instrument to assess autonomic dysfunction. It was used to
assess discriminate validity for the need to develop a new instrument. The COMPASS 31and the pilot item questionnaire were administered to 28 subjects who could
not be sub-classified based (NSB) on existing pain mechanisms and 47 matched controls with chronic pain who could be sub-classified (SB).
Results: The COMPASS 31 discriminated between mechanical pain and non mechanical pain, but not within the non mechanical pain group. The pilot symptom
questionnaire showed that the NSB chronic pain group had symptoms in all 18 systems of a standard review of systems. The items were reduced to; 151 following
input from therapists; and 147 following input from patients. A further 21 items were eliminated following patient completion of the pilot questionnaire for not
being relevant.
Conclusion: NSB complex pain patients have symptoms across all bodily systems. There is a need to develop an instrument to identify NISE dysregulation in order to
identify a potential NISE pain mechanism. Current work is reviewing medical records for the laboratory reports to identify potential combinations of biomarkers. The
pilot symptom questionnaire is being further developed and administered to patient populations to assess psychometric properties.
Implications: These items can form the foundation to develop a screening instrument to identify NISE dysregulation in complex pain and identify a potential NISE pain
mechanism. This can also be used to aid in screening for suitable laboratory tests for suitable interventions. The items can be translated into clinical practice as a
subjective history for those whose past medical history indicates further screening.
Ethics Approval: The Health Research Ethics Authority deemed this stage of the project as program development, therefore full ethics approval was not required
Keywords: Autonomic, Endocrine, Pain mechanism

PO4-PA-063
RELIABILITY OF MECHANICAL DIAGNOSIS AND THERAPY CLASSIFICATION FOR EXTREMITY PROBLEMS USING REAL PATIENTS.
H. Takasaki*
Background: The McKenzie System of Mechanical Diagnosis and Therapy (MDT) is a reliable system for the management of spinal problems and uses nonpathoanatomically specific classifications to guide a management strategy. For classification of extremity disorders, inter-examiner reliability has not been
investigated using real patients. In the literature, reliability studies using real patients have two methodologies: 1) simultaneous assessments, where one therapist
performs the assessment and the other observes and 2) successive assessments, where each therapist assesses individually, usually with a short time period in
between.
Purpose: The purpose of this study was to investigate the reliability of MDT provisional classification for extremity disorders using real patients during simultaneous
and successive assessments.
Methods: A MDT Credentialed therapist observed the assessments of two MDT Diploma therapists who successively performed a MDT assessment of 33 real patients
with extremity pain on the same day. Immediately after each evaluation, the Credentialed therapist and both Diploma therapists assigned the most appropriate MDT
classification out of 15 categories, where they were blinded to each others choice. Observed agreement and Cohen's kappa were calculated for the reliability of MDT
classification.
Results: The observed agreement for the 15-MDT categories of classification between the MDT Credentialed therapist and the first MDT Diploma therapist was
78.8%. Cohens kappa (95% confidence interval) was 0.72 (0.54 0.89), indicating good reliability. However, the observed agreement between the two MDT Diploma
therapists when the patient was assessed separately was 42.4%. Cohens kappa was 0.21 (0.01 0.41), indicating poor reliability.
Conclusion: This study found that inter-examiner reliability for provisional MDT extremity classification was good when the assessor and observer were concurrently
seeing that same patient, but poor when the patient was seen successively. Further studies are required to establish which factors, including study methodology,
were responsible for the divergent results for the MDT assessment of extremity disorders.
Implications: This finding would suggest that trained MDT practitioners have achieved standardized clinical reasoning skills through the MDT educational curriculum
and can reliably assign a classification for musculoskeletal extremity disorders. Importantly, it is a feature of MDT that the classification of a subgroup at the initial
session is provisional and changing the provisional subgroup is possible according to patients symptomatic and/or mechanical responses to a loading strategy
prescribed as home exercises at the initial session. It would be required to consider a robust methodology to investigate the inter-examiner agreement of a
concluding subgroup for full understanding the inter-examiner MDT classification reliability reflecting clinical practice.
Funding Acknowledgements: This study was supported by Saitama Prefectural University Research Grant.
Ethics Approval: Ethical approval for the study was gained from the Human Medical Ethics Committee in the Saitama Prefectural University, Japan.
Keywords: Classification, Musculoskeletal pain, Reliability

PO4-PA-066
A PAIN NEUROSCIENCE EDUCATION PROGRAM FOR FIBROMYALGIA PATIENTS WITH COGNITIVE DEFICITS: A CASE SERIES
D. Pires 1,*, D. Costa 2, I. Martins 3, E. Cruz 4
1
Physiotherapy, Escola Superior de Sade Dr. Lopes Dais - Instituto Politcnico de Castelo Branco, 2Physiotherapy, 3Chronic Pain Department, Unidade Local de Sade
de Castelo Branco Hospital Amato Lusitano, 4Physiotherapy, Escola Superior de Sade - Instituto Politcnico de Setbal, Castelo Branco, Portugal
Background: The literature has suggested that Pain neurophysiology education (PNE) can have positive effects on pain, disability and maladaptive pain cognitions in
fibromyalgia (FM) patients but no significant changes in these variables have been found in response to PNE in FM patients. Reasons for these findings may relate
with the design of the PNE programmes, traditionally composed of only 1 or 2 sessions with a wide variety of complex contents, which do not take into account the
memory and concentration problems identified in those patients.
Purpose: This case series aims to describe the effects of a combined programme of PNE and exercise for FM patients. The PNE was specifically designed for FM
patients with cognitive deficits and included 6 sessions of PNE in a face-to-face format complemented with an educational booklet, the discussion of a case study and
involvement of family members in treatment sessions.
Methods: Nine consecutive patients with a diagnosis of FM and concentration and memory problems (identified by the concentration subscale of the checklist of
Individual strength- CIS-20, and a numeric scale to access memory) were included in this case series. All patients underwent in a 6-week programme (first 3 weeks)
followed by 6 sessions of individualized exercise (aerobic exercise, motor control training and aquatic exercise). Participants were assessed at the baseline, 3 and 6
weeks, and at 3 and 6 months follow-ups. Outcomes measures included the Numerical Pain Rating Scale, the Tampa Scale of Kinesiophobia, the Pain Catastrophizing
Scale, and the Patient Global Improvement of Change Scale.
Results: All 9 participants were women with a median age of 53 years (range: 3864). Six weeks after the beginning of the intervention, all the patients reported
perceived benefits in perception of overall change, and 7 of the 9 patients (78%) demonstrated a clinically meaningful improvement in pain intensity. Of the 9
participants, 8 exhibited reductions in pain catastrophization and 7 in kinesiophobia. However, at the 6 months follow-up, the proportion of patients with a clinically
meaningful improvement in pain intensity and in the perception of overall change decreases to 5/9 and 7/9, respectively.
Conclusion: This case series suggests that an adjusted programme of PNE followed by individualized exercise could change maladaptive pain cognitions and decrease
pain intensity in FM patients. The dilution of the course content for several sessions and the inclusion of additional learning strategies may have been critical for these
results.
Implications: This studys results suggest that cognitive characteristics of FM patients should be considered in the design of PNE programmes in order to optimize
their results. However, since a cause-effect relationship cannot be deduced from this case series, a randomized controlled trial should be taken into account to
evaluate the effectiveness of this programme in FM patients.
Funding Acknowledgements: Not applicable
Ethics Approval: Approved by the Ethics Committee - Castelo Branco Local Health Unit
Keywords: Fibromyalgia, Pain neuroscience education

PO4-SP-067
WHAT DO PHYSIOTHERAPISTS CONSIDER TO BE THE OPTIMAL SITTING AND STANDING POSTURE?
V. Korakakis 1 2,*, V. Evagelinou 2, Y. Sotiralis 2, S. Karanasios 2, K. Sakellariou 2, A. Sideris 2
1
Orthopaedic and sports medicine hospital, Aspetar, Doha, Qatar, 2HOMTD, Hellenic Orthopaedic Manipulative Therapy Diploma, Athens, Greece
Background: Postural education and provision of advice are integral parts of physiotherapy practice. Despite that sitting and standing posture predominate in many
lifestyles and workplaces the definition of optimal sitting and standing posture diverge in the literature.
Purpose: There is evidence that education of specific postures may help reduce spinal symptoms. On top of that, widely accepted clinical beliefs concerning good
and bad posture exist among physical therapists. Interestingly, there is limited evidence of what healthcare professionals perceive as the best sitting or standing
posture.
Methods: A range of postures observed in clinical practice (7 sitting, 5 standing) were chosen and data (9 sagittal angles) were obtained by using VICON motion
analysis system. Photographs of these postures were taken and used for a survey. In this survey 403, so far, Greek physiotherapists participated and were asked to
select the best posture and to justify their selection. Furthermore, physiotherapists were surveyed about their qualifications, level and years of experience, area of
expertise and clinical setting. Finally, they were asked to rate the importance of postural education in clinical practice.
By using SPSS posture selection frequency was calculated. The chi-square test was used to assess significant differences in posture selection frequency and level and
years of experience, qualifications, area of expertise and clinical setting. The level of significance was set at p<0.05.
Results: 95.5% and 98.2% of physiotherapists selected one of three sitting and one of two standing postures. One upright sitting posture was significantly selected
more frequently (41.5%) than others [x2(1,N=275)=12.658 both] and one standing significantly selected more frequently (57.7%) than the other [x2(1,N=395)=12.053]
(all p<0.001). The most frequent sitting and standing posture did not varied between genders, years of experience and qualifications (all p<0.05). The significance of
postural education was rated as important or very important by 94% of the physiotherapists.
Conclusion: The majority of physiotherapists consider sitting and standing posture important in clinical practice. Despite the big percentage of selected postures, the
definition of optimal spinal posture remains unclear even among health professionals.
Implications: The selected sitting and standing postures were quite different from each other indicating a lack of agreement. This study highlighted that several spinal
segments configurations meet the criteria of qualitatively described optimal sitting and standing posture.
Funding Acknowledgements: Funding none
Ethics Approval: University of Thessaly ethics committee
Keywords: physiotherapy, sitting posture, standing posture
Changing roles and scope of practice

PO1-AP-006
PHYSIOTHERAPISTS COULD PLAY A ROLE IN NEUROMUSCULOSKELETAL DIAGNOSIS AND TRIAGE IN FRANCE.
EXAMPLE OF A CASE REPORT OF A PATIENT CONSULTING A PHYSIOTHERAPIST IN SECONDARY CARE FOR GROIN PAIN AND A MEDICAL DIAGNOSIS OF
TENDINOPATHY.
N. Savouroux*
Background: French physiotherapists (FPT) do not have direct access and therefore cannot offer primary care, as this is the monopoly of the French medical
profession. There is, in the mean time, an increased number of physiotherapists trained in neuromusculoskeletal (NMS) and enrolled in post-graduate fellowship
programs taught in France by physiotherapists from countries where there is direct access. Data exists showing a high prevalence of primary care visits to general
practitioners (GP) concerning NMS complaints but these professionals have limited training in this field. French publications are scarce regarding the capacity of the
FPT to thoroughly examine and triage NMS conditions either in secondary or primary health care facilities, whereas there are a number of reports showing safety and
efficiency of NMS physiotherapists working in primary care around the world.
Purpose: The aim of this case report is to demonstrate that FPTs with neuromusculoskeletal education are able to carry out a thorough clinical examination, make a
NMS differential diagnosis, and assist primary care practitioners in deciding the best course of action for their patients.
Methods: A 33 year old male mechanic was sent to physiotherapy by his GP with a prescription for electrophysical modalities for the left ilio-psoas . This patients
main complaint was a transfixing stabbing intermittent pain in the groin and in the buttock with referred pain in the thigh and leg felt more at rest or after work. He
started to develop this pain two months ago while he was on holidays , for no particular reason. A week ago, he started to develop severe night pain which forced
him to get out of bed to move. The patient did not report any other pain anywhere else except for some episodic migraines. Imaging ultrasound of the hip and lumbar
MRI were ordered by his GP but turned out to be normal.
Results: A subjective examination and a lower quadrant scan were performed. The scan included observation/posture, functional tests, active/passive movements of
the low back, hip, knee, ankle/foot, resisted movements at these same joints, neurological examination, neurodynamic testing, lumbar and sacroiliac provocation
tests, palpation, and muscle flexibility.The clinical examination highlighted the inaccuracy of the medical diagnosis as the patient did not present with a tendinopathy
but rather with a hip joint problem. Considering the sudden onset of pain without any particular history, the severity of the pain, the history of night pain, pain at
rest, his past history as a heavy smoker, his family history of inflammatory arthritis, and the fact that all hip movements were painful, the decision was taken to refer
the patient back to his doctor to rule out any vascular problem of the femoral head or inflammatory arthritis of the coxo-femoral joint. The GP sent the patient to the
hospital for more investigations where he underwent hip x-rays, blood tests and analysis of synovial fluid in his hip revealing the presence of infection in the hip joint.
The patient was then put on an antibiotic treatment with monitoring.
Conclusion: This case report shows how a thorough clinical examination and differential diagnosis in the musculoskeletal field in the French context, may result in
success triage.
Implications: Although the French physiotherapists are considered a secondary health care profession, an educated physiotherapist has the knowledge and clinical
skills for doing primary health care screening for NMS conditions. Making proper use of these skilled clinicians would allow patients to be screened sooner and would
save money for social security.
Funding Acknowledgements: No funding sources supported this work.
Keywords: Differential diagnosis, Triage, France

PO1-LB-042
EFFECT OF POPULAR SPINAL MANIPULATIVE THERAPIES
ON ACUTE RADICULOPATHY IN RAT MODEL
P. Zhao*, L. Han
Background: The Spinal manipulative therapy (SMT) has been argued for decades in treating patient with lumbar disc herniation (LDH), especially during the acute
episode of radiculopathy. Despite of ambiguity SMT is now still taken for granted as a one of the most effective treatments to LDH patients as it had done for
thousands of years. There is still a high need for well-designed laboratory study to probe deeply the pathomechanics of SMT in treating LDH patients, especially with
acute radiculopathy, which had motivated the present study.
Purpose: The effect of different popular SMTs were compared using behavioral and immunohitochemical testing in rat model with acute radiculopathy caused by
autologous nucleus pulposus.
Methods: In order to simulate SMT on the rat model of radiculopathy, the autologous nucleus pulposus was implanted at outlet of the foramen, in which the L5
dorsal root passed through. The rat model of left L5 nerve root acute radiculopathy is therefore induced without posteriors joints structure injury. 54 rat models were
produced and randomly divided into 3 groups with 18 rats in each; the rats in group A and B were treated with either spinal thrusting manipulation (SMA) or spinal
mobilization (SMO) techniques respectively at day 3, 7 and 10 after the surgery. The SMT was simulated and quantitively controlled by a specially designed device.
The rats in group C were placebo. Mechanical allodynia, such as 50%PWT (50% paw withdraw threshold) and PWL (paw withdraw latancy) was assessed from days 1
to 14 following the surgery; the expression of NOS(nitric oxide synthase) and NGF(nerve growth factor) were also assessed at the day 5 and day 12 after the surgery in
the left L5 dorsal root ganglion(DRG).
Results: There were no significant differences in the comparison of 50% PWT (P>0.05) among three groups before the SMT interference until 3 days in SMO group
and 5 days in SMA group after the interference. The PWL assessment showed similar results. The 50%PWT showed significant higher improvement at the days 5 after
the SM in SMO group than in SMA groupp<0.05. NOS and NGF assessment showed a significant decreasing in both SM groups compared with the placebo 12
days after the surgery (p<0.05). It also appeared earlier in the SMO group.
Conclusion: 1) SMT therapy is proved effective in treating rat model of radiculopathy caused by LDH according to the study; 2) Spinal mobilization is, at least, equal
effective compared to traditional thrusting spinal manipulation; 3) Spinal mobilization technique is less harmful and relatively safer than thrusting manipulation in
treating the patients with acute radiculopathy.
Implications: Although it is proved that the SMT is effective in treating patients with acute radiculopathy caused by LDH, the side effect of SMT should be carefully
considered. Spinal mobilization is a better choice in treating LDH patient with acute radiculopathy.
Funding Acknowledgements: The study was funded by Medical Founding of Capital Sity.
Ethics Approval: The study was recognized by the Ethical Committee of PLA General Air Force Hospital.
Keywords: Mobilization, Rat model, Thrusting Manipulation

PO1-LL-050
TURIN ACL POST-SURGERY REHABILITATION POSITION STATEMENT
L. Francini 1,*, T. Lat 2, N. Phillips 3, S. Cecchetto 4, D. B. Albertoni 5, M. Constantinou 6, P. Glasgow 7, A. Piazze 8, E. Tortoli 8, C. S. Ramponi 8
1
Department of Neurosciences, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, Italy, 2Member of International Federation of
Sports Physical Therapists, Genoa, Italy, 3School of Healthcare Sciences, Cardiff University, Cardiff, United Kingdom, 4University of Verona, Verona, 5Italian Group of
Manual Therapy, Piacenza, Italy, 6School of Allied Health Sciences, Griffith University, Griffith, Australia, 7Sports Institute Northern Ireland, Newtownabbey, United
Kingdom, 8Italian Group of Sport Physical Therapy, Rome, Italy
Background: One of the more challenging aspects of rehabilitation following ACL reconstruction is to determine when a patient is ready to return to sport without
restrictions. Despite having surgery, deficits in muscle strength, proprioception and neuromuscular control remain and returning to pre-injury level after surgery is
still a challenge. The current literature contains plenty of studies aimed at identifying factors that affect good outcomes and evaluating return to sport, however,
there are no clear guidelines on criteria and progressions of rehabilitation.
Purpose: Considering the large percentage of athletes who do not return to the pre-injury level, the possibility of identifying aspects of ACL reconstruction and its
rehabilitation which is able to influence the results represent the starting point for establishing a new formulation of the phases of rehabilitation no longer based on
time but on the activities. This study also aims to be a resource that could some serve as guidelines and criteria for medical professionals, physiotherapists and
athletes in understanding rehabilitation in Italy and beyond.
Methods: The GISPT working group conducted the initial literature search within the following topic areas:
1. Surgical interventions and indications;
2. Rehabilitative evaluation and prognostic outcome measures;
3. Electro-cryotherapy modalities;
4. Manual therapy and therapeutic exercises;
5. Return to play.
Literature was prioritized/assessed and selected papers summarised prior to a working group meeting. The relative levels of evidence in each topic area was
identified. A further group of international attendees was invited to this discussion session and acted as external supervisors within the different topic areas. Each
topic area was introduced to the whole group by the topic area leader. Each discussion sub-group examined the evidence related to the different topic areas and
discussed priorities and recommendations. Each sub-group then reported back to the whole group and facilitated further discussion. The first draft of the initial
recommendations for practice was compiled and initial draft conclusions were presented at the GISPT conference and further review is invited.
Results: Results of the initial discussions highlighted a need to change wording of the stages of rehabilitation from the more traditional early, middle late stages into
task-based phases: Post-operative phase, double leg, single leg control, sport specific training and Return to Play Phases. Each phase has a criteria that a patient
should pass before progressing to the next phase. Factors such as surgical aspects, outcome measures, use of electro-cryotherapy, therapeutic exercise, symmetrical
strength and range of motion gains, decision - making skills, reactive agility and neuromuscular re-training have physiotherapy implications and can affect return to
play outcomes.
Conclusion: Despite the fact that surgical aspects are mainly between the patient and the surgeon, it is important to understand their implications on physiotherapy
rehabilitation. Traditional wording of phases should be changed to task-based phases of rehabilitation and serve as an objective guideline and include criteria for
progressions for every phase. Physical outcomes for each phase should not be the only criteria for progressions, but patient-reported outcomes, neuromuscular
control, movement confidence and accuracy should also be taken into consideration before progressing and deciding if a patient is ready to return to play.
Implications: The position statement could serve as a clinical model that could assist in decision-making and establishing criteria on rehabilitation progressions for
medical practitioners and physiotherapists in Italy.
Funding Acknowledgements: Not funded work.
Ethics Approval: There was no need to involve the ethics committee to write Position Statement.
Keywords: Anterior Cruciate Ligament, Rehabilitation, return to play

PO2-AP-004
THE NATURE OF THE FEMALE PATIENT-PHYSIOTHERAPIST RELATIONSHIP IN MUSCULOSKELETAL OUTPATIENT SETTINGS
A. Altamimi*
Background: The relationship between the physiotherapist and the patient is fundamental to the delivery of musculoskeletal healthcare. To date, there has been very
little research into the nature of the patientphysiotherapist relationship and none has been conducted in Saudi Arabia.
Purpose: The degree to which patients and physiotherapists interact and the nature of the relationship between them, especially women, in developing countries
remains unknown. Accordingly, more research is needed regarding the nature of this relationship, particularly within Saudi Arabia, a geographic region that has
remained outside of the scope of mainstream academia until recently.
Methods: Purposive sampling was used to initially select participants. Subsequent theoretical sampling, informed by data analysis, allowed specific participants to be
sampled. A constructivist grounded theory approach involving the constant comparative method of analysis was used to code and analyse data to construct a
substantive theory of the nature of the therapeutic relationship between female patients and physiotherapists.
Results: Patients and physiotherapists embraced three types of therapeutic relationships: clinical, professional and personal. These relationships were influenced by
the different physiotherapist professional roles and patient personas that have been adopted during their interaction. The different characteristics of the three
physiotherapist professional roles, along with the two patient personas, led physiotherapists and patients to have different expectations of the relationship, which, in
turn, had an impact upon the experience of the relationship. This ultimately shaped the relationship outcomes between the physiotherapists and patients.
Conclusion: The findings from this grounded theory study offer a number of theoretical insights into the therapeutic relationship, and the relationship between these
insights constitutes the substantive grounded theory. Suggestions have been made for physiotherapist educators need to consider how they can identify, monitor
and guide the development of students therapeutic relationships with patients, and how these aspects relate to the expectations of stakeholders and the values and
mores of the profession.
Implications: The findings of this research provide a substantive theory that help to develop our knowledge of, and feed into, current debates on the impact and
influence of culture, religion, norms, and values on therapeutic relationships and perceptions, attitudes and expectations among female patients and
physiotherapists, which have a direct effect on the nature of the therapeutic relationship between them. The substantive theory developed through this study has
implications for physiotherapy practice, education and research, and may inform physiotherapy curricula development, continuing education, and professional
development activities in Saudi Arabia.
Ethics Approval: Ethical approval was first obtained from the Joint Sub-Committee of the University of Brighton and the Faculty of Health & Social Science Research
Ethics and Governance Committee (FREGC). Approval was then obtained from the Institutional review board (IRB) of the King Fahad Medical City (KFMC) in which the
study was conducted
Keywords: Patient-Physiotherapist Relationship, Saudi Arabia settings, culture and health services Women in Saudi Arabia, health, education and clinical education

PO3-AP-004
PHYSIOTHERAPISTS ROLE IN A DISASTER SITUATION- AN EXPERIENCE OF NEPAL EARTHQUAKE 2015
S. Sharma*, G. M. Nepal 1, B. Khadgi 1, R. S. Acharya 1
1
Department of Physiotherapy, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal
Background: Nepal was struck by a major earthquake measuring 7.8 on a Richter scale on 25th April 2015. To add to this the destruction caused by this, another big
tremor measuring 7.3 Richter scale hit Nepal again after 17 days on 12th May. The after- shocks continued to increase the extent of damage. These damages included
physical and psychological damages. Big number of people lost their lives (about 8,699) and homes, and bigger number (more than 22,000) got injured. These
numbers are under-representation of a true number because of lack of accessibility. Due to increase in the number of injuries, physiotherapists had a big role to play.
During and after the major earthquakes, physiotherapists in Nepal worked and continued to work dynamically and efficiently and carried out different roles in the
medical response team for the comprehensive management of those injured.
Purpose: The aims of this abstract are 1) to present the data on the number of in-patients and out-patients managed by the physiotherapists at Dhulikhel Hospital
before, during and after the disaster situation, 2) to highlight the roles of physiotherapists in a disaster situation such as earthquake.
Methods: Retrospective analysis of the number of injuries treated by physiotherapists during and after the major earthquakes managed at Dhulikhel Hospital, Nepal
was performed. These numbers of injuries were compared with the number of patients that were treated by physiotherapists before the earthquake. Different roles
that the 15 physiotherapists (along with support from students) played during this disaster situation are analysed on the basis of real life experience.
Results: During the month of May 2015, N = 2855 in-patients were treated which was close to the number of patients treated in previous three months of February,
March and April together (N = 2909). The number decreased in subsequent months to 1674 and 1199 in June and July respectively. The total number of out-patients
treated in three months prior to disaster were 1715 (mean = 571), in the month of May it was 375 and the number increased in subsequent months to 880 and 823 in
June and July. About 70% injuries treated were fractures (of spine, pelvis and extremities), and other injuries were spinal cord injuries, amputations, crush injuries,
head injuries and neuropraxia. Physiotherapists during this acute phase screened the patients for various injuries based on the severity, helped in transfer of the
patients. The biggest role the physiotherapist played was in acute care management such as splinting, and dressing of the wounds and applying skin tractions and
plaster of paris. The role gradually switched to the conventional role as physiotherapists (after surgical fixation of fractures were done) in educating, mobilizing and
prescribing assistive devices, braces, and exercises after more surgeries were performed.
Conclusion: The number of in-patient care dramatically increased in the first month post disaster and gradually decreased in the months following. Contrasting
results were seen in the out-patients as the number decreased in the first month and radically increased in the following months. Physiotherapists were identified as
valuable members of team during and after the disaster and have continued to provide the quality care.
Implications: It is a valuable learning for future that physiotherapy care is dynamic and expected to change in a disaster situation. Trauma management training is
essential for physiotherapists in order to fulfill their duty as the member of health care system which will be a useful asset in disaster situation for comprehensive
patient care. This trauma management training if introduced early in physiotherapy training, students can prove themselves as extremely important member of
health care especially in a low resource setting as ours where the human resources are handful in number.
Funding Acknowledgements: No funding
Ethics Approval: Ethical approval was exempted by Institutional review committee of Kathmandu University School of Medical Sciences.
Keywords: disaster, physiotherapist, trauma management

PO3-LB-037
CHRONIC LOW BACK PAIN AND THE CONSTRUCTION OF ILLNESS IDENTITIES IN WOMEN FROM KUWAIT
N. Abdal*
Background: Chronic low back pain (CLBP) has been identified as a prominent health problem and a major cause of disability. Recent research has focused on
providing a better understanding of subjective experiences of people with CLBP; however, emphasis continues to be geared towards the physical restrictions
associated with CLBP. There is a scarcity of literature that considers the relation between self and identity, and peoples experiences with CLBP. Moreover, studies
have concentrated on the experiences of people in Western contexts.
Purpose: To date, no studies have been carried out in Middle Eastern sociocultural contexts including Kuwait. Finally, there is a deficiency of studies that focus on the
particularity of the experiences of women with CLBP and the impact on identity. This is the first study that investigates how women with CLBP construct illness
identities in Kuwait.
Methods: This study adopted a constructivist grounded theory methodology using dimensional analysis. In line with the grounded theory (GT) approach, data
collection and analysis took place concurrently. A longitudinal study design was adopted. Semi-structured interviews were used to investigate womens perspectives
on their experiences with CLBP in relation to their socio-political and cultural context. Eleven women were recruited from three musculoskeletal outpatient clinics in
Kuwait. Initially, five women were purposively sampled. A follow up interview was conducted with four of those women one year after the initial interview to
investigate any changes in their experiences. Subsequently, six women were theoretically sampled with the aim of comparing the influence of age, educational level,
marital status, socioeconomic status and time on womens illness experiences.
Results: The findings of this study offer the first explanatory theory of the construction of illness identities of women with CLBP in Kuwait. Womens identities can be
see as part of a continuum from oppressed at one end to liberated at the other. Salience of oppressed identities was associated with periods of exacerbation of CLBP
and passive coping behaviours. Appearance of liberated identities was accompanied with episodes of remission of CLBP and active coping approaches.
Conclusion: Changes in womens social circumstances, thoughts and feelings over time were related to changes in the identities they portrayed, and changes in their
manifestation of CLBP and illness experiences.
Implications: The substantive theory developed through this study has implications for clinical practice, education and research, and may inform musculoskeletal
physiotherapy professional development.
Funding Acknowledgements: Funded by the Government of Kuwait.
Ethics Approval: The University of Brighton Faculty of Health and Social Science Research Ethics and Governance Committee
Kuwait Institute for Medical Specialisations and Ministry of Health Ethical and Study Approval
Keywords: Chronic low back pain, Gender, Identity

PO3-MT-062
DEVELOPING AN ORTHOPAEDIC MANUAL THERAPY (OMT) CULTURE IN FRANCE ACCORDING TO IFOMPT STANDARDS: OMT-FRANCE PATHWAY
A. Mambriani*, N. Savourous 1
1
OMT-France, Rolampont, France
Background: Before 2012, not much therapists knew the OMT and IFOMPT. The only way to continue ones physiotherapy training was to follow the teachings of
non-validated content. This led to stagnant and poor recognized vision of physiotherapy. Since 2012, an increasing number of physiotherapists are engaged in postgraduated musculoskeletal courses given in France by foreign fellows physiotherapists, but there are still no opportunities of field placements for students studying
OMT. OMT is unknow from ordinal, syndical, and political structures who therefore do not choose to defend it, even not from the medical world, for which it would
be an asset.
Purpose: Create an OMT association meeting international standards of excellence and install this practice in the landscape of healthcare in France.
Methods: OMT-France was born in September 2012. The development axes were set and undertaken by the working committees. The scientific committee produces
French translations used by the communication committee to create information materials, to power the website, and to communicate on social networks. To
develop knowledge of Ifompt in France, translation of its Standards was undertaken. The admission committee evaluates the curriculum of members, referenced in
four grades according to their status level of competence in OMT. They sign a code of conduct ensuring best practices. Members are listed on a map to help public to
find them. Representation committee gathers all the data on which it relies to support the viewpoints we address to the public authorities.Two partnerships have
been established: with the French Society of Physiotherapy and with JOSPT. Several days of workshops and the first congress of the association have been organized.
Visits to physiotherapy training institutes have been conducted.
Results: The word OMT has become part of daily discussions on social networks; the recognition by IFOMPT of an education program is proved to be an important
criterion of choice for graduates. The public and doctors recognize more and more that practitioners trained in TMO have more advanced skills and can more easily
connect with them. The association can ensure the skills of its members and ensure OMTs credibility. Three weekends workshops about OMT have gathered 150
professionals each time; the first congress was held. French translations available on the site are numerous: translated reference articles, summary of guidelines,
LEAP articles. Litterature monitoring on primary care musculoskeletal physiotherapy subjects were undertaken as well as recommendations of clinical practice. The
first version of Standards French translation was presented to IFOMPT in Singapore in May 2015. Appointments with the more representative French organization,
and with the Ordre des Kinesithrapeutes have taken place and future meetings are planned to discuss the status of the TMO. The label RIG (Registered Interest
Group) given by IFOMPT was obtained in April 2013. The association lists a growing number of members, currently over 300.
Conclusion: In three years OMT succeeded to get a place in the vision of the future of physiotherapy, with OMT-France being the reference association.
Implications: Developing an Education Program creation according to IFOMPT Standards.
Funding Acknowledgements: No funding sources supported this work.
Ethics Approval: Ethics approval was not required
Keywords: None

PO3-PA-064
'WHAT DO YOU THINK IS GOING ON: ANALYSIS OF HOW PHYSIOTHERAPISTS' EXPLORE PATIENTS BACK PAIN BELIEFS: A CONVERSATION ANALYTIC APPROACH.
I. Cowell*, A. McGregor, G. Murtagh, P. O'Sullivan, K. O'Sullivan, R. Poyton, V. Schoeb
Background: Evidence suggests that adopting a patient focused and broader biopsychosocial approach results in better outcomes for patients with persistent low
back pain. This approach is associated with patient-centred communication where understanding the patients pain beliefs is recommended. However, evidence
suggests that within physiotherapy a practitioner-centred approach is the dominant model. Empirical studies within physiotherapy are needed to provide greater
understanding of the principles of patient-centred communication and its application[IC1] .
[IC1]643
[IC1]616
Purpose: The purpose of this study is to describe how physiotherapists explore patient back pain beliefs during initial encounters[IC1] .
[IC1]110
Methods: The research setting was primary care. 20 initial physiotherapy consultations were video-recorded (10 physiotherapists and 20 patients), transcribed and
analysed using conversation analysis, a qualitative observational method that describes the actual interaction. Both verbal and non-verbal features of the interaction
were considered[IC1] .
[IC1]299
Results: This study demonstrated that the opportunities for sharing patients beliefs are associated with the communication practices deployed by the therapists.
Where therapists employed a 'passive' style, using weak response tokens, rapid topic shifts, failure to pick up on patient cues and maintain eye contact, then patient
participation was limited. Some examples show, however, that when therapists failed to respond to patient cues, patients were still prepared to pursue their concern.
When therapists responded with a facilitating approach, using open questions, formulating a version of the patient's talk, and affirmative head nodding, then active
patient participation was enhanced. However, responses to the therapists enquiries were not always straightforward if the patient was unable/unwilling to disclose.
When therapists provided reassurance and offered pain explanations without fully exploring/understanding the patients beliefs, the result was weak patient
alignment and in some cases explicit patient disagreement. Alternatively reassurance accompanied with pain explanations congruent with the patients pain beliefs,
produced stronger agreement[IC1] .
[IC1]1238
Conclusion: Patient beliefs are a core part of pain perception and response to pain, yet empirical data is lacking as to how physiotherapists effectively and
systematically explore them. This study suggests that a more facilitating communication style accommodates increased patient input if the patient is willing and able
to disclose[IC1].
[IC1]455
Implications: Raising awareness of the interactional consequences of different therapist communication styles and patients responses to therapists enquiries will
help develop understanding of how to incorporate principles of person-centred communication practice into physiotherapy[IC1].
[IC1]575
Funding Acknowledgements: Private Physiotherapy Educational Foundation (PPEF)
Musculoskeletal Association of Chartered Physiotherapists
Ethics Approval: The North East London Local Research Ethics committee has approved the study protocol (reference Number: 2352) and the study has been
successfully reviewed by the East Midlands-Nottingham 2 NRES committee (14/EM/1045[IC1] ).
[IC1]Total characters so far 2278
Keywords: Back pain, Beliefs, Physiotherapist-patient communication

PO4-AP-001
PATIENT-CENTEREDNESS IN PHYSIOTHERAPY: WHAT DOES IT ENTAIL? A SYSTEMATIC REVIEW OF QUALITATIVE STUDIES
A. Wijma 1,*, A. Bletterman 2, J. Clark 3, S. Vervoort 4, A. Beetsma 5, D. Keizer 6, J. Nijs 7, P. van Wilgen 1
1
Faculty of Physical Education and Physiotherapy,Pain in Motion research group (www.paininmotion.be), Transcare, Vrije Universiteit Brussel, Transdisciplinairy
Painmanagment Centre, Brussel, Groningen, 2Physiotherapy, Physiotherapy Stiens, Stiens, Netherlands, 3Faculty of Health Psychology and Social Care, Pain in Motion
Research Group. (www.paininmotion.be), Manchester Metropolitan University, Manchester, United Kingdom, 4Department of Internal Medicine and Infectious
Diseases, University Medical Centre Utrecht, Utrecht, 5Department of Physiotherapy, Hanze University of Applied Sciences, School of Health Studies, 6Transcare,
Transdisciplinary painmanagement center, Groningen, Netherlands, 7Faculty of Physical Education and Physiotherapy,Pain in Motion research group
(www.paininmotion.be) , Vrije Universiteit Brussel, Brussel, Belgium
Background: Patient-centeredness has been defined in multiple ways in medicine, nursing and occupational therapy. In physiotherapy there is not yet a clear overall
definition on patient-centeredness. This is an omission, as physiotherapy evolves more around the patients and their behavior and perceptions.
Purpose: The goal of this review is to identify the perceptions of patient centred physiotherapy from the perspective of patients and therapists from qualitative
research studies.
Methods: A systematic search was conducted in PubMed, EMBASE, Cochrane, PsychINFO, CINAHL, PEDro and Scopus including articles from September 5th 2015. All
articles were examined for eligibility. Methodological quality was examined by a checklist based on the COREQ statement for qualitative research, checklist by Schoeb
et al. and checklist of the BMJ. The studies were examined for either a model or factors of patient-centeredness in physiotherapy. Data was extracted using a data
extraction form and analyzed following thematic synthesis.
Results: 14 articles were included. Methodological quality was high in five studies. Six major descriptive themes were identified. The descriptive themes were: The
descriptive themes were: The physiotherapist (with subcategories Social characteristics, Confidence and Knowledge):A patient-centered physiotherapist should be
respectful, open, confident and competent. Individuality (with subcategories: Getting to know the patient, Individualized treatment) concerns specific patient-tailored
education, communication and treatment. Communication (with subcategory Non-verbal communication):the need of an ongoing dialogue with patients in clear and
lay speech. Education primarily involves advice about every part of the assessment and treatment. Goal setting: Patient-centered physiotherapists try to allow the
patients to define their own goals. The last theme was Support (with subcategory Empowerment), this consists of a mixture of individuality, equality of responsibility,
understanding, reassuring, and empowerment.
Conclusion: Patient-centredness in physiotherapy entails the characteristics; the physiotherapist (having social skills, being confident and showing knowledge),
offering an individualized treatment, continuous communication (verbal and non-verbal), education during all aspects of treatment, working with patient defined
goals in a treatment in which the patient is supported and empowered. Further research is needed, in order to further enhance our understanding about the clinical
applicability of the conceptual framework and to assess the implementation and implications.
Implications: It is hoped the conceptual framework developed from these study findings will assist physiotherapists in their understanding of patient-centeredness
and the implications of patient-centeredness in clinical practice.
Funding Acknowledgements: This study was not funded
Keywords: patient centered, qualitative research, review

PO4-AP-006
THE UTILITY OF ESP TRIAGE IN A SPECIALIST SECONDARY CARE SPINAL CENTRE: A SERVICE EVALUATION.
E. Dunstan*, L. Wood
Background: In the field of Orthopaedic medicine growth, of extended scope physiotherapy (ESP) practice has led to musculoskeletal service redesign; many
traditional medical roles are now being performed competently and effectively by ESPs, reducing unnecessary referrals to surgical consultants. A rising demand in
service access for lumbar radicular presentations has been noted and the need to review the pathway for this patient group has been highlighted.
Purpose: The purpose of this service evaluation is to establish legitimacy and effectiveness of a secondary care spinal ESP triage service. This evaluation aimed to
establish the rate of independent ESP patient management, record surgical conversion rates and patient satisfaction. A subsection of the evaluation focussed on disc
engendered radicular pain, a group previously considered at Nottingham University Hospital to require surgical opinion and management. Establishing outcome for
ESP triage and management of secondary care spinal referrals consolidates the effectiveness of current service and highlights areas of service growth and redesign.
Methods: A retrospective service evaluation from January 2014 to January 2015, was undertaken by members of the Extended Scope Practitioner (ESP) team. The
following data were collected: rates of independent management, referral rates for surgical consideration, and conversion to surgery. Patients who were referred for
selective nerve root block (SNRB) by the ESP team were reviewed. Inclusion criteria was determined by single-level radicular pain secondary to lumbar disc herniation
(LDH) as confirmed by clinical examination and concordant MRI results. Patients with more than one compromised nerve root, those with canal or bony lateral recess
stenosis, spondylolisthesis, or previous lumbar surgery, were excluded. Surgical or non-surgical outcome was recorded. Patient satisfaction rates were evaluated
retrospectively from questionnaires given to discharged patients.
Results: A total of 2328 patients were seen. 84% of all referrals seen by ESPs were independently managed. The remaining16% required either a discussion with a
surgeon to confirm management or for surgical review, of which 82% were considered to be suitable surgical referrals. 109 (5%) patients seen by the ESP team
underwent SNRB for lumbar disc engendered radicular pain, of these 68% continued to be managed non-surgically at the 12-month time point. A 99% satisfaction
rate was reported from discharged patients.
Conclusion: An ESP service in a specialist secondary care spinal unit is effective at conservatively managing spinal conditions and appropriately identifying surgical
candidates. This service evaluation establishes the utility of a secondary care ESP pathway and reports a high non-surgical yield in patients who present with lumbar
disc engendered radicular pain. Further research is needed to confirm ESPs diagnostic accuracy, patient outcomes and cost effectiveness.
Implications: Decision-making in healthcare involves choosing interventions or pathways that not only benefit patients, but maximise benefits from the available
resources. This evaluation demonstrates benefit to the spinal service by utilising ESPs to deliver aspects of care previously delivered by medical professionals. As the
benefits and validity of ESP roles become established, evaluating the outcomes of specific patient groups who are managed via these alternate pathways becomes of
value and facilitates discussion regarding best practice, for both patient outcome and resource use as well as providing relevant data to inform patient and
commissioning choice.
Funding Acknowledgements: Unfunded Study.
Ethics Approval: Service evaluation therefore ethics not required.
Keywords: ESP, Spinal, Triage
Health promotion/Public health

PO1-AP-001
1000 NORMS PROJECT: HEALTH-RELATED QUALITY OF LIFE ACROSS THE LIFESPAN
N. Moloney 1,*, J. Baldwin 2, M. Mackey 2, C. Hiller 2, J. Nightingale 2, J. Burns 2
1
Health Professions-Physiotherapy, Macquarie University, 2Faculty of Health Sciences, University of Sydney, Sydney, Australia
Background: Decision-making in healthcare, research and policy hinges on access to normative reference data, yet available data are limited. The 1000 Norms Project
is developing crucial health-related quality of life (HRQOL) reference data. Patient-reported outcomes (PROs) provide valuable information regarding HRQOL and
evaluation of health services.
Purpose: The aims of this study were to generate HRQOL normative reference data and investigate the relationship between HRQOL, socio-demographic factors and
physical function in healthy people.
Methods: This study was conducted within the 1000 Norms Project, an observational study investigating measures of health and function in 1000 healthy Australians
aged 3-101 years. Data for adult participants were analysed. Participant characteristics and demographics, physical activity level, workability and measures of physical
function were collected. HRQOL was investigated using the AQoL-8D utility instrument assessing eight dimensions: independent living, pain, physical senses, selfworth, relationships, coping, happiness and mental health. Scores were converted to two super-dimensions (physical and mental) and a global utility total score.
Results: Data from 732 adult participants (18-101yrs) were analysed. Adults aged 80+ years reported significantly lower scores for independent living, senses
dimensions and physical super-dimension (p<.001). Females, and individuals with low physical activity, reported poorer mental super-dimension scores. Physical
super-dimension scores were lower for overweight individuals and individuals with either a chronic pain or smoking history (p<.01). Similar results were identified for
overall AQoL8D utility. Workability was associated with AQoL-8D utility and both super-dimension scores (p<.001). Physical super-dimension scores were negatively
correlated with BMI, waist circumference and weight (p<.001), and positively with 6-minute walking distance, timed up and down stairs, chair stand, and balance
scores (p<.001).
Conclusion: In this sample of 1000 healthy individuals, overall HRQOL was poorer for females, individuals with low physical activity levels and individuals with chronic
pain. The physical element of HRQOL was affected by age, BMI, chronic pain, smoking history and lower limb function, while the mental element of HRQOL was
affected by gender and physical activity level.
Implications: Comprehensive normative data are necessary for clinical, research and policy decision-making. The 1000 Norms Project is developing crucial healthrelated quality of life reference data including PROs and physical function, which will be freely available.
Funding Acknowledgements: This Project is supported by the National Health and Medical Research Council of Australia (NHMRC,#1031893), Intersect Australia
Research Data Storage and Australian Podiatry Education & Research Fund, Australasian Podiatry Council.
Ethics Approval: The study is approved by The University of Sydney Human Research Ethics Committee (no:2013/640)
Keywords: normative, patient-reported outcomes, reference values

PO1-AP-003
ABILITY TO PASS MOVEMENT CONTROL TESTS - DIFFERENCES BETWEEN MEN AND WOMEN
U. Aasa, B. Aasa 1,*
1
Department of Surgical and Perioperative Sciences, Ume University, Ume, Sweden
Background: Standardized movement control tests are often used by physiotherapists. The tests are used to identify the pattern of movement and symtoms that
characterize a persons's relevant lumbar directional tendency.
In cross-sectional studies using tests of movement control, it has been suggested that the performance is different in people with and without pain in the low back
region.
Purpose: The aim of the study was to investigate the performance in two movement control tests in a representative sample of middle-aged men and women in the
general population. A secondary aim was to investigate whether the performance was different in men and women with and without pain in the low back region.
Methods: This is a study with a longitudinal design. We have followed a randomly selected cohort of 429 adolescents that was recruited in 1974 (baseline), when they
were 16 years old. The participants completed physical fitness tests at 16, 34 and 52 years of age and questions about musculoskeletal pain at 34 and 52 years of age.
At the age of 52 years, they also performed the Waiter's Bow and the Supine double leg lower test. These are two commonly used tests of movement control in the
lumbo-pelvic area. The Waiter's Bow evaluates the ability to control flexion movements in the lumbar spine while bending the hips, and the Supine double leg lower
test evaluates the ability to control extension while extending the hips.
Results: A higher percentage of the participants were able to perform the Waiter's Bow (men 43% and women 64%) than the Supine double leg lower test (Men 19%
and women 29%) correctly. Significantly more women than men (p=0.003) were able to control flexion movements in the lumbar spine during the Waiter's bow.
In neither of these tests did the performance differ between cohort participants who reported pain in the lumbo-pelvic region and those who did not.
Conclusion: The ability to control flexion movements in the lumbar spine differ between men and women.
There are more reasons for not being able to control movements in the lumbar spine, than if you have pain or not.
Implications: Physiotherapists should be aware that other factors than having/having had pain in the lumbar spine might influence the ability to control movements
in the lumbar spine.
Funding Acknowledgements: The study was supported by grants from the Swedish Research Council for Health, Working Life and Welfare and the Swedish National
Centre for Research in Sports.
Ethics Approval: The study protocol was in accordance to the Helsinki Declaration of 1975 as revised in 1983 and received ethical approval from the Ethical Board,
Ume, Sweden, Dnr 09-082M. Participation was voluntarily and all participants signed an informed consent form.
Keywords: core control, lumbar spine, gender

PO1-CS-014
SPONTANEOUS VERTEBRAL ARTERY DISSECTION RESULTING FROM A BENIGN MECHANISM OF INJURY; A MEDICAL CASE DESCRIPTION
A. McDevitt 1,*, M. McDevitt 2, P. Mintken 1
1
Physical Therapy Program, University of Colorado, Aurora, Colorado, 2Emergency Department, Rose Medical Center, Denver, Colorado, United States
Background: Cervical manipulation has been implicated as a potential mechanism for vertebrobasilar artery insufficiency (VBI) due to dissection. Recent evidence
suggests that end-range active cervical range of motion (ROM) may be more stressful to the vertebral artery than cervical manipulation. Age and cardiovascular risk
factors increase the likelihood of VBI. Physical screening examinations for VBI carry little diagnostic utility, and recent guidelines suggest utilizing a thorough
subjective history and cardiovascular screening in suspected patients.
Purpose:
The purpose of this case report is to describe a patient who sustained a spontaneous vertebral artery dissection due to a cervical active ROM mechanism. A 69 year
old female with a history of uncontrolled hypertension and hyperlipidemia sustained a right (R) vertebral artery dissection with the suspected mechanism being a
neck rotation to the left (L) after hearing a loud noise. The patients symptoms included immediate L visual field loss followed by occipital neck pain and
headache. The patient reported a prior history of a visual field loss event 2 years prior.
Methods: The patient self-referred to the emergency department complaining of visual field loss within 45 minutes of the incident. The patient examination included
a review of systems and assessment of mental status, cognitive function, cranial nerve and cerebellar testing. Imaging included magnetic resonance angiogram
(MRA) and magnetic resonance imaging (MRI).
Results: The patient scored a 2 on the National Institutes of Health (NIH) stroke scale due to the presence of homonymous hemianopsia. Results of MRA included R
vertebral artery long segment stenosis combined with complete occlusion of V1 and proximal V2 segments suggesting vertebral artery dissection. Additionally, MRI
of the brain resulted in finding of acute ischemia to the R occipital lobe. The patient was treated with anticoagulant therapy and discharged after one day in the
hospital.
Conclusion: Physiotherapists who use cervical spine manual therapy should screen patients for a history of hypertension, hyperlipidemia or history of HA, neck pain,
and visual field loss. This case report highlights the feasibility of spontaneous dissection in the presence of cardiovascular risk factors and increased age, which may
increase the overall risk of a VBI event.
Implications: Spontaneous dissection of the vertebral artery is a rare but serious event. It has been suggested that many adverse events could be avoided with
careful screening. This case report strengthens the argument that physiotherapists should perform a careful history and cardiovascular screen on patients presenting
with head and neck pain.
Ethics Approval: Ethics approval as not required due to the retrospective nature of this case report.
Keywords: vertebral artery

PO1-ED-030
EVALUATION OF AN ACTIVE LEARNING EXPERIENCE FOR EDUCATING PHYSICAL THERAPIST STUDENTS ON ORAL HEALTH SCREENING FOR HEALTH PROMOTION.
A. Markowski 1,*, K. Greenwood 1
1
Physical Therapy, Northeastern University, Boston, United States
Background: Oral health screening (OHS) is the process of screening a patient for oral disease or risk factors for oral disease and provide guidance and education on
oral health maintenance, prevention and early referral for health promotion.1According to the Surgeon General, dental care is the most common unmet health need.
OHS is an important aspect of health promotion and is the responsibility of Physical Therapists (PT), as first contact health care providers.2,3
Purpose: To describe the development, implementation, assessment and modifications of an active educational learning module to promote oral health and assess
the effects of using simulation and reflection in teaching OHS in conjunction with temporomandibular joint (TMJ) evaluation.
Methods: PT students from two separate cohorts within a single program participated in one of two educational experiences to teach OHS. In year one students
participated in an oral health module of lecture, online learning, skills practice, case based simulation and interprofessional debriefing. Four cases were developed to
focus on prevention or pathology. Data was collected from student completed written referral forms completed before and after debriefs. Students identified need
and urgency for referral and patient specific education needs. Students performance on the referral forms was analyzed using SPSS. In year two, after design
modifications, students will receive the same oral health education module with the addition of a clinical reasoning in class reflection. Data on both cohorts will be
presented.
Results: In the first cohort, students identified appropriate referral 68% of the time and case specific education 75% of the time. In pathology cases requiring urgent
care, students referred appropriately 95% percent of the time but lacked appropriate education 12%, identifying an area of need. The educational module was
modified for the second cohort with an additional critical thinking reflection on patient education. The second cohort will complete the improved curricular module
and findings from both cohorts will be presented.
Conclusion: Education of the OHS is the responsibility of PT education programs to ensure students are prepared for oral health promotion. Results from this study
identify students strengths in identifying and referring for pathology and need of further education for pathology illustrating that ongoing improvement is necessary.
The modifications in the second year are focused to improved students ability to identify case specific education.
Implications: OHS is an important component to medical screening and health promotion that PTs should incorporating into their practice when evaluation the
TMJ. Learning modules to teach OHS to students may benefit from active learning experiences including reflection and simulation however ongoing research is
needed to understand the best methods.
Funding Acknowledgements: Dentaquest Foundation
Ethics Approval: IRB approval Northeastern University
Keywords: education, health promotion, Oral Health Screening

PO1-EX-033
EFFECT OF TENSIONER NEURAL MOBILIZATION ON THE FLEXIBILITY OF CONTRALATERAL LOWER EXTREMITY
S. Sharma 1,*, J. Cleland 2
1
Department of Physiotherapy, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal, 2Physical Therapy Program, Franklin Pierce University,
Manchester, NH, United States
Background: The nervous system is a continuum both structurally and functionally. This has been well explained by studies demonstrating the mobility of peripheral
nerve at one site can affect the mobility in the other sites along its course. Neural mobilization has also been shown to improve the flexibility of its mechanical
interface for example, increase in hamstring flexibility in health participants in the ipsilateral side. However it is unknown if neural mobilization has any effect on the
flexibility of the hamstring on the contralateral side.
Purpose: A secondary analysis from a randomized controlled trial previously published examined the effect of neural tensioner maneuver of the sciatic nerve in the
slump position on the contralateral hamstring length.
Methods: Sixty healthy individuals (mean age 22 2.4 years) with reduced hamstring flexibility were randomized to three groups who received static stretching and
sliders (NS-SS); static stretching with tensioner (NT-SS) and static stretching (SS) alone. Knee extension angle (KEA) in degrees was used to record the hamstring
flexibility as the outcome measure using an inclinometer. Tukey HSD post hoc analysis was done using 16 participants who had completed the measurements in NT-SS
and SS groups. NS-SS groups were excluded from the analysis as it included neural slider exercises to bilateral lower limb. Clinical trial registry was done prior to the
research (Clinical trial registration number: CTRI/2012/05/002619).
Results: Mean KEA reduced from 30.81 8.17 to 29.50 8.28 and from 29.38 6.41 to 18.31 7.16 in SS and NT-SS group demonstrating increasing in
hamstring flexibility in contralateral side. The mean difference between the two groups was 6.31 (CI: 0.52, 12), which was statistically significant.
Conclusion: Neural tensioner mobilization of the lower extremity has the potential to increase the hamstring length on the contralateral limb in which mobilization
was not performed. This could be due to mobilization of neuroaxis in slump neural mobilization which in turn may lead to the changes in the hamstring length on the
contralateral side. Further studies with larger sample sizes are required to validate the finding.
Implications: If validated, this information may help guide clinicians selection of interventions to improve muscle flexibility in the affected side by mobilizing the
contralateral side. This will have an important clinical implication especially when a lower extremity is injured and not indicated to move or when it is highly irritable.
The health promotion implication is that athletes or physiotherapists may consider the use of neural mobilization as a strategy to promote flexibility and probably
fitness.
Ethics Approval: This trial received ethical approval from Institutional Ethical Committee (IEC 41/2012), Manipal University, Karnataka, India.
Keywords: Neural mobilization, Neurodynamics, Tensioner

PO1-LB-038
INVESTIGATION OF THE IMPACT OF PEOPLE MANUAL HANDLING TRAINING ON BACK BELIEFS
D. Horgan 1, H. Purtill 2, P. O'Sullivan 3, W. Dankaerts 4, K. O'Sullivan 1,*
1
Clinical Therapies, 2Mathematics and Statistics, University of Limerick, Limerick, Ireland, 3School of Physiotherapy and Exercise Science, Curtin University, Perth,
Australia, 4Dept of Rehabilitation Sciences, University of Leuven, Leuven, Belgium
Background: Healthcare workers who complete manual handling (MH) tasks at work report high levels of low back pain (LBP). However MH training appears to have a
minimal effect at reducing LBP. The beliefs of people with LBP about the nature of their LBP problem, and the danger of the tasks they do, are linked to incidence and
chronicity. The effect of MH training on these beliefs has not yet been examined.
Purpose: To examine the effect of an MH training course (one-day) on back pain beliefs.
Methods: A cross sectional survey with health care workers prior to, and after, MH training. Participants completed a series of questionnaires assessing their
demographic characteristics, previous history and impact of LBP, anxiety levels using the state-trait anxiety inventory (STAI), their beliefs related to LBP using the Back
beliefs questionnaire (BBQ), fear-related pain beliefs using the modified Tampa Scale of Kinesiophobia (TSK) and perceived danger of lifting and bending tasks using a
selection of 12 photographs from the PHODA. PHODA is a collection of photographs depicting common activities ranging from household chores to physical exercise
and represents various biomechanical strategies and activity settings.
Results: MH significantly improved the BBQ (p<0.001) and the TSK (p=0.004) scores. In contrast, lifting and bending tasks on the PHODA were considered significantly
more dangerous after MH training (p<0.001). Anxiety was associated with previous impact of LBP in the past 12 months. Younger individuals with less anxiety traits
and lower perceived risk scores on the PHODA accounted for the negative changes in the PHODA after MH training.
Conclusion: This study shows that a single MH training course has an impact on changing LBP beliefs. Small, yet statistically significant, improvements were
demonstrated on the BBQ and TSK. In contrast, PHODA values were significantly more negative after training. This highlights the fact that beliefs about LBP are
complex, and that using a single measure may miss important information regarding other beliefs. The results suggest that although participants were less fearful of
movement in general (TSK), and less pessimistic about the long-term consequences of LBP (BBQ), they were actually more convinced that everyday tasks involving
lifting and bending were harmful for the back.
Implications: The content and design of MH training courses may need to be re-evaluated to maintain the positive changes on measures such as the TSK and BBQ, but
without increasing the perceived danger of everyday tasks such as bending and lifting.
Ethics Approval: Approved by the University of Limerick Ethics Committee.
Keywords: back pain, beliefs , manual handling

PO1-SP-069
SPINAL PAIN IN HOCKEY PLAYERS : A SYSTEMATIC REVIEW
N. A. Roussel 1 2,*, J. Lemmens 1, J. Rottiers 1, I. Demeure 1, C. Demoulin 3 4, L. Pitance 5 6
1
Medicine and Health Sciences, University of Antwerp, Antwerp, 2Pain in Motion International Research Group, Vrije Universiteit Brussel, Brussels, 3Department of
Sport and Rehabilitation Sciences, Universit de Liege, 43Department of Physical Medicine and Rehabilitation, Liege University Hospital Center, Liege, 5Institute of
Clinical Research (IREC), Universit Catholique de Louvain, Louvain, 6Oral and Maxillofacial Surgery Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
Background: The popularity of hockey is increasing. In Belgium the participation in field hockey increased from 20.000 members in 2007 to 35.000 members in 2014.
Musculoskeletal injuries, including spinal pain, are frequently reported.
Purpose: The purpose of this systematic review is to examine the prevalence, incidence, injury rate and etiology of spinal pain/injuries in field hockey players.
Methods: The electronic databases Pubmed and Web of Science were systematically searched to identify relevant articles using predefined keywords. Full text
reports, which described the prevalence, incidence, injury rate or etiology of spinal pain/injuries in hockey players were included and screened for methodological
quality by independent researchers. Each study was assessed for risk of bias using a checklist derived from the website of the Dutch Cochrane Centre.
Results: Eight studies were used for data extraction. In only 3 studies the methodological quality score exceeded 50%. Six studies examined prevalence rates for
spinal pain/injuries. The prevalence ranged from 2% to 67% for lower back, 7% to 59% for whole spine, 2% to 25% for neck and 3% for pelvis/hip. One study found an
incidence of 14% of lower back injuries. The results were clustered according to the International Classification of Functioning, Disability and Health framework (ICF).
Only one study examined injured body structures and concluded that muscle-tendon strains were common in spinal injuries. Less total lumbosacral range of motion
and less extension were observed in field hockey players with a history of LBP (p < 0,01). Also less peak eccentric extension torque was reported (p < 0,05). Three
papers reported medical attention, hampered performance and time-loss in sports and daily activities as a consequence of spinal pain. Only one study examined the
impact of environmental factors and observed that satisfaction with performance (OR: 0,5) and satisfaction with coaching staff (OR: 0,5) were associated with
significantly lower occurrence of LBP.
Conclusion: A high prevalence rate of low back pain/injuries was observed in field hockey players. However, only few studies examined other dimensions of ICF.
Insufficient evidence was presented to formulate a conclusion concerning cause, risk and contributing factors for development of spinal pain/injuries. However, the
majority of the included studies had a low methodological quality, which might limit the generalization of the results.
Implications: Low back pain is common in field hockey players, but there is a lack of information regarding contributing factors.
Funding Acknowledgements: No funding
Ethics Approval: The study was approved by the Ethics Committee of the Cliniques Universitaires Saint-Luc.

Keywords: hockey, Prevalence, spinal pain

PO2-AP-005
HEALTH PROMOTION IS A BIT OF OUTSIDE OF THE PHYSIOTHERAPY BOX PHYSIOTHERAPY STUDENTS UNDERSTANDING OF HEALTH PROMOTION
C. Hebron*, S. Gore 1, P. Vuoskoski 1
1
School of Health Sciences, University of Brighton, Eastbourne, United Kingdom
Background: Over fifteen million people in England suffer from lifestyle diseases. Lifestyle diseases are preventable illnesses related to unhealthy lifestyle behaviours
and are becoming an ever growing focus of healthcare. With the NHS England Making Every Contact Count agenda physiotherapists are expected to address health
promotion with their patients. Much of the research on health promotion is quantitative in nature. Some qualitative studies have suggested that physiotherapists
have the core competencies to promote health effectively, although the barriers to engagement within health promotion were also highlighted. Evidence on the
perceptions of physiotherapy students of health promotion, however, has been largely unreported.
Purpose: This study was an interpretive qualitative enquiry, applying a phenomenographic analysis on the physiotherapy students perceptions and experiences of
health promotion whilst on practice placement, in the context of a university in the south of England.
Methods: Four student volunteers were recruited to the study by sending an advertisement via university email. All participants were student physiotherapists who
had undertaken two or more practice placements in the context of MSc entry level degree programme. Data were gathered using semi-structured interviews and indepth interview techniques. The data were analysed idiographically by looking at the different ways of understanding and experiencing the phenomenon of interest;
the what (structural) and the how (referential) aspects of it; that is, when talking about their perceptions and experiences of health promotion, what did the
students talk about and how did they talk about it. The analysis continued by grouping the participant descriptions based on similarities and differences into
categories, and looking for relationships and potential hierarchies between the categories, as well as non-dominant ways of understanding. The analysis was first
carried out independently by two of the authors, which was then combined and critically discussed to determine the (hierarchical) structure in the outcome space.
Results: Data analysis resulted in five categories of expression; sense of self in relation to health promotion, health promotion as tactful practice, health promotion as
individual behavioural change, health promotion as tertiary level prevention, and naturalistic approach to health promotion.
Conclusion: In this study physiotherapy students expressed perceptions of self, such as uncertainness and avoidance of health promotion due to lack of knowledge
and experience. They also expressed their experiences of therapeutic encounters reflecting an individualistic view towards health promotion and behavioural change,
focussing on physical problems and physical activity as the core components in physiotherapeutic health promotion and prevention of unhealthy lifestyles. What
were absent were more holistic considerations of health promotion and social or environmental circumstances possibly maintaining and promoting the behavioural
risks that were the focus of intervention.
Implications: The findings of this study may have implications on educational practices of similar contexts, both academically and clinically, and students and
educators awareness of health promotion. This in turn may help to discover the potential and optimal points for enhancing the students understandings of health
promotion, should it be required.
Ethics Approval: Ethics was granted by the University of Brighton, School of Health Sciences, Research Ethics and Governance Committee.
Keywords: health promotion, phenomenography, physiotherapy education

PO2-AP-006
IT IS A BIG THING: EXPLORING THE IMPACT OF OSTEOARTHRITIS FROM THE PERSPECTIVE OF ADULTS CARING FOR PARENTS: THE SANDWICH GENERATION.
K. Barker*, C. Minns Lowe 1, F. Toye 1
1
Physiotherapy Department, Nuffield Orthopaedic CEntre, Oxford University Hospitals NHS FT, Oxford, United Kingdom
Background: Around 6.4 million people provide unpaid care in the UK. Approximately 25% of adult children currently provide personal care and / or financial support
to a parent. Although it may not be perceived as a long term condition with high associated burden, osteoarthritis and musculoskeletal disorders are highly prevalent
and cause disability and the need for patients to receive care, usually from a family member. There is limited research concerning people who provide care for
parents with osteoarthritis and the impact that this has upon them.
Purpose: To explore the experiences and impact of caring for an individual with osteoarthritis from the perspective of adult children looking at the relationship
between adult children caring for parents with arthritis and the tensions of the Sandwich Generation.
Methods: A mixed methods approach, combining focus groups and individual semi-structured interviews was used. In total 36 participants were purposively sampled
and discussed the impact of caring for a parent with osteoarthritis. Data analysis was based upon grounded theory.
Results: Findings reported the impact and complexity of caring for a parent with osteoarthritis. We present three themes related to the work of caring for a relative
with osteoarthritis: (1) the physical and emotional work of caring; (2) changes in reciprocal family roles; (3) the imbalance in caring roles within the family.
Conclusion: Participants described the significant and extensive impact on their lives of caring for a parent with long term osteoarthritis, particularly the physical and
emotional work of caring, the changes in reciprocal family roles, the imbalance in caring roles within the family and being faced with the pressures of caring for their
own children as well.
Implications: The research highlights the problems facing the Sandwich Generation in meeting the care needs of parents facing poor health from a chronic
musculoskeletal condition. An awareness of the pressures faced by carers of older patients with osteoarthritis will inform health professionals in their interactions
with both patients and carers and with carers when seen as patients in their own right and inform their communication with them.
Funding Acknowledgements: OHSRC grant 8073
Ethics Approval: The study received local institutional review and approval NOCRD.2013.049
Keywords: osteoarthritis, carers, qualitative

PO2-EX-033
RELATIONSHIP BETWEEN THE FREQUENCY OF FOOTBALL PRACTICE DURING SKELETAL GROWTH AND THE PRESENCE OF A CAM DEFORMITY IN ADULT ELITE
FOOTBALL PLAYERS
I. Tak*, A. Weir 1, R. Langhout 2, H. J. Waarsing 3, J. Stubbe 4, G. Kerkhoffs 5, R. Agricola 6
1
Sports Medicine, Aspetar Hospital, Doha, Qatar, 2Manual therapy and sports rehabilitation, Physiotherapy Dukenburg, Nijmegen, 3Orthopaedics, Erasmus Medical
Centre, Rotterdam, 4Sports Medicine, University of Applied Sciences, 5Orthopaedics and Sports Traumatology, Academic Medical Centre Amsterdam, Amsterdam,
6
Orthopaedic Surgery, Erasmus Medical Centre, Rotterdam, Netherlands
Background: Cam deformity is most likely a bony adaptation in response to high impact sports practice during skeletal growth and can therefore possibly be
prevented. This is relevant as cam deformity has been associated with an increased risk to osteoarthritis of the hip later in life. Associations were found between
presence of cam and type of loading. A dose response relationship has been suggested.
Purpose: The objective was to study whether there is a dose-response relationship between the frequency of football practice during skeletal growth and the
presence of a cam deformity in adulthood. Findings may guide further research and loading programs of youth athletes.
Methods: Professional elite footballers from two Dutch football clubs were invited to participate. Standardized anteroposterior and frog-leg lateral radiographs were
obtained during the seasonal screening. A cam deformity was quantified by an alpha angle >60, a pathological cam by an alpha angle >78, in either view. Data on
age in relation to frequency of football loading were collected by standardized questionnaires. The differences in prevalence per hip between groups were calculated
by logistic regression with generalized estimating equations.
Results: 63 players participated revealing 126 hips for analysis. The mean(sd) age was 23.1(4.2) years (range 18.238.4 years). All were skeletally mature. The
prevalence of a cam deformity on the frog-leg view was lower in footballers that started playing football frequently (5 times/week) from the age of 12 years or older
(40.2%, n=82) than in footballers who started playing football frequently before the age of 12 years (63.6%, n=44, p=0.042). This was also true for a pathological cam
(12%, n=10 vs. 30%, n=13, p=0.038).
Conclusion: The results show that in players who report starting frequent football practice at an early age a higher prevalence of cam lesions is found. This suggests a
dose response relationship of football during skeletal growth and the development of a cam deformity, which should be confirmed in future prospective studies.
Implications: Professionals working with young athletes should consider the findings of this study regarding load management in the period around the growth spurt
with regard to health of the hip joint in future life and eventually prevention of osteoarthritis.
Subjects Act).
Keywords: bone adaptation, cam deformity, Football

PO2-EX-034
"RETURN TO GOLF": A COMMUNITY BASED FITNESS PROGRAM FOR GOLFERS WITH DISABILITIES
J. Ciolek*, M. Ciolek, A. Lake 1
1
Cleveland Clinic Rehabilitation and Sports Therapy, Cleveland Clinic, Cleveland, United States
Background: Many individuals with musculoskeletal and neuromuscular impairments experience decreased participation in fitness and sport related activities. Golf is
one typical lifetime sport that these individuals find difficulty participating in.
Purpose: The goals of the program are to improved quality of life in individuals with disabilities by promoting fitness, social interaction, physical recreation,and
community reintegration through golf fitness and skills programming.
Methods: The Return to Golf (RTG) program was developed to integrate the rehabilitation and fitness expertise of physical therapists with golf instruction of PGA golf
professionals to engage participants to return to activity in a safe and rewarding manner. Sessions take place at the Wharton Golf Center, that includes, an indoor golf
fitness center that allows for the participation 45 weeks per year, and North Olmsted Golf Club which was renovated specifically for handicap accessibility. This allows
the RTG participants the ability to safely drive golf carts onto the tees, greens and other areas around the course. RTG sessions involve a rehabilitation based fitness
session, individualized golf skills training, and integration to play on course with peers. Fitness activities are designed by physical therapists to address specific
impairments and functional deficits of each participant. Physical therapists perform evaluations and screenings including functional outcome measures such as the
timed up and go, 10 meter walk, 30 second sit-stand, and Titleist Performance Institute (TPI) golf screen. Exercise programming is designed to progressively improve
the individuals golf specific fitness, as well as their overall health and wellness. Components of the program includes mobility and stability, strength, power,
disassociation drills, balance, coordination and cardiovascular endurance. Participants receive one on one golf instruction by PGA professionals to adapt or improve
the way the play golf to account for their specific disabilities and impairments. Adaptive techniques and equipment are utilized to assist the golfers, such as a single
rider carts, custom adapted clubs, and modifying golf swings based on physical capabilities and skills. Unique training aids and equipment such as the Opti Shot Golf
Simulator, K-Vest 3D, and Vector Launch Monitor to provide quality feedback and motivation. Finally, participants are gradually integrated into play on the course as
they are safe and physically able. This integration allows golfers to experience the success of golf with their peers in the program.
Results: Since 2003, more than 10,000 rounds of golf have been played by the participants. Currently over 100 active golfers participated in over 1000 clinics and
rounds of golf. Over 300 different participants have benefited from the program since the inception. Participants vary by golfing experience, age between 14-90
years old, and represent a broad range of disabilities. Injuries include stroke, amputation, spinal cord injury, cerebral palsy, multiple sclerosis, Parkinsons disease,
ALS, Guillain-Barre syndrome, and numerous other orthopaedic and musculoskeletal issues.
Conclusion: This program has successfully utilized the expertise of multiple professionals to develop a health promotion program focussed on returning disabled
individuals to the game of golf and improving their quality of life. Future work should focus on analyzing the effecte of the Return to Golf program on fitness and
quality of life outcomes.
Implications: This project demonstrates a viable model for health promotion programming that utilizes the physical therapists knowledge of rehabilitation and
fitness combined with functional activities. This program offers a platform for the physical therapist to engage with members of the community in a postrehabilitation fitness role.
Funding Acknowledgements: NOGA Charities and Foundation
Ethics Approval: The program development did not require formal ethics approval.
Keywords: Community Based Program, Disability , Golf Fitness

PO2-LB-036
EFFECT OF A MULTIDISCIPLINARY PROGRAM FOR THE PREVENTION OF LOW BACK PAIN IN HOSPITAL EMPLOYEES: A RANDOMIZED CONTROLLED TRIAL
N. A. Roussel 1 2,*, D. Kos 3, I. Demeure 1, A. Heyrman 1, M. De Clerck 3, E. Zinzen 4, F. Struyf 1 2, J. Nijs 2
1
Medicine and Health Sciences, University of Antwerp, Antwerp, 2Pain in Motion, Department of Human Physiology and Physiotherapy, Vrije Universiteit Brussel,
Brussels, 3Occupational Therapy, AP University College, Antwerp, 4Movement Education and Sports Training, Vrije Universiteit Brussel, Brussels, Belgium
Background: Hospital workers with physically demanding jobs are at risk for developing recurrent LBP. Mono-disciplinary intervention strategies have been found
ineffective in nurses (Dawson et al., 2007; Smedley et al., 2003) or in other workers in physically demanding jobs, which are at risk for developing LBP (IJzelenberg et
al., 2007). Several authors therefore suggest that because of the multifactorial aetiology of LBP researchers should develop new and innovative multidisciplinary
prevention approaches together with existing strategies to reduce or prevent LBP in the workplace (Dawson et al., 2007; Hartvigsen et al., 2005) and tailor the
programme to the risk profile of the individual or the workplace (Linton and van Tulder, 2001; van der Molen et al., 2009). There is however a lack of studies
evaluating such multidisciplinary prevention programmes of low back pain (LBP) in hospital workers.
Purpose: This randomized controlled trial evaluates the effect of a multidisciplinary prevention program, focusing on a client-centred approach, on hospital workers
at risk for developing LBP.
Methods: Caregiving hospital workers were allocated to an experimental (12-weeks lasting multidisciplinary prevention program) or control group (no intervention).
They were evaluated prior to the intervention and after a 6 months follow-up period. Primary outcome measures included incidence of LBP, work absenteeism and
general health. Secondary outcomes included daily physical activity, job satisfaction and coping strategies.
Results: A significant improvement was seen for passive coping after 6 months follow-up, but no significant differences were observed between groups in primary
(i.e. incidence of LBP, work absenteeism or general health) or other secondary outcome measures (i.e. daily physical activity and job satisfaction) (p>0,05).
Conclusion: The results of this study demonstrate that a 12-weeks multidisciplinary prevention program has no effect compared to a control group receiving no
intervention at six months follow-up. This multidisciplinary prevention program fitting into a bio-psychosocial context may not have been intensive enough to
promote a change in daily habitudes, and had no effect on work absenteeism, incidence of LBP or general health. Further research should determine whether
prevention of LBP is possible in caregiving personnel.
Implications: This study includes an innovative design and shows that there is a need for research in a multidisciplinary and primary prevention setting. Further
research of high methodological quality is needed to evaluate whether prevention of LBP in caregiving personnel is beneficial.
Funding Acknowledgements: The work was funded by the Artesis Hogeschool Antwerpen, Belgium.
Ethics Approval: The study was approved by the Ethics Committee of the Vrije Universiteit Brussel.
Keywords: low back pain, Multidisciplinary intervention, prevention

PO2-MT-059
THE TIME COURSE OF THE EFFECT OF INTERVENTION USING FASCIAL MANIPULATION : ANALYSIS BY DIAGNOSTIC ULTRASOUND, AND ROM AND MUSCLE
STRENGTH MEASUREMENT
H. Takei 1,*, K. Ichikawa 2, M. Hata 2, R. Sunaga 2
1
Department of Physical Therapy, Graduate School of Human Health Sciences, Tokyo Metropolitan University, 2Senkawa-Shinoda Orthopedic Clinic, Tokyo, Japan
Background: Sites of degeneration on the epimysium of each muscle were named centers of coordination (CCs) by Luigi Stecco, an Italian physiotherapist and an
inventor of Fascial Manipulation. CCs are small points where muscle vectors converse when muscles are activated. A CC in one segment spreads either proximally or
distally along six myofascial sequences via the aponeurotic fascia.
Purpose: The myofascial sequence of retromotion in the lower limb is a line linking CCs of Retro-Coxa, Retro-Genu (RE-GE), Retro-Talus (RE-TA) and Retro-Pes. In this
study, we performed Fascial Manipulation on the CC of either RE-GE or RE-TA, and examined the therapeutic effect at three time points: pre-intervention (pre), 3
minutes after intervention (3min) and 1 week after intervention (1w).
Methods: Twenty healthy adult men were divided into the RE-GE group and the RE-TA group. The following examinations were performed at three time points (pre,
and 3min and 1w). First, the level of pain was obtained using NRS by palpating the CCs of RE-GE and RE-TA. Next, we performed ultrasound elastography at three
sites: 1. the superficial layer of the long head of the biceps femoris muscle; 2. the superficial layer of the lateral head of the gastrocnemius muscle; 3. the deep layer
of the lateral head of the gastrocnemius muscle. Further, the length of the fascial movement during the 015 dorsiflexion (d.f.) of the ankle was measured. The ankle
d.f. ROM, and the knee extension ROM with the hip joint position of 90bending were measured using the Twin Axis Goniometers. Moreover, the following were
measured using the hand-held dynamometer: the resistance of the triceps surae muscle during the movement from 0 to 15 d.f. position; and the isometric muscle
force of plantar flexion (p.f.) at the ankle angle of 0.
Results: The mean NRS scores of the CC of RE-GE and RE-TA were significantly lower 3min and 1w than before intervention in both the RE-GE group and the RE-TA
group. Ultrasound elastography investigated stiffness of three sites, and found that 1 and 2 became significantly softer 1w than pre in the RE-GE group. On the other
hand, in the RE-TA group, 1 was significantly softer 1w than pre, while 2 was softer 3 min and 1w than pre. 1 and 2 moved significantly in the distal direction 1w from
pre the RE-GE group. On the other hand, in the RE-TA group, the 1 moved significantly in the proximal direction 1w from pre. 3 moved significantly in the distal
direction 1w from pre. The ankle d.f. ROM was significantly higher 1w than pre in the RE-TA group. The knee extension ROM were higher 3min and 1w than pre in
both groups. The difference in the resistance between the 0 and 15 d.f. positions was significantly higher 1w than pre in the RE-TA group. The muscle force in
isomeric p.f. was increased 1w compared with pre value in both groups.
Conclusion: In the myofascial sequence of retromotion, intervention at the proximal RE-GE CC resulted in decreases in stiffness in the superficial layer of the lateral
head of the gastrocnemius muscle 1 week after intervention. Intervention at the distal RE-TA CC resulted in softening of the superficial layer of the long head of the
biceps femoris muscle 1 week after intervention. In the RE-GE group, the fascia smoothly moved in the distal direction because of the reduction of the pulling force in
the proximal direction as a result of softening of the long head of the biceps femoris muscle. On the other hand, the fascia of the RE-TA group smoothly moved in the
proximal direction because of the reduction of the pulling force in the distal direction as a result of softening of the gastrocnemius muscle.
Implications: It is likely that simultaneous treatment across multiple segments along the myofascial sequence, but not treatment of a single segment, is effective in
curing fascial dysfunction occurring along the myofascial sequence.
Funding Acknowledgements: Research expenses in Tokyo Metropolitan University
Ethics Approval: The Research Safety and Ethics Committee of the Tokyo Metropolitan University, Arakawa Campus (approval number 12061)
Keywords: Center of coordination, Fascial Manipulation, Myofascial sequence

PO3-AP-005
IMPLEMENTING AND DEVELOPING A STAFF PHYSIOTHERAPY SERVICE TO IMPROVE THE HEALTH AND WELLBEING OF TRUST STAFF
C. Alexander*
Background: Western Sussex Hospitals NHS Trust identified high rates of sickness absence due to stress and musculoskeletal (MSK) problems. The Occupational
Health Department did not include physiotherapy but there was a strong request for direct access to a designated staff physiotherapy service. As a result of this,
eighteen months ago the Staff Physiotherapy Service was implemented. This built on the foundations of the Boorman report (2009) which stated NHS organisations
which prioritise staff health and wellbeing achieve enhanced performance; improve patient care; are better at retaining staff and have lower rates of sickness
absence.
Purpose: The reason for developing this service was to improve management of MSK problems for members of staff and reduce sickness absence.
The service was developed to give staff direct access to physiotherapists experienced in Occupational Health to help support them at work and on their return to
work. The team liaise with Occupational Health Advisors, Manual Handling Team and managers on how to best manage MSK conditions. The service forms part of the
Health and Wellbeing Steering Group which monitors services and discuss how to further progress these and events for staff.
Methods: The service was developed with 0.8 WTE band 7 and 0.2 band 6 physiotherapists and promoted through Occupational Health, information on the trust
Intranet, via training and induction programmes and through word of mouth.
Staff access the service via self-referral routes, either electronically, by paper or by phone. Referrals can also be received from GPs, consultants, and managers, or the
Trust Occupational Health Advisors and Manual Handling Team.
Telephone triage takes place within 7 days. At this point staff are either given advice +/- exercises, or booked an appointment. Those solely given advice and exercise
contact the department if their condition is not resolving.
Results: The service received 53.8 referrals per month on average with 25% of staff living out of the local CCG referral area. This group would not usually have been
able to access physiotherapy through the Trust. 44% of staff seen required advice on occupational health matters. Feedback was very positive, detailing the efficiency
and appropriateness of the service through a satisfaction survey.
Waiting times were 1-30 days with an average of 7 days for first contact. Outcomes measure demonstrated a significant improvement in visual analogue pain scores,
with an average improvement of 4.73 points, and significant PSFS (Patient Specific Functional Scale) improvement with an average change of 4.42.
Conclusion: The staff physiotherapy service has been received well by staff, managers and the Health and Wellbeing steering group. Staff members have direct access
to MSK physiotherapy to enable them to remain at work, prevent and manage MSK conditions, reduce sickness absence and support return to work. More time and
resources are needed to improve health promotion and prevention.
Implications: This service has proved to be effective and highly valued. Further development of the service in line with the five year NHS plan is anticipated.
Funding Acknowledgements: A legacy fund was donated to the trust specifically for staff health and wellbeing initiatives and activities, which was matched by
charitable funds.
Ethics Approval: No ethics approval has been required
Keywords: None

PO3-EX-031
THE COMPARATIVE EFFECTIVENESS OF EXERCISE-BASED GROUP AND INDIVIDUAL PHYSIOTHERAPY FOR MUSCULOSKELETAL CONDITIONS: A SYSTEMATIC REVIEW
AND META-ANALYSIS.
M. O'Keeffe 1,*, A. Hayes 1, K. McCreesh 1, H. Purtill 2, K. O'Sullivan 1
1
Clinical Therapies, 2Mathematics and Statistics, University of Limerick, Limerick, Ireland
Background: Musculoskeletal pain is a common and costly disorder. Both group and individual physiotherapy programmes which incorporate exercise have shown
positive effects on pain and disability. However, it remains unclear whether the additional time and costs associated with individual programmes result in superior
outcomes.
Purpose: The aim of this review was to assess the comparative effectiveness of group and individual exercise-based physiotherapy on pain and disability in patients
with musculoskeletal pain conditions.
Methods: 11 electronic databases were searched by two independent reviewers. Randomised controlled trials (RCTs) including participants with musculoskeletal
conditions which compared exercise-based group and individual physiotherapy interventions were eligible. Study quality was assessed using the PEDRO scale by two
independent reviewers, and treatment effects were compared using meta-analyses.
Results: 14 RCTs were included; seven were on low back pain, three on neck pain, two on knee pain and one on shoulder pain. No statistically significant benefit for
pain and disability was found for individual exercise programmes across a range of musculoskeletal conditions in the short-, medium- and long-term.
Conclusion: Based on this review, it is difficult to justify physiotherapy exercise programmes which are delivered on an individual basis. There may be a need for
individual care to better match exercise prescriptions to an individuals baseline exercise capacity and progress appropriately, and/or consider other barriers to
recovery from pain across the biopsychosocial spectrum.
Implications: This review suggests that group physiotherapy should be implemented more often in clinical practice for treating people with musculoskeletal pain.
Keywords: group physiotherapy , individual physiotherapy , MUSCULOSKELETAL

PO3-LB-038
THE PREVALENCE OF LOW BACK PAIN IN AFRICA
L. Morris 1,*, K. Daniels 1, Q. Louw 1
1
Physiotherapy, Stellenbosch University, Cape Town, South Africa
Background: According to the Global Burden of Disease (GBD) 2010 study, low back pain (LBP) is currently the sixth highest burden on a list of 291 conditions, results
in significant losses in productivity at work and incurs billions of dollars in medical expenditure annually. LBP and other musculoskeletal disorders have therefore
been prioritized as a global health concern during the Bone and Joint decade (2000-2010, WHO). Despite the GBD 2010 and WHO reports, LBP and other
musculoskeletal conditions remain less prioritized in low-to-middle income countries (LMICs), due to more pressing health issues like HIV/AIDS.
Purpose: A better understanding of the current burden of LBP in African LMICs was therefore required. An updated search of the current literature into the
prevalence of LBP among African nations was therefore conducted. Specific challenges faced in retrieving epidemiological information in Africa, the methodological
quality of reported African studies and on conducting meta-analyses of LBP data were also highlighted.
Methods: (Protocol reg.#:CRD42014010417) A comprehensive search of all accessible bibliographic databases via the Stellenbosch Universitys Medical and Health
Sciences Library website was conducted (April 2014-October 2014); updated March 2015. Population-based studies into the prevalence of LBP among
children/adolescents and adults living in Africa were included. Methodological quality of included studies was appraised using an adapted tool. Meta-analysis were
conducted using methods described by Neyeloff et al (2012). Subgroup analyses, sensitivity analyses, publication bias and meta-regression analyses were also
conducted.
Results: Fifty-four studies were included in this review. The majority of the studies were conducted in Nigeria (n=22;41%) and South Africa (n=15;28%). Thirty-six
included studies (66.7%) were found to be of higher quality. The lifetime, one-year and point prevalence of LBP in Africa was 55.8 (95% CI 19.8;91.8); 57.5 (95% CI
51.6;63.5) and 41.9 (95% CI 29.2;54.6), respectively. There was little difference in LBP prevalence between African males (48.6%,95% CI 36.1;61.1) and African
females (49.5%,95% CI 38.6;60.5). The prevalence of LBP was estimated to be higher among African adults (54.3%; 95% CI 44.9;63.7) compared to African children
and adolescents (32.1%; 95% CI 18.9,45.3).
Conclusion: This review found that the lifetime, one-year and point prevalence of LBP among African nations was considerably higher than or comparable to global
LBP prevalence estimates reported.
Implications: Despite the high burden of LBP rin Africa, African healthcare budgets and systems may generally be ill-prepared to deal with the management of LBP.
Successful development and implementation of strategies and policies to address the burden of LBP on poorer countries or countries with emerging economies, like
those in Africa, is therefore warranted.
Funding Acknowledgements: Work was not funded.
Ethics Approval: This study was exempt from ethical approval since it was a systematic review.
Keywords: Africa, epidemiology, low back pain

PO3-LB-044
WHO GETS UPPER BODY AND/OR LOW BACK PAIN IN MIDDLE AGE?
U. Aasa, B. Aasa 1,*
1
Ume University, Ume, Sweden
Background: It is important to show which factors are related to good upper body and low back health in middle age since upper body pain is costly for the society
and causes much suffering for the individual. Few studies using a longitudinal design have follow-up periods of more than five years and few studies have investigated
both work-related and individual factors in a general population.
Purpose: This longitudinal study investigated the ability of work-related measurements, body composition, physical activity and fitness levels to predict
neck/shoulder pain (upper body pain, UBP) at the age of 52 years. Another aim was to investigate the cross-sectional relationships between reporting current
pain, work-related factors and individual factors at the age of 52 years.
Methods: We followed a randomly selected cohort of 429 adolescents that was recruited in 1974 (baseline), when they were 16 years old. The participants
completed physical fitness tests, questions about sociodemographic and life-style factors at 16, 34 and 52 years of age, and questions about work-related factors and
pain in the follow-ups.
Logistic regression analyses were used to examine the associations between neck/shoulder pain and the other variables.
Results: Univariate logistic regression analyses showed that high body mass index (BMI) and social support and control at the age of 34 years were related to pain at
the age of 52 years. Cross-sectional relationships at the age of 52 differed from the longitudinal in the sense that measures of joint flexibility and work posture were
also significantly associated with pain.
Conclusion: The fact that the cross-sectional differed from the longitudinal relationships strengthens the importance of performing longitudinal studies when
studying factors that might influence development of musculoskeletal pain. Patients who already have developed pain seem to have lower flexibility and lower
muscular strength than those who have not. Measurements of flexibility and strength in adolescent and young adulthood do however, not influence on the
development of pain.
Implications: Preventative measures might need to include both life-style (such as dietary habits and physical activity to ensure that the individuals are not
developing overweight) and work-related factors such as social support.
Funding Acknowledgements: The study was supported by grants from the Swedish Research Council for Health, Working Life and Welfare and the Swedish National
Centre for Research in Sports.
Ethics Approval: The study protocol was in accordance to the Helsinki Declaration of 1975 as revised in 1983 and received ethical approval from the Ethical Board,
Ume, Sweden, Dnr 09-082M. Participation was voluntarily and all participants signed an informed consent form.
Keywords: longitudinal design, prevention, risk factors

PO3-LB-046
SPINAL PAIN IN FIELD HOCKEY PLAYERS: A CROSS SECTIONAL STUDY
N. A. Roussel 1 2,*, I. Demeure 3, C. Demoulin 4 5, L. Pitance 6 7
1
Medicine and Health Sciences , University of Antwerp, Antwerp, 2Pain in Motion International Research Group, Vrije Universiteit Brussel, Brussels, 3Medicine and
Rehabilitation Sciences, University of Antwerp, Antwerp, 4Physical Medicine and rehabilitation, Liege University Hospital Center, 5Department of Sport and
Rehabilitation Sciences, Universit de Liege , Liege, 6Institute of Clinical Research (IREC) , Universit Catholique de Louvain, Louvain, 7Oral and Maxillofacial Surgery,
Cliniques Universitaires Saint-Luc, Brussels, Belgium
Background: Hockey is a popular sport. In Belgium the participation in field hockey increased from 20.000 members in 2007 to 35.000 members in 2014.
Epidemiological studies have consistently shown that injuries in field hockey are numerous. In addition to injuries to the extremities and the head, spinal pain is
frequently mentioned in the scientific literature. However, studies examining spinal pain in field hockey players are lacking.
Purpose: The main aim of the present study was to examine the prevalence of spinal pain in amateur field hockey players and its relationship with pain
catastrophizing.
Methods: Belgian male field hockey players from first to third division were recruited in nine clubs. Hockey players were included if they had a minimum age of
eighteen years, had an hockey experience for at least three years in the first to third division, were fluent in French or Dutch speaking and were willing to sign the
informed consent. The participants were asked to fill in a battery of questionnaires. The Nordic Musculoskeletal Questionnaire was used to examine the prevalence of
low back pain (LBP) and neck pain and activity limitations due to back or neck pain. The Dutch and French translations of the Pain Catastrophizing Scale (PCS) were
used to assess pain catastrophizing.
Results: Eighty-eight male players volunteered for the study (mean age = 28.8 +/- 7.6 years). They played on average 5h hockey per week and played since 17.8 +/- 9
years. The lifetime and 12-month prevalence of LBP were 46% and 36%, respectively. Half of the players which suffered from LBP the previous year indicated that the
LBP interfered with their hockey play. The lifetime and 12-month prevalence of neck pain were 40% and 20%, respectively. Only six players reported that their neck
pain influenced their hockey play. No significant differences were observed in total PCS-scores between players with and without LBP or neck pain during the last 12
months (p>0.05).
Conclusion: Low back pain is common in field hockey players and interferes with the game in 18% of the field hockey players. However, it appears unrelated to pain
catastrophizing. Neck pain is less common, and does not seem to influence hockey playing.
Implications: Low back pain should be further examined in both amateur and elite field hockey players as it might influence hockey playing in a fifth of the amateur
players. Further research should examine contributing factors.
Ethics Approval: The study was approved by the Ethics Committee of the Cliniques Universitaires Saint-Luc
Keywords: hockey, low back pain, neck pain

PO4-AP-007
DEVELOPMENT OF AN INJURY RISK ASSESSMENT WORKPLACE WELLNESS SCREENING TOOL
A. Markowski*, M. Watkins 1, L. Thompson 1, J. Vasquez 1
1
Physical Therapy, Northeastern University, Boston, United States
Background: Heath promotion is in the forefront of healthcare reform in the USA and prevention of health disparities remains a global initiative. With emerging
workplace wellness programs (WWP) there is a need for a screening tool to identify employees at risk for injury.
Purpose: Review the evidence on the most common injuries among individuals participating in WWP. Identify evidence-based cardiovascular and musculoskeletal
assessments specific to these common injuries. Create a comprehensive screening tool to identify at risk individuals who would benefit from a medical or physical
therapy referral.
Methods: A review of the literature identified common medical and physical injuries associated with WWP in middle age adults. Eleven peer reviewed articles were
identified. Physical injuries most commonly described are knee and back pain, ankle sprains, shin splints, and shoulder tendinitis.3 A second literature review
identified specific evidence based medical and physical screening tools used to identify risk factors for common injuries and cardiovascular disease. Articles were
searched from 2005-present using the following databases: EBSCOhost Sports Discus, PubMED, and CINAHL.
Results: More than 100 articles utilizing examination or assessment tools specific to these common injuries were identified. From the identified articles, 47 were
used to compile the screening tool, based on the strongest evidence, demographics and feasibility for our specific workplace population. The tests chosen for
inclusion in the screening tool were shown to be individually reliable and valid at identifying associated risk factors.
Conclusion: The Wellness Program Screening Tool (WPST) is a comprehensive cardiovascular and musculoskeletal screening tool developed to be administered by a
physical therapist or trained medical professionals. This tool compiles evidence informed risk assessments for medical, cardiovascular events and upper extremity,
lower extremity and spine injuries. The WPST includes a detailed history, vitals, biometric measurements, Heart Rate Recovery Bike Test, Flexibility test, Scapular
stability test, Single Leg Squat, Navicular Drop, Star Excursion Balance test and a Side Bridge test. Detailed instruction and interpretation documents accompany the
data sheet. Future directions includes establishing reliability and validity for the screening tool.
Implications: The WPST will provide an important individualized risk assessment, which can be used to modify exercise programs and/or to identify the need for a
referral to the appropriate medical personnel to address these potential health concerns. With the emphasis for preventative medicine, the WPST will help promote
health and safety, while still encouraging workers to participate in physical activity and exercise. Physical therapists or trained medical professionals have the
education and skills to administer, interpret the results and recommend modifications or referrals.
Ethics Approval: Ethical approval not required
Keywords: health promotion, screening tool, workplace wellness

PO4-CS-017
PLAYING-RELATED MUSCULOSKELETAL DISORDERS AMONG PROFESSIONAL ORCHESTRA MUSICIANS IN SCOTLAND - A PREVALENCE STUDY USING A VALIDATED
INSTRUMENT: THE MUSCULOSKELETAL PAIN INTENSITY AND INTERFERENCE QUESTIONNAIRE FOR MUSICIANS (MPIIQM)
P. Berque*
Background: Many epidemiological surveys on playing-related musculoskeletal disorders (PRMDs) have been carried out among professional musicians, but none
have evaluated or confirmed the psychometric properties of the self-report instruments that were used.
Purpose: The aim of this study was to evaluate the prevalence of PRMDs among professional orchestra musicians in Scotland, and to gather information on pain
intensity and pain interference (impact of pain on function and psychosocial variables) using a self-report instrument developed specifically for a population of
professional orchestra musicians, and psychometrically validated by the present authors in a previous study.
Methods: Out of 183 professional orchestra players, 101 took part in the study (55% response rate), and completed the Musculoskeletal Pain Intensity and
Interference Questionnaire for Musicians (MPIIQM). Statistical tests were performed using a 5% level of significance ( = 0.05).
Results: Lifetime prevalence of PRMDs was 77.2%, one-year prevalence was 45.5%, and point prevalence was 36.6% (n = 37). Although no statistically significant
relationship was found between gender and the number of reported pain sites (2 = 2.571, p = 0.463), 68.8% of males in the PRMD group (n = 11) reported two or less
pain sites whilst 52.4% of the females (n = 11) reported three or more pain sites. The most commonly reported locations of PRMDs were the right upper limb, the
neck, and the left forearm and elbow. However, predominant sites of PRMDs varied between instrument groups. The mean pain intensity score for the PRMD group
was 12.4 7.63 (out of 40). The mean pain interference score was 15.2 12.39 (out of 50), increasing significantly in relation to an increase in the number of reported
pain locations (F = 3.009, p = 0.044). There were no statistically significant differences between males and females for the pain intensity (t = 0.145, p = 0.882) and pain
interference (t = 0.434; p = 0.064) scores.
Conclusion: This study confirms that musculoskeletal complaints are common in elite professional musicians. Future studies are required to investigate the
interactions of the constructs pain intensity and pain interference with other demographic variables and potential risk factors of PRMDs, and to compare the
population of professional musicians to other professions involving repetitive movements and prolonged static and dynamic loading of neuromusculoskeletal
structures.
Implications: The use of an operational definition of PRMDs and a self-report instrument specifically developed and validated for professional orchestra
musicians contribute to the determination of more accurate and meaningful estimates of pain prevalence in this population.
Funding Acknowledgements: Work was unfunded.
Ethics Approval: The study was approved by the Research Ethics Committee of the School of Health and Life Sciences at Glasgow Caledonian University, Glasgow,
Scotland, UK.
Keywords: Musculoskeletal pain, Musicians, Prevalence
Intergrating Research into practice

PO1-AP-002
APPOINTMENT REMINDER SYSTEMS ARE EFFECTIVE BUT NOT OPTIMAL: RESULTS OF A SYSTEMATIC REVIEW AND EVIDENCE SYNTHESIS EMPLOYING REALIST
PRINCIPLES
S. Mclean 1,*, A. Booth 2, M. Gee 3, S. Bhanbhro 3, S. Salway 2, M. Cobb 4, S. Nancarrow 5
1
Faculty of Health and Wellbeing, Sheffield Hallam University, 2School of Health and Related Research, Sheffield University, 3Centre for Health and Social Care
Research, Sheffield Hallam University, 4Therapeutics & Palliative Care, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom, 5 School of
Health and Human Sciences, Southern Cross University, Lismore, Australia
Background: Missed appointments are an avoidable cost which impacts upon the health of patients, treatment outcomes and service efficiency. Non-attendance
rates of between six to 46 per cent are frequently reported in physiotherapy-led clinics. Reminder systems are used increasingly to counter these negative effects and
improve the efficiency of the appointment system and many healthcare organisations are increasingly investing in SMS, telephone and email reminder systems.
However they frequently employ a one-size-fits-all approach, with little evidence of differential effectiveness or acceptability for particular populations or
subgroups.
Purpose: To review the effectiveness of reminder systems for promoting attendance, cancellation and rescheduling of appointments and set out the evidence which
shows that reminder systems are not being employed optimally.
Methods: We conducted three inter-related reviews of quantitative and qualitative evidence involving a review of conceptual frameworks of reminder systems and
adherence behaviours (review 1), a review of the reminder effectiveness literature (review 2) and a review informed by realist principles to explain the contexts and
mechanisms which explain reminder effectiveness (review 3). Firstly, using pre-existing models and theories, we developed a conceptual framework to inform our
understanding of the Contexts and Mechanisms which influence reminder effectiveness. Secondly, we performed a review following Centre for Reviews &
Dissemination (CRD) guidelines to investigate the effectiveness of different methods of reminding patients to attend health service appointments. Finally, to
supplement the effectiveness information, we completed a review informed by realist principles to identify factors likely to influence non-attendance behaviours and
the effectiveness of reminders.
Results: The preliminary database searches yielded 1200 records; following screening stages a total of 466 records were included for Reviews 2 and 3. Findings from
31 randomised controlled trials and 11 separate systematic reviews (Review 2 only) revealed consistent evidence that all types of reminder systems are effective at
improving appointment attendance across a range of health care settings and patient populations. Reminder systems may also increase cancellation and rescheduling
of unwanted appointments. Reminders plus, which provide additional information beyond the reminder function, may be more effective than simple reminders at
reducing non-attendance at appointments in particular circumstances. We also identified six areas of inefficiency which indicate that reminder systems are being
used sub-optimally.
Conclusion: The results of this review showed that unless otherwise indicated, all patients should receive a reminder to facilitate attendance at their physiotherapy
appointment. The choice of reminder system for a physiotherapy service should be tailored to the individual service and informed by a variety of contextual factors.
To optimise appointment and reminder systems, healthcare services need supportive administrative processes to enhance attendance, cancellation, rescheduling and
re-allocation of appointments to other patients.
Implications: Physiotherapy services should install optimised reminder systems to enhance attendance, cancellation, rescheduling and re-allocation of appointments
to other patients
Funding Acknowledgements: National Institute for Health Research Health Services and Delivery Research Programme (project number 10/2002/49).
Ethics Approval: None required for this evidence synthesis
Keywords: None

PO1-AP-007
PELVIC ORGAN PROLAPSE - WOULD YOU MOVE DIFFERENTLY IF YOUR UTERUS WAS FALLING OUT - A NARRATIVE REVIEW
K. Mcpherson, I. Nahon 1, G. Waddington 1, A. Fearon 1,*
1
University of Canberra, Canberra, Australia
Background: Inital Literature review for PHD reserach looking at the relationship of movment and pelvic organ prolpase(POP)
Purpose: Narrative literature review to define future research examining the relationship of POP and a women's movement.
Methods: Narrative literature review
Results: This is a narrative review of Pelvic organ prolapse (POP)and its relation to a womens movement . POP is defined as the symptomatic descent of the pelvic
organs from their normal anatomical position. The integrated lifespan model, proposed by DeLancey et al, (2008) may help explain causal factors for the development
of POP, suggesting that instead of there being one risk factor, cumulative damage and overload of the tissues may lead to the development of POP. This perhaps
suggests poor loading of the tissues from altered movement with normal everyday activities over a long time may lead to changes within the tissues. Although, POP is
not life threatening it can affect a womens quality of life. The overall movement of a woman before and after she develops POP maybe the key in optimising overall
muscle function of the pelvic and abdominal muscles in their role to support the pelvic organs.
Conclusion: There is a need to investigate how a women with POP moves on simple clinical tests for failed load transfer and if these tests and qualitative information
gained for her experiences of how the POP has affected her movement and activities can be used to develop a clinical predictive tool for identifying POP and
developing rehabilation guidelines.
Implications: Pelvic organ prolapse is a growing concern due to lack of awareness with women and an increasing incidence with an aging poopulation. Although there
is eveidence for pelvic muscle training to help reduvc the symtpoms of POP, it is expensive and limited to those with acess to specialist women health
physiotherapist. There is a need to look differently at the organ support to inform preventive and rehabilition mangaement.
Ethics Approval: University of Canberra ethics committee
Keywords: FAILED LOAD TRANSFER, MOVEMENT, PELVIC ORGAN PROLAPSE

PO1-CS-008
ADVERSE EVENTS ASSOCIATED WITH THE USE OF CERVICAL MANIPULATION OR MOBILIZATION AND PATIENT CHARACTERISTICS: A SYSTEMATIC REVIEW
R. Kranenburg 1 2,*, M. Schmitt 1, L. Puentedura 3, G. J. Luijckx 4, C. Van der Schans 1 2
1
Research group Healthy Ageing, Alied Health Care and Nursing, Hanze University of Applied Sciences, 2Department of Rehabilitation, University Medical Center
Groningen , Groningen, Netherlands, 3Department of Physical Therapy, University of Nevada Las Vegas, School of Allied Health Sciences, Las Vegas, United States,
4
Department of Neurology, University Medical Center Groningen, Groningen, Netherlands
Background: Cervical spinal manipulation (CSM) and cervical mobilization are frequently used in patients with neck pain and headache. Pre-manipulative cervical
instability and arterial integrity tests appear to be unreliable in identifying patients at risk. It would be valuable if patients could be identified by specific
characteristics during the preliminary screening.
Purpose: To systematically analyze retrospective case reports describing patients who experienced severe adverse events (AE) after CSM or cervical mobilization and
therewith to identify the clinical characteristics of 1) patients, 2) practitioners, 3) the treatment process and 4) the AE occurring after CSM or cervical mobilization.
Methods: A systematic search was performed in PubMed, Embase, CINAHL, Web-of-science, AMED, and ICL (Index Chiropractic Literature) up to December 2014.
Results: Of the initial 1043 studies, 144 studies were included, containing 227 cases. 117 cases (52%) described male patients with a mean age of 44.74 (SD 11.91)
and 39.22 (SD 11.12) for females. for male. The overall distribution of gender for CAD is opposite with 55% (n= 71) for female and 45% (n= 58). Most patients were
treated by chiropractors (65.6%). Manipulation was reported in 95.2% of the cases, and neck pain was the most frequent indication. Cervical arterial dissection (CAD)
was reported in 57% (P = 0.21) of the cases and 45.8% had immediate onset symptoms.
Conclusion: No clear patient profile could be extracted from the reported parameters, however, women seem more at risk for CAD. There appears to be an underreporting of cases. In the reported cases, patient characteristics were described poorly. A more detailed and systematic method of reporting AE should be
implemented.
Implications: Further research should focus on a more uniform and complete registration of AE using standardized terminology.
Ethics Approval: N.A.
Keywords: adverse events, Cervical manipulation, systematic review

PO1-CS-009
IMMEDIATE AND SHORT-TERM RESPONSE TO POSTERIOR PRESSURES VERSUS LATERAL GLIDES IN PATIENTS WITH NECK PAIN- A PILOT RANDOMIZED CLINICAL
TRIAL
E. Yung 1 2 3 4,*, M. Wong 4 5 6, M. I. Ali 7 8, E. M. Barton 4, K. Peterson 4, K. Ching 4
1
Doctor of Physical Therapy and Orthopaedic Physical Therapy Residency Programs, Sacred Heart University, Fairfield, 2Elevating Practice in Orthopaedic Physical
Therapy, MGH Institute of Health Professions, Boston, MA, 3PhD Program in Ergonomics and Biomechanics, New York University, New York, NY, 4Doctor of Physical
Therapy Program, Azusa Pacific University, Azusa, CA, 5Physical Therapy Spine Fellowship, University of Southern California, Los Angeles, CA, 6Physical Therapy Spine
Fellowship, Kaiser Permanente, Los Angeles, 7Doctor of Physical Therapy Program, Sacred Heart University, Fairfield, 8United States Army Reserve, West Hartford, CT,
United States
Background: Joint mobilization (JM), such as lateral glides (LAT) & posterior pressures (AP) appears efficacious for non-specific neck pain (NSNP).
The neurophysiologic system that modulates pain overlaps with blood pressure (BP) as observed in BP-related hypoalgesia. Nevertheless, evidence is sparse
characterizing the cardiovascular response (CR) to LAT or AP in NSNP. 5 sets of (10 seconds on & 10 off) AP and LAT have evidently produced disparate CR in pain-free
adults. What is indeterminate is whether these procedures, when dispensed in the same minimal regimen, yield comparable or divergent outcomes in patients with
NSNP.
Purpose: Our study aspires to explore whether AP or LAT: (1) is more effective in altering neck disability, pain, range of motion (ROM); and (2) whether the
procedures cause BP and heart rate elevation or depression in patients with NSNP.
Methods: Ten participants (5 females; mean age of 26.8 8.6) with unilateral NSNP were recruited from two universities. Each individual is randomly allocated to 1 of
2 groups. Both Group 1: AP and Group 2: LAT obtained posterior pressures and lateral glides respectively to the most tender & restricted segment. Baseline neck and
shoulder ROM with numeric pain rating scale (NPRS), and Neck Disability Index (NDI) were collected at the initial session. An OMRON automatic monitor measured
the systolic blood pressure (SBP) and heart rate (HR) with recording time points: (1) 5 minutes, and (2) 7 minutes after lying supine; (3) during the 1st set, (4) 5th set
of one of the glides, (5) 2 minutes after time point #4, and (6) 4 minutes after time point #4. Following time point #6, the assistant gathered a global rating of change
(GROC) based on the neck and shoulder ROM retest. Blinded to the random allocation and data, the primary author performed one of the techniques on all
participants. Within 1 week, follow-up NPRS, NDI, and any adverse effects were obtained.
Results: ANOVA indicates that AP and LAT altered the cervical spine extension ROM by an average of +7.00 8.00 compared to -6.00 5.10 [(r)= 0.46, p < 0.05]
respectively. There were no other between-group comparisons (NDI, NPRS, GROC, & ROM) that have statistical significance. As for the within-group comparisons, the
one-week improvement in NDI (41% for AP and 52% for LAT) surpassed the minimal clinically important difference and/or the minimal detectable change (MDC) of
30% change. In addition, some statistical and clinically noteworthy CR were found: (1) in the AP group, the HR diminished by an average of 5.2 2.7 beats per minute
(bpm) from time point #1 to time point #3, exceeding the MDC of 4.3 bpm; and (2) in the LAT group, the mean SBP reduction is 5.6 3.9 mmHg from time point #2 to
time point #3, exceeding the MDC of 4.2 mmHg. Finally, within the LAT group, the mean increase in shoulder elevation ROM was 16.80 11.90 [(r)=0.42, p < .05]. And
there were no reported adverse effects.
Conclusion: Pilot results suggest that AP and LAT triggered an immediate sympatho-inhibitory CR. Following LAT and AP, shoulder elevation and neck extension ROM
increased respectively. More notably, both low-dose procedures improved neck disability within 1 week.
Implications: Although preliminary, LAT and AP caused analogous CR and seem equally effective in improving short-term neck disability. These intriguing findings
imply that an alternate dosage, with resultant sympatho-inhibitory cardiovascular reaction (SICR), can enhance the desired functional outcome that is akin to the
standard regimen of JM. Remarkably, both techniques brought about SICR; thereby, disputing the dominant notion that JM only causes sympatho-excitation.
Therefore, it is arguable that CR could be more a function of dosage regimen, rather than a function of technique. Finally, while the LAT seems to improve shoulder
ROM; AP may be a sounder option than LAT, in restoring ROM of the neck.
Funding Acknowledgements: Dr. Yung's PhD studies at New York University (NYU) is funded by a tuition award from the United States Government's National
Institute of Occupational Safety and Health (NIOSH/NIH) Education and Research Center Grant through NYU School of Medicine.
This research study is funded by the American Academy of Orthopaedic and Manual Physical Therapists (AAOMPT) OPTP Research Grant
Ethics Approval: The Ethics Committees of Sacred Heart University and Azusa Pacific University approved the protocol of this study. All patients signed their informed
consent.
Disclosure of Interest: E. Yung Conflict with: United States Government's National Institute of Occupational Safety and Health Education and Research Center Grant
Tuition awardee for PhD studies, M. Wong: None Declared, M. I. Ali: None Declared, E. M. Barton: None Declared, K. Peterson: None Declared, K. Ching: None
Declared
Keywords: Cervical Spine Manipulation

PO1-CS-010
EMG ACTIVITY BEFORE, DURING AND AFTER DRY NEEDLING OF THE UPPER TRAPEZIUS MUSCLE: PRELIMINARY RESULTS
K. De Meulemeester 1,*, P. Calders 1, B. Cagnie 1
1
Rehabilitation sciences and physiotherapy, Ghent University, Ghent, Belgium
Background: Several studies have demonstrated a higher surface electromyography (sEMG) activity of the upper trapezius in patients with trapezius myalgia,
compared to healthy controls. This sEMG activity also increases during a repetitive low-level task and patients with trapezius myalgia often have problems to relax the
upper trapezius after completion of this task.
Dry needling is a myofascial treatment technique, which is frequently applied to treat trapezius myalgia. Several physiological and clinical treatment effects have
already been reported but the underlying mechanisms are still unclear. There is currently also a lack of research regarding the importance of eliciting local twitch
responses (LTRs) during dry needling. LTRs are involuntary contractions of muscle fibers, which may lead to muscle relaxation by reducing spontaneous electrical
activity. This may cause a reduction of pain and stiffness.
Purpose: The aim of this study was to determine the effect of dry needling, compared to rest, on the sEMG activity of the upper trapezius after fatiguing the muscles
with a typing task. This effect is evaluated in a subgroup of muscles where LTRs were elicited and a subgroup without LTRs during dry needling.
Methods: Bilateral surface EMG (sEMG) activity of the upper trapezius muscle was evaluated in fifteen female office workers with myofascial neck/shoulder pain
before, during and after two typing tasks of 20 minutes. The first typing task was followed by a resting pause of 10 minutes and the second typing task was followed
by the bilateral application of dry needling to the upper trapezius muscle. sEMG activity was measured before and after the resting pause and before, during,
immediately after and 10 minutes after the dry needling session.
A Wilcoxon matched-pairs signed-ranks test with a significance threshold of p < 0.05 was performed to explore differences in changes of sEMG after dry needling and
after rest. This analysis was performed separately for a subgroup of muscles with LTRs and a subgroup without LTRs
Results: Local twitch responses were elicited in 14 muscles whereas in 16 muscles no LTRs were provoked. No significant differences were found between changes in
sEMG activity immediately after dry needling, compared to rest for the subgroup with LTRs (P=0,638) and the subgroup without LTRs (P= 0,098). In the subgroup of
muscles with LTRs, significant decreases in sEMG activity were found 10 minutes after dry needling compared to rest (P=0,048). The sEMG activity decreased 10
minutes after dry needling whereas the sEMG activity increased after rest. In the subgroup of muscles without LTRs, no significant differences were found (P=0,098).
Conclusion: Based on these results we can conclude that dry needling of the upper trapezius leads to a decrease in sEMG activity, compared to rest when local twitch
responses are elicited. It is important to note that these results should be interpreted with care since these results are preliminary and in view of the performed
power analysis another 10 subjects are currently tested.
Implications: These preliminary results might indicate the importance of eliciting a LTR during treatment with dry needling of the upper trapezius.
Funding Acknowledgements: Kayleigh De Meulemeester, PhD student at University Ghent, is funded by the Special Research Fund of Ghent University (BOF-Ghent).
Ethics Approval: This study was approved by the Local Ethics Committee of the Ghent University Hospital, Belgium.
Keywords: Dry needling, EMG activity, Trapezius myalgia

PO1-CS-017
CERVICAL RADICULOPATHY EFFECTIVELY MANAGED BY A PHYSICAL THERAPY STUDENT UTILIZING A CERVICAL LATERAL GLIDE MANIPULATION IN A RADIAL NERVE
NEURODYNAMIC POSITION: A CASE REPORT
J. Rot 1,*, C. Lempert
1
Physical Therapy, University of St. Augustine for Health Sciences, St. Augustine, United States
Background: Cervical radiculopathy (CR) can cause significant neck pain and dysfunction. The reported annual incidence of CR is 83.2 per 100,000 cases while the
reported prevalence is 3.5 per 1000 cases. Physical therapists commonly examine and treat patients with CR. Determining effective conservative intervention
strategies are essential. Manipulation, cervical traction, and postural exercises have shown to be effective multimodal intervention strategies. One manipulation
techniqe with effective results was a cervical lateral glide technique in a median nerve neurodynamic position. Manipulation using a cervical lateral glide
manipulation technique in a radial nerve neurodynamic position has not knowingly been studied.
Purpose: The purpose of this case was to report the effect of a cervical lateral glide manipulation technique in a radial nerve neurodynamic position as a part of a
multimodal intervention strategy for a 42 year old female patient clinically diagnosed with CR.
Methods: This case report describes the examination, evaluation, and intervention completed by a student physical therapist for a patient with CR. The patient was a
42-year-old right hand dominant female who presented with a three week insidious onset of unilateral pain at the base of her left neck, with pain and paresthesia
radiating down to her left hand. She presented with forward head posture, limited cervical range of motion, decreased dermatomes, myotomes, and reflexes
consistent with C6 nerve root involvement. Functional limitations included reaching or lifting with the affected extremity as well as driving and sleeping secondary to
pain and paresthesia. All criteria for Wainners CR clinical prediction rules were met in addition to a positive radial nerve upper limb tension test. The patient received
a cervical lateral glide manipulation technique in a radial nerve neurodynamic position as part of a multimodal (manual physical therapy, cervical traction, and
postural exercise) intervention approach. The patient was seen in physical therapy two times per week for three weeks for a total of six visits.
Results: Primary outcome measures included the numerical pain rating scale (NPRS), the Neck Disability Index (NDI), and goniometric measurements for cervical
range of motion. At discharge, the patient reported a 1/10 pain with activity and a 0/10 pain at rest compared to the initial examination scores of 7/10 and 2/10
respectively. The NDI score at discharge was 10% disability (minimal) when compared to the first visit of 46% disability (moderate). The patient's cervical active range
of motion was within functional limits at the last treatment session.
Conclusion: A cervical lateral glide manipulation technique was effective as part of a multimodal intervention strategy to treat a 42 year old female patient with
cervical radiculopathy. The patient was able to resume all daily activities with minimal pain and no functional limitations. Future randomized controlled studies are
recommended utilizing a cervical lateral glide manipulation in a radial nerve neurodynamic position for patients diagnosed with CR with a positive upper limb tension
test B (radial nerve bias).
Implications: To this author's knowledge, there are no studies that have measured the effect of a cervical lateral glide manipulation in a radial nerve neurodynamic
position. Physical therapists should consider using a cervical lateral glide manipulation technique in a radial nerve neurodynamic position as part of a multimodal
intervention strategy for patients diagnosed with CR who have a positive upper limb tension test B (radial nerve bias).
Ethics Approval: Ethics approval was not required for this case report.
Keywords: Manipulation, Neurodynamic, Radiculopathy

PO1-CS-018
RELIABILITY OF A LOW COST METHOD OF MEASURING POSTERIOANTERIOR MOVEMENTS TO THE THORACIC SPINE AND WHAT DIFFERENCES RELATE TO
THERAPIST PERCEPTION OF MOBILITY
N. Tuttle 1 2,*
1
Menzies Health Institute Queensland, 2School of Allied Health Sciences, Griffith University, Gold Coast, Australia
Background: A variety of devices have been developed to measure force displacement (FD) curves of posteroanterior (PA) movements of the spine. Most of these
devices are expensive, have limited availability and have not had their repeatability evaluated for the thoracic spine. Furthermore little is known about the ability of
these devices to detect the differences that are perceived as relevant by therapists.
Purpose: The purposes of this study were 1) to evaluate the reliability of a simple, low cost method of measuring FD curves of the thoracic spine and 2) to determine
how the FD curves of spinal levels differ with differences in therapist-perceived mobility.
Methods: Ten female participants aged 18-25 had PA glides up to a force of 40 N applied to each level of their thoracic spine from T3 to T7. To assess repeatability,
each glide was applied four times. To determine what characteristics of the FD curves are related to therapist perception of mobility, an experienced musculoskeletal
physiotherapist selected two of these locations - one perceived to have less movement than the other. The PA force was applied through a FDX Wagner Digital Force
Gauge with a digital readout and each application was videotaped.
The point of force application was tracked by automated tracking software (Kinovea) enabling calculation of frame-by-frame displacement. Reading the digital output
from the force gauge enabled synchronisation of the force and displacement data points. The resulting FD curve was smoothed and interpolated using a one way
spline function (Srs1software.com). The limits of agreement that indicate the difference in displacement within which 95% of repeated measures would be likely to
occur for that magnitude of force were calculated at each N of force. Confidence bands of the mean were calculated for the locations on each participant that had
been judged to have different degrees of mobility. Areas where the confidence bands did not overlap were considered to be significantly different.
Results: Limits of agreement ranged from 1.2 to 2.4 mm or 15- 25%. For nine out of ten of the stiff/less stiff comparisons, the curves diverged at levels of force below
10 N and most were significantly different by 5 N.
Conclusion: The method described is able to produce force displacement curves of PA movements where repeated measures are within 15 -25% at each level of
force. While this may seem like a large error, differences between locations perceived as having different levels of movement often varied by 50% to over 100%
particularly in the lower force ranges of 5 - 10 N.
Implications: A simple, low cost method of measuring force displacement curves of the thoracic spine is described. While the measurement error may seem large, the
repeatability is sufficient to be able to detect differences that are perceived by a clinician. Differences in movement are most obvious at forces as low as five N
(approximately the force necessary to click a retractable pen) which is far lower than what is often used.
Funding Acknowledgements: No funding was received to support this work
Ethics Approval: Ethics approval was granted through the Griffith University Ethics Review Board
Keywords: Assessment, measurement, Thoracic spine mobility

PO1-CS-020
PILOT STUDY DESCRIPTIVE CORRELATIONAL OF ELECTROPHYSIOLOGIC AND CLINICS MEASUREMENTS IN PATIENTS WITH CARPAL TUNNEL SYNDROME (MILD OR
MODERATE).
S. Jimnez Del Barrio*, J. M. Trics Moreno, C. Hidalgo Garca, S. Prez Guilln, M. Fortn Agud, S. Cabanillas Barea, S. Rodrguez Marco, L. Ceballos Laita, P. Pardos
Aguilella, J. Esteban Prez
Background: The aim of the study was to determine the relationships between the different valid clinical and electrophysiological variables frequently used to know
the status of the patient with carpal tunnel syndrome (mild or moderate).
Purpose: A correlational cross-sectional study was performed. The patients were diagnosed medically as carpal tunnel syndrome (mild or moderate intensity) by
electrodiagnostic testing.
Methods: The following variables were measured: epidemiological variables, clinical variables (nighttime symptoms, pain and numbness in last 3 days, functional
capacity of the upper limb and intensity of disability caused by carpal tunnel syndrome, mechanosensitivity of nervous system measured by neurodynamic test,
length of wrist flexors and teres pronator, grip test), ultrasonography variables (cross sectional area of the median nerve) and electrophysiological variables (motor
distal latency, sensory conduction velocity of the median nerve and their amplitudes).
Results: 38 volunteer were included in the study. We established the following correlations:
In relation to the age there was an inverse relationship between age and nocturnal symptoms, pain and numbness during day (p= - 0,37, - 0,47, - 0,36).
Nighttime symptoms were directly related to the symptoms of daytime pain (p=0,) with degree of disability (p=0,4) and the motor amplitude (p=0,4-0,34).
An inverse relationship between nighttime symptoms and length of the pronator (p=0,42) and fingers flexors (p=0,5) was shown.
There were direct links between the pain experienced and numbness during the day (p=0,63), the functional capacity of the upper limb (p=0,6) and
mechanosensitivity of the nervous system (p=0,4). There was also an inverse relationship between pain and both pronator muscle length (p=0,6) and wrist flexors
(p=0,4).
Concerning numbness during day, there was a direct relationship between functional capacity of the upper limb (p=0,5) and disability (=0,4). Also there was an
inverse relationship between numbness and pronator length (p= - 0,47).
Mechanosensitivity of the nervous system measured by neurodynamic test showed an inverse relationship between length of pronator teres (0= - 0,4 / -0,54) and the
cross-sectional area of the median nerve (p= - 0,5). In addition, there was a direct relationship between mechanosensitivity and disability (p=0,4).
Disability was inversely related to the cross-sectional area of the median nerve (p=-0,5) and the length of the wrist flexors (p=0,4).
Ultrasonography variables showed an inverse relationship between the pain during day and cross-sectional area of the median nerve (p=0,4), functional capacity of
the upper limb (p= - 0,35), and mechanosensitivity of the nervous system (0=0,53).
Regarding the electrophysiological variables: there was a direct relationship between the amplitude in the palm sensitive to pain perceived in the day (p=0,52), also
there was a direct relationship between the amplitude in the palm sensitive and numbness (p=0,82). Furthermore there was an inverse relationship between sensory
conduction velocity in the palm to second finger and cross sectional area of the median nerve (p= - 0,6). There was an inverse relationship between the length of the
flexor muscles of the wrist and the amplitude.
Conclusion: The relationships between the clinical variables used in the daily clinical practice and electrophysiological test are very important to help us to
understand the development of patients and also to control the effects of our treatments, but relationship between these variables are not clear.
Implications: This study supports kind of relationships between different variables considered in carpal tunnel syndrome (mild to moderate intensity)
Funding Acknowledgements: Researching Unit of Physiotherapy, OMT Spain.
Ethics Approval: Ethics Approval: Comite Etica Aragn
Keywords: Assessment, Carpal tunnel syndrome, Neurodynamic

PO1-CS-024
EFFECTIVENESS OF PHYSIOTHERAPY TREATMENT THROUGH DIACUTANEOUS FIBROLYSIS IN PATIENTS WITH CARPAL TUNNEL SYNDROME. 12 CASE SERIES.
M. Fortn Agud, S. Jimnez Del Barrio, J. M. Trics Moreno, C. Hidalgo Garca, S. Prez Guilln*, S. Cabanillas Barea, S. Rodrguez Marco, L. Ceballos Laita, P. Pardos
Aguilella, J. Esteban Prez
Background: The objective of the study was to analyze the effectiveness of physiotherapy treatment through diacutaneous fibrolysis in 12 case series of patients
with carpal tunnel syndrome (mild to moderate intensity)
Purpose: It has developed a series of 12 cases diagnosed medically by electrodiagnostic testing.
There have applied 5 sessions with diacutaneous fibrolysis in forearm and hand. Before and after the treatment the variables considered have been measured.
Methods: Methods. 12 subjects (47,25 years) medically diagnosed with mild to moderate intensity (8 patients, 4 bilateral, 4 unilateral) participated voluntarily. In
these patients it was applied 5 sessions of diacutaneous fibrolysis. Before and after these variables were measured: nocturnal and daytime symptoms, functional
capacity, mechanosensitivity of the nervous system, sensitivity and strength. A month after treatment symptoms and functional capacity were assessed. For statistical
analysis it was used nonparametric Wilcoxon test.
Results: After treatment nocturnal symptoms improved statistically (p=0,01). Also we found statistically significant improvements in pain after treatment (p=0,008)
and in numbness (p=0,002). Functional capacity improvements are also observed after treatment (p=0,002). Mechanosensitivity of the nervous system measured
with neurodynamic test showed significant improvement after treatment (p=0,033 0,003). Improvements were also observed for grip strength and pinch measured
by a dynamometer (p=0,025). One month after treatment there were observed improvements in nocturnal symptoms, pain (p=0,465), numbness (p=0,932) and
functional capacity (p=0,109).
Conclusion: Diacutaneous fibrolysis in a 12 cases series with carpal tunnel syndrome with mild to moderate intensity has shown improvements statistically significant
in terms of symptoms, functional capacity, mechanosensitivity of the nervous system, strength and sensitivity in the second and third finger.
Implications: This study supports the effectiveness of effective management with fibrolysis diacutaneous in carpal tunnel syndrome (mild to moderate intensity)
Funding Acknowledgements: Researching Unit of Physiotherapy, OMT Spain.
Ethics Approval: Comite Etica Aragn
Keywords: Carpal tunnel syndrome, outcome measure, Physical Therapy

PO1-CS-026
EFFECTS OF POSTERIOR SHOULDER STRETCHES ON THE ISOKINETIC STRENGTH OF ROTATOR CUFF MUSCLES IN YOUTH BASEBALL PLAYERS WITH SCAPULAR
DYSKINESIS
I. Yu 1, T. Kim 2, D. Jung 3, J. Oh 4,*
1
Rehabilitation Science, INJE University, GIMHAE-SI, 2Physical Therapy, Daegu University, Daegu-si, 3Physical Therapy, Joongbu University, Geumsan, 4Physical
Therapy, INJE University, GIMHAE-SI, Korea, Republic Of
Background: Shoulder injuries injuries are common in youth baseball players, it caused by repetitive high-velocity dynamic overhead throwing motion. The repeated
throwing motion leads to alters the scapular kinematics defined as scapular dyskinesis (SD), it has been associated with RC muscles strength. Recently, posterior
shoulder tightness (PST) has been suggested as an important factor causing the SD. Furthermore, PST is considered a risk factor for various shoulder injuries, and
leads to imbalance of shoulder muscles. Therefore, it should focus on the posterior shoulder stretches with a scapular stabilization exercise (PSSE). Some authors
reported that effects of PSSE on the RC muscles isometric strength however, no studies have investigated the effects of PSSE on the isokinetic strength of RC muscles.
Purpose: The purpose of present study was to determine the effects of PSSE on the isokinetic strength of RC muscles, range of motion (ROM), and shoulder pain in
youth baseball players with SD.
Methods: Twenty-four youth baseball players in Busan, Korea, participated in this study. They all had scapular dyskinesis, 15 to 20 glenohumeral internal rotation
deficit (GIRD) on the throwing shoulder, and shoulder pain during participation training or baseball game. The subjects were allocated in to two groups: PSSE (n=12)
and scapular stabilization exercise (SSE) (n=12). PSSE group performed sleeper stretches with four SSE for 6 weeks and SSE group performed four SSE for 6 weeks,
respectively. The main outcome measures were concentric, eccentric internal rotation (IR) and external rotation (ER) peak torque/body weight (PT/BW) at 120/sec,
IR ROM, GIRD and shoulder pain was assessed pre- and post-intervention. A two-way repeated-measures analysis of variance (ANOVA) was used to determine the
time-by-group interaction and main effect. A t-test was used for post hoc analysis.
Results: The concentric and eccentric ER PT/BW (concentric ER: 40.81%6.25% vs. 46.83%5.16%, eccentric ER: 44.00%4.78% vs. 49.40%3.54%), IR ROM
(59.167.81 vs. 74.506.08), and GIRD (17.250.96 vs. 2.412.19) was significantly difference pre- and post-intervention in PSSE group and showed significant
difference between groups. However, no significant difference pre- and post-intervention in SSE group. The shoulder pain (PSSE: 53.33mm18.74mm vs.
20.83mm13.11mm, SSE: 64.16mm 19.28mm vs. 35.8319.28mm) was significantly difference pre- and post-intervention in both groups however, no significant
difference between groups. The IR PT/BW was no significantly difference pre- and post-intervention in both groups and no significant difference between groups.
Conclusion: The PSSE improved concentric and eccentric ER PT/BW, ROM, and shoulder pain after 6 weeks intervention.
Implications: Our results suggest that the PSSE can be more effective training technique for improving the dynamic strength of shoulder ER muscles, shoulder pain,
and restore the PST in youth baseball players with SD.
Funding Acknowledgements: None declared
Ethics Approval: Ethics approval was obtained from the Inje University Ethics Committee for Human Investigations.
Keywords: Scapular dyskinesis; Posterior shoulder tightness; Rotator cuff muscles strength

PO1-CS-027
HYPOALGESIC EFFECTS OF MANUAL THERAPY IN PATIENTS WITH CERVICOGENIC HEADACHE AND POSSIBLE MECHANISMS
M. Malo-Urris*, J. M. Trics, E. Estbanez, C. Hidalgo, E. Bueno, P. Fanlo, A. Ruiz de Escudero, S. Prez, A. Carrasco, S. Cabanillas
Background: Manual therapy has evidenced hypoalgesic effects on headache patients.

Purpose: To describe clinical effects produced by manual therapy treatment of the upper cervical spine on pain, in patients with cervicogenic headache, as well as
describe the possible hypoalgesic mechanisms.
Methods: A randomized controlled trial on 82 patients with cervicogenic headache was carried out. Participants were divided into two groups: intervention and
control. Intervention group received 3 sessions of manual therapy treatment of the upper cervical spine. Control group did not receive any treatment. Different
variables were measured before and after each treatment session as well as at one month follow-up. Variables include headache intensity and pressure pain
threshold in several head and neck points.
Results: Intervention group showed a statistically significant reduction of headache intensity, passing from VAS=1,3 (SD=2,3) at the beginning of ths study to VAS=0,5
(SD=1,0) at the end of the third session (p=0,041). On the other hand, control group did not show any significant modification of headache (p>0,05). The differences
between both groups were statistically significant (p=0,001). Hypoalgesic effect demonstrated in the present study could be explained through the activation (by the
manual technique) of pain modulation descending mechanisms.
Conclusion: Manual therapy treatment of the upper cervical spine in patients with cervicogenic headache produce a hypoalgesic effect. This effect can be explained
based on the mechanical input created by the mobilization technique, that produces physiological effects at peripheral, spinal and central level.
Implications: Manual therapy has hypoalgesic effects that can be explained throughout several mechanisms.
Ethics Approval: Comit tico de Investigacin Clnica de Aragn
Keywords: Cervical manipulation, Headache, Manual Therapy

PO1-EX-031
EXERCISE ADHERENCE MEASURES - WHY WE NEED TO START AGAIN. FINDINGS OF A SYSTEMATIC REVIEW AND CONSENSUS WORKSHOP
S. Mclean 1,*, M. Holden 2, T. Potia 1, M. Gee 3, R. Mallett 1, S. Bhanbhro 3, H. Parsons 4, K. Haywood 5
1
Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, 2Arthritis Research UK Primary Care Centre, Keele University, Keele, 3Centre for Health and
Social Care Research, Sheffield Hallam University, Sheffield, 4Warwick Medical School, 5Royal college of Nursing Research Institute, Warwick University, Coventry,
United Kingdom
Background: Exercise programmes are frequently advocated for the management of musculoskeletal disorders; however, adherence is considered to be an important
pre-requisite for their success. The assessment of exercise adherence requires the use of relevant and appropriate measures, but guidance for appropriate
assessment does not exist.
Purpose: To evaluate the measurement and practical properties of measures of exercise adherence that are utilised in the musculoskeletal field.
Methods: There were two key stages to the research. First, a systematic review of the availability, quality and acceptability of measures used to assess exercise
adherence in musculoskeletal disorders; second, a consensus meeting. The systematic review was conducted in two phases and reported in accordance with the
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to ensure a robust methodology. Phase one identified all reproducible
measures that have been used to assess exercise adherence in a musculoskeletal setting. Phase two identified published and unpublished evidence of the
measurement and practical properties of identified measures. Study quality was assessed against the COnsensus-based Standards for the selection of health
Measurement INstruments (COSMIN) guidelines. A shortlist of measures was produced for consideration during stage two: a meeting of relevant stakeholders (n=14)
in the United Kingdom. Stakeholders were invited to participate different relevant groups; patient representatives (n=3), clinicians who use therapeutic exercise
(n=3), researchers with expertise in adherence or measurement (n=2) and service managers (n=3). During this meeting consensus on the most relevant and
appropriate measures of exercise adherence for application in research and/or clinical practice settings was sought.
Results: Our systematic review identified 238 different measures which had been used as measures of exercise adherence within musculoskeletal research. From 36
defined measures which have been used to evaluate exercise adherence only six had been evaluated as a specific measure of exercise adherence. Limited evidence in
support of measurement reliability and/ validity was identified from 10 articles for these six measures. Assessment of relevance and comprehensiveness of measures
was largely absent and there was no evidence of patient involvement during the development of any of the measures. During the consensus process the stakeholders
reached agreement that none of the measures were relevant, appropriate or acceptable for use in musculoskeletal clinical or research settings.
Conclusion: Numerous exercise adherence measures are currently used within musculoskeletal research. However, many of these measures were not originally
developed for this purpose; many approaches are not reproducible; and evidence of essential measurement and practical properties was only identified for a limited
number of measures. Substantial methodological and quality issues were identified in the development and evaluation of the six short-listed measures which reduces
confidence in the ability of these measures to reliably and validly evaluate adherence to exercise. Stakeholders in our consensus workshop unanimously agreed that
all six measures were unacceptable and irrelevant for use in musculoskeletal clinical or research setting
Implications: Exercise adherence measures need to be clearly conceptualised and developers must seek to involve patients, clinicians and researchers as active
collaborators and use credible methods to develop and evaluate an appropriate measure of exercise adherence.
Funding Acknowledgements: This work was supported by the Chartered Society of Physiotherapy Charitable Trust [grant number PRF/12/13]
Ethics Approval: Ethics approval was obtained from the Faculty Research Ethics Committee at Sheffield Hallam University
Keywords: adherence measures, exercise and physical activity, musculoskeletal disorders

PO1-LB-036
USING THE RE-AIM FRAMEWORK TO EVALUATE AND GUIDE A QUALITY IMPROVEMENT PROGRAM: IMPLEMENTATION OF LOW BACK PAIN CLINICAL PRACTICE
GUIDELINES
W. Kolb*, B. Harper
Background: Clinicians and health care organizations often fail to implement Clinical Practice Guidelines (CPGs) to the detriment of the patient and profession. CPGs
are evidence-based best practice standards developed to assist clinical decision making and to influence clinical practice behavior. Implementation of CPGs within a
multiple clinic hospital system is a complex and dynamic process. The RE-AIM (Reach-Effectiveness-Adoption-Implementation-Maintenance) process is designed to
facilitate the incorporation of research into clinical practice behavior with evaluative criteria that can help guide implementation phases and provide clarification of
stakeholder critical data.
Purpose: Use the RE-AIM framework at both the clinician and patient levels to evaluate the first phase of a CPG Low Back Pain (LBP) knowledge to action cycle in
preparation for a complete system implementation.
Methods: This was an administrative review of an ongoing quality improvement (QI) program using the RE-AIM framework. For the pilot study, two clinics received
CPG training and two clinics served as controls. At the clinician level measurement of change of behavior to consistent use of CPGs was established by exceeding a
target of 75% active charge codes. At the patient level outcome measures of the Oswestry Disability Index (ODI) and Numeric Pain Rating Scale (NPRS) were used to
compare sites. One-way ANOVAs were used for comparisons with < 0.05.
Results: Reach: Two clinics received CPG implementation and two served as controls representing 20 and 13 clinicians respectively. During the study period, sixty out
of 270 patients receiving care met the inclusion and exclusion criteria with 31 cases at the CPG implementation sites. Most cases (135) were lost due to incomplete or
low (<10%) ODI scores. Effectiveness: No differences at the patient level were found for LBP disability (ODI) or pain scores (NPRS) between CPG implementation and
control clinics. Adoption: Strategies included training local clinical champions, hands on manipulation sessions (81% attendance of staff at implementation sites for
live trainings), clinical rounds, electronic medical record (EMR) algorithms, peer audit, and staff meetings to address barriers. Implementation: Average of 15
separate training contacts of approximately 1 hour each provided per site. At the clinician level differences were found in charge code behavior comparing CPG
trained versus control sites (p<0.05) for all patients with LBP diagnoses, however this may be a low indicator of treatment fidelity. Maintenance: One year after
trainings retrospective charge data for both CPG training sites remain above target of 75% active codes.
Conclusion: Each strategy was evaluated with RE-AIM criteria at both the clinician and patient levels which is burdensome but necessary to guide next QI steps.
Strengths of phase one included use of clinical champions, EMR changes to prompt users, and adapting education needs for each site. Opportunities for
improvement include assessment of implementation fidelity, audits to capture outcome measures and database development to provide more meaningful
feedback. Multiple levels of complexity exist that demand a pragmatic approach to adapt to each site to maximize effectiveness. Selecting universal key data points,
which are easily understood by clinicians and organizational stakeholders is necessary to promote continual site/system-wide readiness to change.
Implications: The gap between current practice and evidence will continue to widen and costs of health care may continue to skyrocket unless active educational
strategies are implemented to incorporate evidence-based CPG services. Use of the RE-AIM framework is beneficial to organize the knowledge to action
implementation process and clarify pragmatic outcomes for all stakeholders.
Funding Acknowledgements: Carilion Clinic Research Acceleration Grant
Ethics Approval: Exempt status by Carilion Clinic Institutional Review Board
Keywords: Clinical Practice Guidelines, Information Dissemination, Translational Medical Research

PO1-LB-037
BARRIERS TO HEALTH CARE PROFESSIONAL ADHERENCE TO CLINICAL GUIDELINES FOR THE MANAGEMENT OF LOW BACK PAIN: A SYSTEMATIC REVIEW AND
META-SYNTHESIS OF QUALITATIVE STUDIES
S. Slade 1,*, P. Kent 2, S. Patel 3, T. Bucknall 4, R. Buchbinder 1
1
Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia, 2Department of Sports Science and Clinical Biomechanics, University of Southern
Denmark, Odense, Denmark, 3Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, United
Kingdom, 4School of Nursing & Midwifery, Deakin University, Melbourne, Australia
Background: Low back pain is the highest ranking condition contributing to years lived with disability according to the most recent Global Burden of Disease study
and is associated with significant societal and individual cost. Despite the availability of consistent evidence-based treatment recommendations for low back pain
management in primary care remains suboptimal with over-reliance on imaging and medical intervention.
Purpose: We performed a systematic review and meta-synthesis of qualitative studies that explored what primary care clinicians believe about clinical practice
guidelines for low back pain, including perceived enablers and barriers to adherence.
Methods: The study was registered with PROSPERO (CRD42014012961) and our methods conformed to Cochrane guidelines and the COREQ and ENTREQ checklists.
English-langauage studies investigating perceptions and beliefs about low back pain guidelines were included if participants were primary care clinicians and
qualitative methods were used. Eight electronic databases were searched until July 2014. Pairs of reviewers independently screened titles and abstracts, extracted
data, appraised method quality using the CASP checklist, conducted thematic analysis and synthesised reults in narrative format.
Results: From a search yield of 1880 titles, 32 papers were read in full and 17 papers fulfilled the inclusion criteria. All studies reported research aims, a justification of
qualitative methods and a purposive sampling strategy and the majority reported recruitment and data collection details. Many studies failed to report key
components of method quality. We identified three key themes: clinicians have beliefs/pereptions that influence guideline implementation/adherence; they maintain
the patient-clinician relationship with imaging referrals; and they have beliefs/perceptions that act as barriers to guideline adherence. Clinicians believe that
guidelines are categorical, prescriptive and constrain professional practice; popular clinical practices supersede the guidelines; and imaging can be used for a
definitive diagnosis. Their perceptions reflect lack of content knowledge and understanding of guideline devlopment.
Conclusion: Addressing misconceptions and other barriers to uptake of evidence-base guidelines is needed to improve knowledge transfer and close the evidencepractice gap in the treatment of low back pain.
Implications: Guideline implementation researchers will need to consider alternative and/or improved ways in which clinical practice guidelines are presented to
clinicians, both the reporting of content and the descriptions of how the evidence-base was derived.
Funding Acknowledgements: this work was unfunded
Keywords: CLINICAL PRACTICE GUIDELINES, LOW BACK PAIN, PRIMARY CARE

PO1-LB-039
INDIVIDUAL PATIENT RESPONDER ANALYSIS OF THE EFFECTIVENESS OF A PAIN NEUROSCIENCE EDUCATION PROGRAMME IN CHRONIC LOW BACK PAIN
D. Pires 1,*, C. Caeiro 2, E. Cruz 2
1
Physiotherapy, Escola Superior de Sade Dr. Lopes Dias - Instituto Politcnico de Castelo Branco, Castelo Branco, 2Physiotherapy, Escola Superior de Sade Instituto
Politcnico de Setbal, Setbal, Portugal
Background: Chronic low back pain (CLBP) is a common health problem to which a large number of types of treatments seem to produce similar mean improvement
in patients symptoms. Individual responder analyses offer the possibility of providing patients and clinicians with supplementary information about the chance of
achieving particular degrees of pain relief, which may improve the decision-making process as well as communication with patients.
Purpose: To examine the effectiveness of a combined programme of pain neuroscience education and aquatic exercise (EDU+EXE) versus aquatic exercise alone (EXE)
in pain intensity in CLBP patients, and to determine the time course of response in pain intensity and the time course of effectiveness for clinically significant
improvements.
Methods: A single blind randomized trial, was conducted in patients with CLBP lasting >3 months. The EDU+EXE group (n=30) received 2 sessions of pain
neuroscience education followed by 12 sessions of a 6-week aquatic exercise programme, whereas the EXE group (n=32) received 12 sessions of the aquatic exercise
programme alone. Patients were assessed at baseline, 3 and 6 weeks after the beginning of the aquatic exercise programme and then at a 12 weeks follow-up. The
primary outcome was pain intensity (Visual Analogue Scale). Clinically significant treatment response was defined as a pain relief over baseline of >50%.
Results: Analysis using mixed-model ANOVA revealed a significant treatment condition interaction on pain intensity at the 3 months follow-up, favouring the
EDU+EXE group (mean SD change: -25.426.7 vs -6.630.7, p<0.005). At patient-level response, there were differences in the response rates and patterns. In the
EDU+EXE group, the proportion of patients that experienced substantial pain relief (>50%) raised from 47% to 70%, at 3 and 12 weeks, respectively. In the EXE group
this proportion raised from 25% to 34% (Relative risk of 1.87, and 2.04 respectively). At 3 weeks, 41% of the participants in the EXE group achieved a level of response
of no important change (<15%) compared to 27% in the EDU+EXE group. In the EDU+EXE group, and for those who achieved a pain relief of at least 50% at 3 weeks,
the rate of sustained pain relief response was approximately 93% and 86%, at 6 and 12 weeks respectively. These rates were higher than those of 63% and 50% found
in the EXE group.
Conclusion: This studys findings support the provision of pain neuroscience education as a clinically effective addition to aquatic exercise. Individual response
analysis showed that the patients receiving EDU+EXE achieved an early response to pain, had higher response rates at all the endpoints and were also more likely to
achieve a sustained response over time compared to those receiving EXE only.
Implications: Intervention studies should examine patient-level responses in addition to average treatment effects in order to enhance the clinical decision-making
and patient communication.
Funding Acknowledgements: Not applicable
Ethics Approval: Approved by the Ethics Committee - School of Health Care, Polytechenic Institute of Setbal
Keywords: Pain Neuroscience Education, Chronic low back pain, Responder analysis

PO1-LB-040
THE LIVED-THROUGH EXPERIENCES OF PERSISTENT RADICULAR LEG PAIN: A PHENOMENOLOGICAL DESCRIPTIVE STUDY
J. Holte*, C. Ridehalgh, P. Vuoskoski
Background: Low back pain (LBP) with or without radicular leg pain is still a topical issue today, as it is considered the leading cause of years lived with disability in the
United Kingdom. While there is a plethora of quantitative research around the topic, qualitative research on the lived-through experiences of radicular leg pain, or
spinally referred persistent leg pain in general, is lacking. Currently most LBP research is still situated in a positivist paradigm, where randomised controlled trials are
considered the gold standard for judging the benefits of treatment. This empirical research model, however, is becoming more and more challenged by alternative
(qualitative) approaches.
Purpose: In this study, a phenomenological, qualitative enquiry was implemented into the lived experiences of persistent radicular leg pain, attempting to clarify the
phenomenon of interest from a physiotherapeutic perspective. The aim of the study was to gain an in-depth understanding of the persistent radicular leg pain
experience, from the perspective of those who are living and going through the phenomenon in their daily lives.
Methods: The methodology of the study is drawing from the phenomenological philosophy of Edmund Husserl, and Giorgis (2009) modification of his
phenomenological method. Currently, most of the phenomenological research in the field of health sciences is based on interpretive (or hermeneutic)
phenomenology, highlighting the idiographic approach. For Husserl, the central theme and purpose in phenomenology is to describe the essence as a general level
structure of a phenomenon under exploration, by adopting the phenomenological attitude and reduction, and the use of conscious acts. In this study, five
participants were purposely recruited via advertisements in local (print) media. Qualitative data was obtained through individual, face to face, in-depth
interviews. Participants were asked to describe their concrete experiences of radicular leg pain, in as much detail as possible.
Results: The main result of the study revealed the individual and varied ways in which participants experienced their persistent radicular leg pain. The essential
meaning structure of the persistent radicular leg pain experience, and the key constituents and their relationships within that structure will be discussed in more
detail in the conference presentation.
Conclusion: Based on the preliminary results, the most foundational meaning constituent seems to be the persistence of the leg pain, which is lived and expressed
in individually, varied ways. The final conclusions will be discussed in detail in the conference presentation.
Implications: The study has significant implications for obtaining new knowledge and phenomenological insights, and a more in-depth understanding of the
persistence of the radicular leg pain, as a lived-through experience. Clinicians may gain an appreciation of the varied ways in which participants experience
persistent radicular leg pain enabling them to empathise with their patients and help them understand that having persistent radicular leg pain is an (embodied)
experience rather than just a set of symptoms.
Funding Acknowledgements: The author is enrolled on a Masters in Clinical Research, funded by NIHR at university of Brighton.
Ethics Approval: Ethical approval was obtained from the University of Brighton Health and Social Science, Science and Engineering Research Ethics and Governance
Committee.
Keywords: Qualitative research, descriptive phenomenology, radiculopathy, persistent leg pain

PO1-LB-041
THE EFFECTS OF MCKENZIES RETRACTION-EXTENSION EXERCISE ON POSITION OF THE POSTERIOR NUCLEUS PULPOSUS IN SYMPTOMATIC PARTICIPANTS
A. Elmaazi*, S. Lewis 1, C. Morse 1, I. McEwan 1
1
Exercise and Sports Science, Manchester Metropolitan University, Manchester, United Kingdom
Background:
Neck pain is a very common complaint in adults in the UK and affects people in both sedentary as well as manual occupations. The cause of neck pain is often difficult
to determine and is described as non specific in most cases. There are, however, certain anatomical structures that have been shown to cause cervical pain including
the spinal discs as well as the spinal dura and nerve roots. Although evidence of cervical disc protrusions often represent normal degenerative changes, more
significant herniations and nerve root compromise has been correlated with spinal pain and neurological symptoms.
There is one non-invasive treatment approach developed by Robin McKenzie, a New Zealand born physiotherapist, that involves a simple set of exercises specifically
aimed at reversing herniated cervical disc material. This technique takes only a few minutes to perform, can be completed independently by the patient allowing selfmanagement and incurs the cose of the appointent session with the McKenzie trained therapist only. If this treatment technique is found to cause a significant
degree of specific disc migration, it may strengthen the support for its use with patients with known radiculopathy secondary to disc herniation who have failed with
other conservative measures.
Purpose: This study was undertaken as part of a doctorate in philosophy, aimed at assessing the effects of posture on the cervical discs as well as the effects of a
specific McKenzie exercise on the posterior disc nucleus.
Methods: Twenty participants with a history of neck pain participated in this study. They were each scanned with a 0.2 T MRI scanner before and after completion of
10 McKenzie retraction-extension exercises. The PI was a trained McKenzie therapist who demonstrated and facilitated performance of the exercises.
Results: Completion of 10 McKenzie retraction-extension exercises caused an immediate, significant degree of anterior disc migration at the C5-6 disc level (p = 0.04).
Conclusion: There was a definite pattern of anterior migration of the disc at both levels post exercise, with a significant difference found in position of the posterior
nucleus at the C5-6 level. These findings help support McKenzies claim that discs are moveable structures that respond in a predictable manner to specific directional
forces.
Future work may assess the effects of McKenzies extension based exercises on a specific patient population with known radiculopathy secondary to disc herniation
that have not responded to other treatment approaches. The patient group may be taken from a neurosurgical waiting list awaiting cervical decompression.
Implications:
These results may help increase the confidence of McKenzie therapists who use this technique in an attempt to re-position herniated disc material. This study may
also encourage further use of the exercise progressions in order to increase the degree of disc migration achieved. If further studies show that these exercises are
able to reduce cervical radiculopathy through re-positioning of disc material, this may encourage the wider use of the McKenzie technique among manual therapists
and possibly reduce the number of patients on neurosurgical waiting lists.
Ethics Approval: This study was approved by the Ethics Committee of Manchester Metropolitan University.
Keywords: Anterior disc migration, McKenzie's retraction-extension exercise, Nucleus pulposus

PO1-LB-043
EFFECTIVENESS OF PAIN NEUROSCIENCE EDUCATION IN PATIENTS WITH LOW BACK PAIN MANAGED CONSERVATIVELY AND IN THOSE UNDERGOING LUMBAR
SPINAL SURGERY: A CURRENT REVIEW OF LITERATURE.
L. Wood*, P. Hendrick 1, N. Quraishi 2
1
Physiotherapy, University of Nottingham, 2Spinal, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
Background: Pain Neuroscience Education (PNE) may offer improved long term outcomes for those patients who do not attain significant pain relief with surgical
decompression. Evidence to date suggests PNE can improve patient expectation and coping strategies; factors identified as positive prognostic indicators following
surgery.
Purpose: This paper aims to review the evidence available for the use of PNE in a surgical and chronic low back pain subgroup to evaluate the efficacy when
considering outcomes over the short, medium and long term.
Methods: The following databases were searched over the period of three months between January and March 2015: Cinahl, Medline, Science Direct, Web of
Science, Scopus, Bielefeld Academic Search Engine (BASE), OpenGrey and Cochrane. All research designs were considered that included pain neuroscience education
in a chronic low back pain and surgical population. Papers which met inclusion criteria were graded according to the Oxford evidence based medicine rating, and
analysed with Cochrane risk of bias, CASP, CONSORT and PRISMA tools as appropriate.
Results: 13 papers were included; 3 papers (one RCT, one case-report, one single-subject experimental design) were specific to surgical low back pain population, and
ten papers reported on PNE in a chronic low back pain population (one systematic review, 6 RCTs, one controlled trial and 2 case reports). Most studies (n = 7/9 RCTs)
were of moderate quality (8-9/12 on the Cochrane risk of bias tool). Clinically and statistically significant changes in pain scores were seen in favour of PNE in 3 CLBP
studies in chronic low back pain populations. Five studies reported clinically and statistically significant improvements in disability. However the surgical RCT did not
show statistical or clinically significant improvements in pain or function, with mixed results demonstrated in the single-subject experimental design and
improvements noted in the case report. Only three studies reported clinical and statistically significant improvements in measures of psychological function, whilst
two studies documented a statistically significant change in physical performance over three month follow up in a chronic low back pain population.
Conclusion: The evidence regarding the utility and benefit of PNE in a CLBP group is difficult to quantify due to the heterogeneity in bothdelivery, study design and
outcome measures utilised. Although results appear promising, all studies involved had small sample sizes and employed a number of co-interventions with delivery
of PNE. Low to moderate quality evidence exists for the utility of PNE in CLBP, either in isolation or in conjunction with physiotherapeutic interventions, and group
education appears to be similarly effective.
Implications: PNE is gaining support as a useful adjunct to usual physiotherapy to improve pain cognitions, function and patient outcomes. However, limited research
exists to date to support its widespread administration. Further research is needed with larger scale trials to evaluate its utility and best practice in a surgical and
chronic low back pain population.
Funding Acknowledgements: HEEM Clinical Scholarship
Ethics Approval: Not applicable - literature review.
Keywords: low back pain, Pain neuroscience education, spinal surgery

PO1-LL-047
TRUNK KINEMATICS AND MOTOR CONTROL IN ATHLETES WITH AND WITHOUT PATELLOFEMORAL PAIN DURING A LATERAL STEP-DOWN TEST
M. Corkery 1,*, E. Cohen 1, M. Esposito 1, R. Newton 1, M. Rogazzo 1, C. Rudnick 1, B. Salanitro 1, R. Santilli 1, S.-C. Yen 1
1
Department of Physical Therapy, Movement and Rehabilitatation Sciences, Northeastern University, Boston, United States
Background: Patellofemoral pain syndrome (PFPS) is a clinically challenging condition commonly occurring in athletes. PFPS has been associated with hip muscle
weakness and altered lower extremity kinematics. However, the relationship between PFPS and trunk control is unclear.
Purpose: The purpose of our study was to examine the relationship between trunk kinematics, motor control and PFPS.
Methods: A cross-sectional design was used. A total of 20 athletes were recruited (10 healthy and 10 with PFPS) to participate in this study. All subjects completed a
questionnaire with questions pertaining to demographics, activity level, medical history, pain intensity and location. Knee pain was assessed using a numerical pain
rating scale (0-10) and function was assessed using the Lower Extremity Functional Scale. Trunk endurance and neuromuscular control were assessed using the
sidelying plank and double leg lowering tests respectively. A lateral step down test was used to assess and compare movement patterns between groups. Three
dimensional motion analysis was used to evaluate kinematics while subjects performed 3 consecutive step down movements. Ranges of upper trunk transverse
rotation, trunk abduction-adduction, flexion-extension, pelvic lateral drop, and pelvic transverse rotation in each cycle were calculated. Descriptive statistics were
compiled and linear mixed models were used to detect between-group differences in these variables. The correlation between repetitive cycles were modelled as
autoregressive (AR1).
Results: Weight, height, and body-mass index were not significantly different between the two groups. The range of trunk abduction-adduction showed a significant
between-group difference (p = 0.04; Healthy Group: 3.21.2; PFPS group: 4.72.6). No other significant differences were detected in other variables.
Conclusion: PFPS may affect trunk control in the frontal plane during a lateral step down. The presence of this altered kinematic movement pattern of the trunk may
be a significant clinical finding and associated with patellofemoral pain syndrome in athletes.
Implications: These findings may aid in the development of screening and intervention techniques to reduce the prevalence of PFPS in an athletic population. Further
research into the relationship between trunk kinematics, motor control and PFPS is needed.
Funding Acknowledgements: This study was funded by a Northeastern University Provost Office Undergraduate Research and Creative Endeavors Award. We would
like to thank the athletes who participated in the study and Kristin Kapuza and Laura Olsavsky for their assistance.
Ethics Approval: This study was approved by the Northeastern University Institutional Review Board.
Keywords: None

PO1-LL-048
THE EFFECT OF MANIPULATIVE MANUAL THERAPY, IN IMPROVING RANGE OF MOTION AND REDUCING THE INTENSITY OF PAIN IN SUBJECTS WITH ANKLE SPRAIN
- A SYSTEMATIC REVIEW
F. Silveira 1, L. Teixeira 2, L. C. Nogueira 2 3,*
1
Escola de Osteopatia de Madrid, 2UNISUAM, 3IFRJ, Rio de Janeiro, Brazil
Background: Decrease in dorsiflexion movement is a common finding after the episode of ankle sprain (AS). Joint techniques are commonly used to restore joint
mobility and decreased pain.
Purpose: this study aims to conduct a systematic review of the literatureon the effect of manual therapy in improving joint range of motion and reduced pain.
Methods: A systematic review was conducted following the PRISMA's recommendations. A search of the journals was carried out by a reviewer in PEDro databases,
Pubmed and Science Direct. Between 1999 and 2013, using the descriptors "ankle sprain" combined with "manipulation" or "mobilization". We selected only full
texts of randomized controlled trials, in English and Portuguese. Later two reviewers perform the analysis of the journals and the extraction of data and in the case of
disagreement a third reviewer could be called. PEDro scale was used for the methodological quality check. The clinical improvements seen as a
positive outcome was the range of motion and pain intensity after therapeutic intervention. Initially, forty-five articles were identified in databases. Forty articles
were excluded for not presenting information on the diagnosis, treatment modality or does not meet the eligibility criteria. Five articles were selected for analysis.
Results: The joint mobilization techniques showed satisfactory results for improved dorsiflexion range. Collins et al. (2004) demonstrated improvement in joint
mobility in 16 patients with subacute AS, after further sliding of the talus combined with active movement and weight bearing with ten repetitions in 3 sets. Bill
Vicenzino et al. (2006) also identified improvement after the completion of 10 oscillations in 4 series
using the same technique in 16 patients with chronic AS. Koon Yeo and Wright (2011) identified improved range of motion after 3 sessions in 13 subjects with AS
during subacute phase, using higher slip talus without weight bearing for 3 sets of one minute with intensity grade 3 Beazell et al. (2012) identified the similar effects
after performing sessions 4 mobilizations compared with manipulation in 43 patients with chronic AS. However, Cosby et al. (2011) do not find favorable results in 17
subjects with acute AS after a single application with the subsequent sliding of the talus intensity II and duration of thirty seconds.
For pain, reduction parameters have not been found satisfactory in the study data. Collins et al., Cosby et al. and Beazell et al., did not identify no decrease in
pain intensity. Koon Yeo and Wright (2011) found greater pressure pain threshold, but there was no difference in pain intensity by subjective evaluation.
Conclusion: Based on the results, this study suggests that joint mobilization techniques with subsequent slip associated talus or no weight bearing, increase
dorsiflexion range regardless of the intensity applied, except for cases of acute AS. However, the decrease in pain intensity remains inconclusive.
Ethics Approval: Ethical approval was not required.
Keywords: Ankle sprain, manipulative therapy, Physical Therapy

PO1-LL-049
DIAGNOSTIC ACCURACY OF NEUROPATHIC PAIN ASSESSMENT METHODS FOR THE DIAGNOSIS OF NEUROPATHIC PAIN IN KNEE OR HIP OSTEOARTHRITIS: A
SYSTEMATIC REVIEW
H. French 1,*, K. Smart 2, F. Doyle 3
1
School of Physiotherapy, Royal College of Surgeons in Ireland, 2Physiotherapy Department, St Vincent's University Hospital, 3Division of Population Health Sciences
(Psychology), Royal College of Surgeons in Ireland, Dublin , Ireland
Background: Emerging evidence suggests a possible neuropathic component to OA-related pain which is commonly determined by self-report screening
questionnaires. Guidelines were developed in 2008 by the IASP Special Interest Group on Neuropathic Pain (NeuPSIG) for grading the certainty of a diagnosis of
neuropathic pain in clinical presentations of pain, based on the presence/absence of four criteria1.
Purpose: To evaluate the diagnostic accuracy of neuropathic pain screening methods for identifying neuropathic pain in patients with knee and/or hip OA using the
NeuPSIG neuropathic pain grading system.
Methods: PubMed, CINAHL, Embase and PsychInfo databases and Google Scholar were systematically searched by two independent reviewers from 2008 onwards.
Interventional and observational studies published in English language involving human participants aged 18 or over with hip and/or knee OA were eligible for
inclusion. Diagnostic accuracy of neuropathic pain using an experimental/index test, against the diagnostic reference standard of NeuPSIG guidelines was a further
inclusion criterion.
Results: Following screening by two independent reviewers, 27 potentially eligible studies were identified; nine were available as fulltext, the majority of which were
conducted on a knee OA population. None of the full-text studies used the NeuPSIG guidelines as a reference standard to diagnose neuropathic pain. Neuropathic
questionnaires only were the most common method used to identify neuropathic pain (n=6), whilst three studies also used quantitative sensory testing. One study
assessed response to lignocaine injection as an indicator of neuropathic pain.
Conclusion: The diagnostic accuracy of assessment methods for identifying neuropathic pain in patients with hip/knee OA is unknown.
Implications: Appropriately designed studies are needed to test the diagnostic accuracy of available assessment methods in line with NeuPSIG guidelines.
References
1.
Treede RD, Jensen TS, Campbell JN, et al. Neuropathic pain: redefinition and a grading system for clinical and research purposes. Neurology. 2008;70:16301635.
Funding Acknowledgements: No funding was received for this study
Ethics Approval: No ethics approval was required for this systematic review.
Keywords: neuropathic pain, osteoarthritis, systematic review

PO1-LL-053
RELATIONSHIPS BETWEEN DIFFERENT EVALUTION TECHIQUES IN LOWER MEDIAL LONGITUDINAL ARCH SUBJETCS
A. Gomez-Conesa*, J. C. Zuil-Escobar, C. Martnez-Cepa, J. A. Martn-Urrialde
Background: The foot has important impact absorption and ground reaction force transmission functions in both gait and bipedal standing position.
The medial longitudinal arch is formed by the calcaneus, the talus, the navicular, the three cuneiform bones and the first three metatarsal bones4 and it is supported
by the plantar aponeurosis, by means of the windlass mechanism and the extrinsic and intrinsic muscles.
The evaluation of the medial longitudinal arch is neccesary in Physical Therapy. Changes in its height affect several lower limb functions and are related to lower limb
injuries
Purpose: To evaluate the correlation between the navicular drop test, the foot posture index-6 and several footprint parameters in lower medial longitudinal arch
subjects. In addition, reliability was also studied
Methods: A correlation study was carried out in 30 lower limb subjects (17 women and 13 men; 22.43.6 years). The navicular drop test, the arch angle, the Staheli
index, the Chippaux-Smirnak index and the foot posture index-6 were collected in the dominant foot. The Pearson correlation coefficients (r) and the intraclass
correlation coefficient were calculated.
Results: Strong statistical correlations (p< .05) were obtained between the navicular drop test and the footprints parameters (r=|0.650-0.722|) and between the
navicular drop test and the foot posture index (r=0.743). Excellent intrarater and interrater reliability were obtained for all the parameters (CCI=0.941-0.94)
Conclusion: The navicular drop test showed strong correlations with the arch angle, the Staheli index, the Chippaux-Smirnak index and the foot posture index-6.
Implications: The navicular dropt is an easy, reproducible and well-correlated test in lower medial longitudinal arch subjects
We have no funding research
Ethics Approval: Work approved by the Ethics Committee of CEU San Pablo University (Madrid- Espaa). All patients signed an informed consent document in
accordance with the ethical code of the World Medical Association (Helsinki Declaration).
Keywords: Foot posture index-6, Footprint, Medial longitudinal arch

PO1-LL-055
RELATIONSHIP BETWEEN MYOFASCIAL TRIGGER POINTS AND MUSCLE FUNCTION IN THE LOWER EXTREMITIES. DESCRIPTIVE AND CORRELATIONAL STUDY
A. Ruiz De Escudero Zapico, J. M. Trics Moreno*, C. Hidalgo Garca, S. Prez Guilln, E. Estbanez de Miguel, A. Casasnovas Rocha, L. Ceballos Laita, P. Pardos
Aguilella, M. Santos, L. Ventura Trallero
Background: Musculoskeletal pain is a major cause of morbidity in the current society, in which one in every three patients with musculoskeletal pain is diagnosed as
myofascial pain syndrome. The myofascial trigger points can be an independent cause of pain which is often not associated with another clinical diagnosis, but may
be related to many musculoskeletal or visceral conditions. Although some myofascial trigger points can be spontaneously painless, they can cause a restriction of joint
movement and/or cause weakness. For these reasons, it was considered relevant to perform a study to give insight about the relation between the presence of
myofascial trigger points and muscle function.
Purpose: We hypothesized that subjects with active or latent myofascial trigger points have a greater muscle shortening, decreased muscle strength and decreased
pressure pain threshold compared with subjects who do not have myofascial trigger points, so we had the aim of studying the relationship between the prevalence of
myofascial trigger points and muscle function of the lower extremities.
Methods: 54 subjects volunteered for the study, they were interviewed to determine the compliance with the inclusion criteria which mainly was the absence of
important lower extremity dysfunction. First a history taking with personal information and data such as weight, height, BMI and fat mss percentage, was performed.
After, pain and overall muscle function was assessed, by measuring muscle strength by a dynamometer, muscle length by stretching technique and goniometric
measurements and pain by an algometer of rectus femoris, hamstrings and gluteus medius muscles.
Results: The sample studies was representative of young, active and asymptomatic population, showing low values of BMI and high prevalence of myofascial trigger
points, as well as high muscle function values.
The presence of myofascial trigger points in the gluteus medius produces a decrease in the maximum isometric contraction strength of ipsilateral and contralateral
side. Myofascial trigger points are also related to a reduction in the maximum isometric force in the hamstrings.
The presence of myofascial trigger points in the gluteus and rectus femoris is related to a decrease in muscle length. Also rectus femoris myofascial trigger points are
related with an increase in the length of its antagonist's muscles, the hamstrings, suggesting an agonist-antagonist compensation pattern.
Conclusion: The presence of myofascial trigger points affects muscle function, leading to less strength of sontraction of the hamstrings and gluteus medius, and
affects in the same way in order to produce muscle shortening both of gluteus medius and rectus femoris as well as an elongation of its antagonist muscles, the
hamstrings.
Implications: Main clinical implications of the findings of this study are related to the fact that even latent myofascial trigger points can cause muscle dysfunction
such as a decreased strength and decreased length, highlighting the importance of assessing both agonist and antagonist muscles in this situations.
Ethics Approval: The study followed the Ethical Principles for Medical Research Involving Human Subjects (Helsinki Declaration, 2008).
Keywords: muscle function, myofascial trigger points, strength

PO1-MT-056
MYOFASCIAL FORCE TRANSMISSION. EVIDENCE FROM UNEMBALMED CADAVERS DISSECTIONS.
A. Pilat 1, J. Salom-Monreno 2,*, E. Castro 3, C. Fernandez-de-las-Penas 4
1
Escuela de Terapias Miofasciales Tupimek. Escuela Universitaria de la ONCE - Universidad Autnoma de Madrid, 2Departmento de Fisioterapia, Terapia
Ocupational, Rehbilitacion y Medicina Fisica, Universidad Rey Juan Carlos, Madrid, 3Departmento de Fisioterapia Facultad de Ciencias de la Salud, Universidad de
Granda, Granda, 4Departmento de Fisioterapia, Terapia Ocupacional, Rehabiliraction y Medicina Fisica, Universidad Rey Juan Carlos, Madrid, Spain
Background: In anatomical research, using a topographical approach performed on embalmed cadavers, the concept of fascia relates to some anatomical
structures such as the tensor fasciae latae, the palmar fascia and the thoracolumbar fascia. It suggests a series of unrelated elements instead of a unique and
continuous configuration that links the body structure. Such an approach makes analysis of the dissected elements difficult, when integrated into a higher level of
organization. Anatomical studies of unembalmed cadavers have provided a new perspective of the fascia, which differs from the traditional fibrous sheet that
hides the muscle. Most contractile forces are directed to myotendinous units, however, approximately 30% of them use epimismal transmission paths, parallel to
the tendinous paths. The myofascial force transmission concept involves any kind of transmission from the full surface of a myofibril, excluding the direct
participation of the myotendinous/myoaponeurosis unit. The recent research focuses on the myofascial force transmission regarding: a) spasticity and post-traumatic
and post-surgical scars in relation to movement patterns; b) intrinsic connective tissue mechanics in relation to muscular synergism paths.
Purpose: Demonstrate (using dissections of unembalmed cadavers) the continuity of the fascial structure, its correlation to other body systems and its effect on
movement (force transmission).
Methods: Anatomical dissections were performed on unembalmed cadavers preserved at 2-3C, where the fascial structure was conserved. A photographic and video
record was kept of mechanical processes, which were subsequently analyzed to assess the relevance of the fascias participation in body movement.
Results: 1) The presence of the structural continuity of the fascial system throughout the body together with parallel epimysial paths for the transmission of muscle
contractile force. 2) Numerous muscle fibers terminate their path without reaching any of the extremes of the tendon/aponeurosis. 3) Muscles are laterally
connected to the fascia that wraps adjacent structures, such as blood vessels or peripheral nerves, which could represent an important route in force transmission. 4)
The intramuscular and perimuscular connective tissue could act as a protective net in the case of a traumatic event related to the tendon or the muscular belly.
Conclusion: The existence of the structural continuity of the fascial system, which can act as a secondary pathway of force transmission affecting muscle
performance. The results are far from definitive; however, they suggest a review should be carried out of the current body movement model.
Implications: The body movement model related to the fascial system may allow new and effective approaches to be developed to treat muscle injuries and
diseases, such as muscular dystrophies, repetitive strain injury and spasticity.
Funding Acknowledgements: The work was not funded.
Ethics Approval: Ethics approval is not required.
Keywords: Fascia, myofascial force transmission, unembalmed cadaver dissections.

PO1-MT-061
TREATMENT FIDELITY: IMPLICATIONS FOR MANUAL THERAPY RESEARCH
S. Karas*, L. Plankis
Background: Treatment Fidelity (TF) involves methodological strategies to enhance the reliability and validity of the independent variable in research, improve
statistical power and produce greater confidence in the results. Components of TF have been documented in research of scientific disciplines since the 1970s. TF
contains five components: treatment design, provider training, treatment delivery, treatment receipt, and enactment of treatment skills.
Purpose: To the best of our knowledge, TF has not been implemented into Manual Therapy research and is rarely mentioned in Physical Therapy / Physiotherapy
journals. There are multiple proposed reasons why TF is not consistently monitored in research including increased time, increased cost, and increased researcher
responsibility. Our purpose was to develop and present a new TF checklist for Manual Therapists. We theorize it will improve TF, confidence in research results, and
ultimatley more efficient translation to clinical practice.
Methods: We performed a systematic review of the literature to evaluate TF and propose a new method for its utilization that will not overburden the
researcher. We utilized methods that have been effective in other scientific and healthcare fields. From this data, we constructed a simple checklist to allow
researchers to monitor TF in the key areas: treatment design, provider training, treatment deleivery, treatment receipt, and treatment skill enactment.
Results: After a literature review and assessment, we developed a TF checklist that Manual Therapy researchers can efficiently utilize. We provide this tool and
encourage its use an additional means to strengthen research conclusions so their results may be more effectively translated into practice.
Conclusion: TF has the ability to improve the quality of and strength of research. The addition of the five components of TF within our proposed check list may
improve statistical power, enhance research design, and produce increased confidence in the results researchers publish.
Implications: Strength of research design and structure enhances conclusions that are valid, reliable, and applicable to clinical practice. By using the concept of TF,
which is new to Manual Therapy, and the simple check list we have developed, research may be stregnthened allowing for stronger confidence in the results and an
increase in their translation. Thus newly emerging concepts may be held in higher regard and translated confidently into clinical practice.
Funding Acknowledgements: No funding.
Ethics Approval: No human subjects were utilized and no ethics approval was needed.
Keywords: treatment fidelity, reliability, validity

PO1-MT-062
A RANDOMIZED, PLACEBO-CONTROLLED, CARDIOVASCULAR RESPONSE COMPARISON OF UNILATERAL POSTERIOR-TO-ANTERIORLY DIRECTED MOBILIZATION OF
THE NECK IN PAIN-FREE ADULTS
E. Yung 1 2 3 4,*, M. Wong 4 5 6, M. I. Ali 7 8, T. Smith 7, E. M. Barton 4, K. Peterson 4, D. Cameron 7, J. Grimes 1, K. Ching 4, A. Sullivan 1
1
Doctor of Physical Therapy and Orthopaedic Physical Therapy Residency Programs, Sacred Heart University, Fairfield, 2Elevating Practice in Orthopaedic Physical
Therapy, MGH Institute of Health Professions, Boston, MA, 3PhD Program in Ergonomics and Biomechanics, New York University, New York, NY, 4Doctor of Physical
Therapy Program, Azusa Pacific University, Azusa, CA, 5Physical Therapy Spine Fellowship, University of Southern California, Los Angeles, CA, 6Physical Therapy Spine
Fellowship, Kaiser Permanente, Los Angeles, 7Doctor of Physical Therapy Program, Sacred Heart University, Fairfield, 8United States Army Reserve, West Hartford, CT,
United States
Background: Neck pain is a prevalent global malady. Physiotherapists apply joint mobilization (JM) as a routine, pragmatic procedure for neck pain. Perhaps because
JM is widely acknowledged as an effective intervention as concluded by multiple systematic reviews and meta-analyses. Unilateral anterior glide (UPA) is an entrylevel variant of JM. And the purported rationale of how pain modulation is attained when employing JM is expounded as a neurophysiologic
mechanism. Notwithstanding, the neurophysiologic system that alters pain overlaps with blood pressure (BP) as observed in BP-related hypoalgesia. Therefore, BP is
a pertinent and easily quantified variable to examine. Nonetheless, there is scant evidence on the cardiovascular response to UPA. Moreover, it is unsettled whether
JM produces sympatho -excitatory or -inhibitory reaction as determined by two published reports that employed central anterior glide (CPA) and unilateral posterior
pressures (AP), respectively.
Purpose: To compare the blood pressure (BP) and heart rate (HR) response of healthy volunteers to UPA applied to the neck versus its corresponding placebo (UPAP).
Methods: Two university-wide mass emails yielded 40 (17 females) healthy, pain-free participants (mean age, 23.4 1.9 years) who consented to this clinical trial.
Those enrolled have no history of syncope, no cardiovascular disease, and no cervical-shoulder pain. Thereafter, each participant was randomly allocated to 1 of 2
groups. Group 1 received a UPA-P when light touch was applied to right 6th cervical vertebra. Group 2 received a UPA to the right 6th cervical vertebra. An OMRON
automatic monitor measured the BP and HR in the following order (time points): (1) 5 minutes, (2) 7 minutes after resting supine, (3) during the first set, (4) during
the fifth set of UPA-P or UPA, (5) 2 minutes and (6) 4 minutes after the fifth set was applied. Each set consists of 10 seconds on & 10 off. Blinded to the random
allocation and the data gathered, the primary author performed UPA-P or UPA on all volunteers. ANOVA and paired-difference statistics were employed to ascertain
the BP & HR response between both groups and within each group, respectively for all time points. A research assistant followed up with the participants to see if
there is any adverse and/or side-effects at 2 weeks and again at 4 weeks.
Results: There was a significant mean difference in the following: (a) UPA SBP at time point 1 minus SBP at time point 3 [3.8 mmHg, 95% CI -5.5 mmHg and -2.1
mmHg; P < .01]; and (b) UPA SBP at baseline (time points 1 & 2) minus SBP during intervention (time points 3 & 4) [2.7mmHg, 95% CI -4.7 mmHg and -0.7 mmHg, P <
.05]. All p-values were Bonferroni-corrected. Some SBP drop (i.e. lower bounds of 95% CI) exceeded the 4.2 mmHg minimal detectable change. There were no other
noteworthy differences for the between-group and within-group comparisons. Participants did not have any adverse and/or side-effects during the follow-up periods.
Conclusion: When compared to placebo, UPA of the neck resulted in an SBP drop within the range of 0.7 to -5.5 mmHg in pain-free, healthy young adults. An
expanded benefit of these results is that they could serve as reference values that may be contrasted to those with neck pain in future research.
Implications: When executing UPA, therapists may anticipate a likely SBP drop in pain-free adults. This may exemplify a sympatho-inhibitory effect similar to that of
AP. Both UPA and AP used a distinctive dose. Consequently, this could explicate why the effect is divergent to the dominant paradigm that JM exclusively produce
sympatho-excitatory effect. Caution: the dose of UPA, similar to AP, was simply a fraction that of a CPA. In addition, it may be valuable to detect if this analogous
response would transpire in patients with neck pain in future work.
Funding Acknowledgements: Dr. Yung's PhD studies at New York University (NYU) is funded by a tuition award from the United States Government's National
Institute of Occupational Safety and Health (NIOSH/NIH) Education and Research Center Grant through NYU School of Medicine.
This research study is funded by the American Academy of Orthopaedic and Manual Physical Therapists (AAOMPT) OPTP Research Grant
Ethics Approval: The Ethics Committees of Sacred Heart University and Azusa Pacific University approved the protocol of this study. All patients signed their informed
consent.
Disclosure of Interest: E. Yung Conflict with: United States Government's National Institute of Occupational Safety and Health Education and Research Center Grant
Tuition awardee for PhD studies, M. Wong: None Declared, M. I. Ali: None Declared, T. Smith: None Declared, E. M. Barton: None Declared, K. Peterson: None
Declared, D. Cameron: None Declared, J. Grimes: None Declared, K. Ching: None Declared, A. Sullivan: None Declared
Keywords: cervical spine

PO1-PA-066
KINESIOPHOBIA AND MALADAPTIVE COPING STRATEGIES PREVENT IMPROVEMENTS IN PAIN CATASTROPHIZING FOLLOWING PAIN NEUROSCIENCE EDUCATION IN
FIBROMYALGIA/CHRONIC FATIGUE SYNDROME: POOLED RESULTS FROM 2 RANDOMIZED CONTROLLED TRIALS
A. Malfliet*, J. Van Oosterwijck 1, M. Meeus 2, B. Cagnie 1, L. Danneels 1, M. Dolphens 1, R. Buyl 3, J. Nijs 4
1
Revaki, 2Ghent University, Ghent, 3Vrije Universiteit Brussel, Brussels, Belgium, 4Revaki, Vrije Universiteit Brussel, Brussels, Belgium
Background: Many patients with chronic fatigue syndrome (CFS) and/or fibromyalgia (FM) have no understanding of their condition, leading to maladaptive pain
cognitions and coping strategies. These should be tackled during therapy, e.g. by providing pain neurophysiology education (PNE). Although the positive effects of
PNE are well-established in chronic pain populations, it remains unclear why some patients benefit more than others. Identifying predictive factors for therapy would
add great value to clinical pratice.
Purpose: This study aims at identifying pretreatment characteristics of patients that respond poorly to PNE to further improve and extend its effectiveness.
Methods: Data from two previously published RCTs were pooled to search for baseline predictors. Included subjects suffered from CFS/FM and underwent PNE
treatment. Self- reported questionnaires including the Pain Catastrophizing Scale (PCS); the Pain Coping Inventory (PCI) and Tampa Scale of Kinesiophobia (TSK) were
defined as outcome measures.
Results: There was a significant negative relationship between baseline TSK and the change in both PCS total score and PCS rumination; and between the change in
PCS total score and baseline PCI worrying and retreating.
Conclusion: Patients with FM/CFS who tend to worry allot about pain and with high levels of kinesiophobia will experience less reductions in catastrophizing following
PNE. It seems that PNE in this case is insufficient to reduce catastrophic thinking and supplementary treatment is needed.
Funding Acknowledgements: Anneleen Malfliet is a PhD research fellow of the Agency for Innovation by Science and Technology (IWT) Applied Biomedical
Research Program (TBM), Belgium.
Ethics Approval: Both original protocols were approved by the ethical committee of the University Hospital Brussels / Vrije Universiteit Brussels.
Keywords: Chronic Fatigue Syndrome, Fibromyalgia, Pain neuroscience education

PO1-SP-068
DOES TENSION OF KINESIO-TAPING PRODUCE EFFECTS IN THE UNDERLYING SOFTTISSUES OF THE THORACOLUMBAR AREA? A CROSS-SECTIONAL OBSERVATIONAL
STUDY USING ULTRASOUND
S. J. Tu 1,*, A. Khakwani 1, D. Morrissey 1 2
1
Sports and Exercise Medicine, Queen Mary University of London, 2Physiotherapy Department, Barts Health NHS Trust, London, United Kingdom
Background: Lower back pain (LBP) is a common disorder with a high recurrence and lifetime prevalence. Kinesio-Taping (KT), which is a popular therapeutic taping
techniques, are increasingly used to treat LBP, albeit with variable effects and unclear mechanisms. One study indicated that applying different tensions of Kinesio
tapes did not affect measured clinical outcomes; these results therefore challenge the proposed mechanism of action of KT therapy. However, judging effects without
clarity about the underlying mechanism of KT may confound clinical studies.
Purpose: This study aims to (i) determine the mechanism of differing KT tension on thoracolumbar tissues; and (ii) inform treatment of LBP.
Methods: Male and female asymptomatic subjects are being recruited, aged 18 - 60, Thoracolumbar ultrasound videos of known orientation and position were taken
from participants while performing velocity-guided lumbar flexion without taping and with two different tensions of KT. An automated algorithm using crosscorrelation to track contiguous tissue layers across sequential frames, in two planes, was applied to the movements of each subject in each taping condition.
Differences of tissue movements and paracutaneous translation in tissue boundaries were tested with repeated measures ANOVA.
Results: In 11 participants recruited to date, KT with lower tension significantly reduced paracutaneous translation at the boundary of the skin and superficial fascia
when compared to no taping (p<0.01). paracutaneous translation at the boundary of superficial and deeper fascia was significantly reduced when KT with lower
tension was applied, in comparison with no taping (p=0.01) and KT with higher tension (p<0.05).
Conclusion: Preliminary data yields two suggestions: (i) KT alters soft tissue dynamics during lumbar flexion, however what direction of change in tissue movement
may represent a beneficial result from applying KT is uncertain; (ii) applying different tensions of the tape in therapeutic taping KT treatment may provide various
results as the tissue effects differ systematically
Implications: Preliminary data yields two suggestions: (i) KT alters soft tissue dynamics during lumbar flexion, however what direction of change in tissue movement
may represent a beneficial result from applying KT is uncertain; (ii) applying different tensions of the tape in therapeutic taping KT treatment may provide various
results as the tissue effects differ systematically.
Funding Acknowledgements: Dr Morrissey is part funded by the NIHR/HEE Senior Clinical Lecturer scheme. This abstract presents independent research part-funded
by the National Institute for Health Research (NIHR). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the
Department of Health.
Ethics Approval: Ethical approval was granted by the Queen Mary Ethics of Research Panel (QMREC2014/24/3) on 08/04/2015.
Disclosure of Interest: S. J. Tu: None Declared, A. Khakwani: None Declared, D. Morrissey Conflict with: part funded by the NIHR/HEE Senior Clinical Lecturer scheme.
This abstract presents independent research part-funded by the National Institute for Health Research (NIHR). The views expressed are those of the author(s) and not
necessarily those of the NHS, the NIHR or the Department of Health., Conflict with: part funded by the NIHR/HEE Senior Clinical Lecturer scheme. This abstract
presents independent research part-funded by the National Institute for Health Research (NIHR). The views expressed are those of the author(s) and not necessarily
those of the NHS, the NIHR or the Department of Health.
Keywords: Kinesio Taping, lower back pain , Thoracolumbar fascia

PO2-CS-009
DO PEOPLE WITH TEMPOROMANDIBULAR DISORDER HAVE MORE CERVICAL IMPAIRMENTS THAN PEOPLE WITHOUT? A CROSS-SECTIONAL STUDY
H. Von Piekartz *, A. Pudelko, M. Danzeisen, T. Hall, N. Ballenberger
Background: Temporomandibular disorder (TMD) is an umbrella term used to define all problems affecting the temporomandibular joints and associated
musculoskeletal structures. TMD is a highly prevalent disorder and is the most common cause of non-dental orofascial pain. Cervical spine musculoskeletal
impairment may contribute to TMD due to the close anatomical and neurophysiological connections between the cervical spine and temporomandibular region.
Despite preliminary evidence, the prevalence and nature of cervical musculoskeletal impairments in TMD has not been fully investigated.
Purpose: To investigate the presence and pattern of cervical musculoskeletal dysfunction in volunteers with TMD signs (with and without pain) and in asymptomatic
volunteers without TMD signs.
Methods: Based on the Conti Amnestic Questionnaire and examination of the temporomandibular joint, patients were classified with TMD according to Axis 1 of the
Research Diagnostic Criteria for TMD (RDC/TMD). Of 144 people, 100 were classified to a TMD group with pain, 23 to TMD without pain and 21 to an asymptomatic
control group without TMD. Subjects were evaluated for cervical signs and impairment measures including the Neck Disability Index (NDI), active cervical range of
motion, the Flexion-Rotation Test (FRT), mechanical pain threshold of the Trapezius and Obliquus Capitis Inferior muscles, Cranio-Cervical Flexion test (CCFT) and
passive accessory movements (PAMs) of the upper 3 cervical vertebrae.
Results: There were a significantly greater number of cervical signs in the group with TMD and pain, compared to the two other groups. This difference was only
significant for PAMs.
Conclusion: These findings provide further evidence that the cervical spine should be examined in patients with TMD as a potential contributing factor.
Implications: The amount of cervical signs may be a prognostic and treatment indication in patients with TMD with and without pain.
Funding Acknowledgements: This study is not funded
Ethics Approval: The study was approved by the ethic commission of the University of Applied Science Osnabrck in Germany.
Keywords: cervical spine, cervico-trigeminal complex , Temporomandibular

PO2-CS-015
VALIDITY OF THE SPANISH CONSTANT-MURLEY SCORE TEST (S-CMST)
D. Saorn-Morote 1,*, A. Gmez-Conesa 2, A. Velandrino-Nicols 3
1
Physiotherapy, 2Physioterapy, 3Psychology, Murcia University, Murcia, Spain
Background: Shoulder pain is the third most common cause of consultations in primary health care for musculoskeletal problems.
The Constant-Murley Score Test (CMST) is a 100-point scoring system That is divided into four subscales: pain, 15 points; activities of daily living (ADL), 20; range of
motion (ROM), 40; and strength, 25, used to assess shoulder function, which can be applied independently of diagnosis or pathologic condition of the shoulder.
It is necessary the existence of a suitable measuring instrument liable of evaluating and detecting changes in the function of the painful shoulder, adapted to the
Spanish speaking population, capable of clinical and research implementation.
The original version (CMST) has been translated into Spanish and adapted to the Spanish population leading the Spanish Constant-Murley Score Test (S-CMST).
In this contest, it is important to evaluate the validity of the S-CMST.
Purpose: The aim of this study was to assess the validity of the Spanish Constant-Murley Score Test (S-CMST).
Methods: After making the cross-cultural adaptation of Constant-Murley Score Test (CMST), it was carried out the validation study of its Spanish version, the S-CMST.
Sixty patients (43.3% male; mean = 50.1 years; SD = 15.28), diagnosed with painful shoulder syndrome, formed the study sample.
The total score is obtained by adding the partial scores of the questionnaire regarding pain, ADL, ROM and strength, and results in S-CMST version.
In addition, all patients completed the Spanish Shoulder Disability Questionnaire (S-SDQ) to analyse the criterion validity.
Results: There is an inverse nature correlation, of medium-high magnitude between the S-CMST and the S-SDQ. This value shows that there is a statistically significant
inverse association (r = -0,683; p < 0.05) between the two tests.
The moderate-high level obtained of inverse association between the two tests is a very appropriate value because evidence that almost 50% (r2 = 0.481) of the
variability in results is common between both assessment tools.
Conclusion: After the cross-cultural adaptation, the validation process has shown that the S-CMST has good validity.
Implications: The S-CMST is a recommended instrument for use in clinical practice and research in Spanish-speaking population with painful shoulder syndrome.
Funding Acknowledgements: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Ethics Approval: This research was approved by the Ethics Committee for Research of the Murcia University (ID: 1123/2015). Murcia, Spain.
All patients signed an informed consent document in accordance with the ethical code of the World Medical Association (Helsinki Declaration).
Keywords: Constant Score, Spanish Translation, Validation

PO2-CS-024
SCAPULOTHORACIC MUSCLE ACTIVITY DURING DIFFERENT TYPES OF ELEVATION EXERCISES, BOTH IN PATIENTS WITH SUBACROMIAL IMPINGEMENT SYNDROME
AND HEALTHY CONTROLS
B. Castelein*, B. Cagnie 1, T. Parlevliet 1, A. Cools 1
1
Rehabilitation Sciences and Physiotherapy, Ghent University, Ghent, Belgium
Background: The scapula has to create a stable basis for the humerus during elevation of the arm. The surrounding scapulothoracic muscles(Trapezius, Serratus
Anterior(SA), Pectoralis Minor (Pm), Levator Scapulae(LS) and Rhomboids(RM)) are responsible for this coordinated scapular movement during elevation. Therefore,
scapular exercises with an elevation component are often included in the scapular rehabilitation program. However, until now, a comparison of both deep and
superficial scapulothoracic muscle activity between different types of elevation exercises is lacking. Also, besides the well-known changes in Trapezius and SA activity
in patients with subacromial impingement syndrome (SIS), no studies exist that have investigated the activity of the smaller less superficial scapular muscles in a
population with SIS, despite the hypothesized importance of these muscles in shoulder function.
Purpose: To evaluate scapulothoracic muscle activity during different types of elevation exercises in the scapular plane, both in healthy subjects and in subjects with
SIS.
Methods: Activity of the deeper lying (Pm,LS,RM) and superficial lying scapulothoracic muscles (Trapezius,SA) was collected with fine-wire and surface EMG in the
dominant side of
1)21 healthy subjects(10F/11M) while performing 3 elevation tasks (elevation in scapular plane, towel wall slide and elevation with external rotation using a
Theraband) without and with additional moderate load(15RM) and
2)17(F) subjects with SIS and 20(F) matched healthy subjects while performing the same elevation tasks without additional load.
A linear mixed model was used to study possible differences between (1)different elevation exercises and load, and between (2)patients with SIS and healthy subjects
Results: The UT was significantly more activated during scaption than during the wallslide (p=0,005) and the elevation with external rotation (p<0,001). Performing
elevation in the scapular plane with an external rotation component resulted in significantly higher MT and LT activity in comparison with scaption and wall slide
(p<0,001). PM and SA showed the highest activity during the towel wall slide (PM:p<0,008). The towel wall slide activated the retractors to a significantly lesser
degree (MT, LT, LS, RM)(p<0,001). Adding load resulted in higher muscle activity of all muscles (p<0,001), with some muscles(MT,LT, LS) showing a different
activation pattern between the elevation exercises pending on the loading. When comparing scapulothoracic activity between patients with SIS and healthy subjects
during the elevation exercises, the PM was significantly more active in the SIS group in comparison with the healthy controls.
Conclusion: Scaption activated UT to its highest. The addition of an extra external rotation component could be used when the goal is to activate LT and MT. The wall
slide was found to increase Pm activity. Adding load resulted in higher muscle activity. Some muscles showed a different activation pattern between the elevation
exercises pending on the loading. Patients with SIS show significantly higher Pm activity during elevation tasks in comparison with healthy controls.
Implications: The findings of this study give information about which elevation exercises a clinician can choose when the aim is to facilitate specific muscle
scapulothoracic activity.
This study supports the idea of a possible role of the PM in patients with SIS.
Funding Acknowledgements: Ghent University ( BOF)
Ethics Approval: The study was approved by the ethics committee of Ghent University Hospital.
Keywords: EMG, Exercises, Scapula

PO2-CS-028
UPPER LIMB NEURODYNAMIC TEST FOR RADIAL NERVE: A STUDY OF INTRA AND INTER RATER RELIABILITY IN AN ASYMPTOMATIC POPULATION
D. Komninos 1,*, A. Rushton 2
1
School of Sport and Rehabilitation Science, 2School of Sport, Exercise and Rehabilitation Science, University of Birmingham, Birmingham, United Kingdom
Background: Interest in the relationship between mechanical forces, mechanosensitivity of the nervous system and musculoskeletal pathologies is growing. The
Upper Limb Neurodynamic Test 2b (ULNT2b) is widely used by clinicians as an outcome measure but also as a diagnostic tool for patients experiencing neurogenic,
particularly radial nerve, mechanosensitivity. Intra and inter rater reliability are important measurement properties of outcome measures and are required for
validity. Prior to exploring reliability in a symptomatic population, it is first important to establish reliability in a healthy population. There is currently no high quality
study establishing the level of intra and inter rater reliability of the ULNT2b in a healthy population. Due to few previous low quality studies, with methodological
limitations and procedures not possible in practice evidence, a high quality study is required to assess reliability of ULNT2b.
Purpose: To investigate the level of intra and inter rater reliability of the ULNT2b as used in clinical practice without the use of external stabilisation devices in a
healthy population.
Methods: A prospective, same participant, single-session, repeated measures with double blinding of researcher and raters, intra & inter rater reliability study was
designed. Ethical approval was obtained. A sample size calculation providing discrimination between intra and inter rater (2 raters) reliabilities of 0.90 and 0.70, with
power 80% and level of significance p=0.05, estimated the required number of participants to n>19. Twenty two healthy participants were recruited via e-mail, from
students and staff (eight males aged 27.3 1.4 years and fourteen females aged 25 2.4 years, range 23-32 years) at an United Kingdom University. Two raters
assessed the ULNT2b twice on each participant, on their right upper limb, without the use of external stabilisation devices, using the Biometrics Ltd. K800
Electrogoniometer (Biometrics Ltd., Gwent, United Kingdom) to measure elbow extension range of movement. The Intraclass Correlation Coefficient (ICC(2,1)),
Standard Error of Measurement (SEM) and Smallest Detectable Difference (SDD) provided an analysis of reliability and precision, while Standard Deviations (SD) and
Differences (Diff) for the inter and intra rater measurements of elbow extension were calculated to enable comparison to previous studies.
Results: Data were analysed using the Statistical Package for the Social Sciences (SPSS, Version 19). Findings for intra rater reliability were Rater A ICC(2,1) 0.88 and
Rater B ICC(2,1) 0.80. Inter rater reliability ICC(2,1) was 0.48. Precision was acceptable owing to the low values of SEM and SDD for both intra rater (SEM Rater A 1.59,
Rater B 1.13; SDD Rater A 3.49, Rater B 2.94) and inter rater data (SEM 1.14; SDD 2.95).
Conclusion: The ULNT2b used as an outcome measure and performed by two raters without the use of external stabilisation devices in a healthy population,
demonstrated good intra rater reliability and moderate inter rater reliability. This data supports a further study using a symptomatic population to inform clinical
practice.
Implications: The findings, suggest that the ULNT2b may be a reliable outcome measure for use in clinical practice. Further work is required to establish intra and
inter rater reliability in a symptomatic population.
Funding Acknowledgements: Authors wish to thank Musculoskeletal Association of Chartered Physiotherapist (MACP) for providing funding support for this project.
Ethics Approval: Ethical approval was gained from the Ethics Committee of the School of Health and Population Sciences, University of Birmingham
Keywords: upper limb neurodynamic test, radial nerve, reliability.

PO2-CS-030
VALIDATION OF THE PECTORALIS MINOR LENGTH TEST: A NOVEL APPROACH
C. Weber*, M. Enzler, K. Wieser, J. Swanenburg
Background: Adaptive Pectoralis minor (PM) shortness has been associated with shoulder pain in athletes and is believed to promote faulty shoulder mechanics
including reduced scapular posterior tilt. A pectoralis minor length (PML) test that measures the acromion-table distance with and without manual pressure on the
coracoid process (CP) is supposed to examine the passive mechanical properties of the PM. A threshold for shortening has been set at 2.6 cm, but data regarding its
validity are lacking.
Purpose: The aim of this study was to investigate the PML test regarding (1) the reliability and setting comparability in a clinical and intraoperative setting and (2) the
construct validity through evaluation of the immediate effects of PM tenotomy. If the PM truly restricts the position of the scapula in this test, we expected the
results to be substantially lower after its tenotomy and, if the threshold valid, below 2.6cm.
Methods: Sixteen subjects with anterior shoulder instability who were undergoing open Latarjet procedures were recruited. Within the Latarjet procedure (an
established operative treatment for anterior shoulder instability) the complete tenotomy of the PM is realized due to the later transfer of the CP. We performed the
PML test (1) in a clinical setting and (2) in an intraoperative setting immediately before and after PM tenotomy. The subjects position was slightly different in the
clinical setting (supine with arms neutral and legs bent) than in the intraoperative setting (beach chair position with back of the table at 20, head on a cushion of 6cm
in height, arm held parallel by an assistant). We repeated the following measurement procedure twice at each testpoint: first with a diagonal pressure on the CP
(controlled with a handheld dynamometer) of 65Newton, second with 85Newton and third without manual pressure. The test with pressure was performed by 2
experienced physiotherapists, one applying the pressure, the other one taking the measurements of the acromion-table distance with a metal scale in mm. We used
intracorrelation coefficients (ICC) to calculate reliability and setting comparability. The effect of tenotomy was calculated by mean changes, percentages of change
and Wilcoxon test.
Results: The PML test exhibited excellent intra-tester reliability (ICC > 0.94) in both settings. The setting comparability was low to moderate (ICC 0.31-0.54). The
change following intraoperative PM tenotomy was significant (p < .008) but small (mean = 0.46-0.50 cm, 8-13%) compared to the measurement variability (standard
deviation 1.0-1.5 cm). In 12 of the 16 subjects, the measurements remained above the threshold of 2.6 cm after tenotomy.
Conclusion: The excellent reliability results in our study ensure the precondition to detect a within-group effect of tenotomy. The setting comparability was
reasonable as we had different factors influencing the intraoperative testing (subjects position, anesthetic and surgical interventions). However, there was no
systematic difference found between the two settings.
The influence of the PM on the PML test seems to be minor compared to other factors (ie thoracal and scapulothoracal structures or the table itself) that cause high
measurement variability. A threshold of 2.6 cm cannot distinguish between short and normal PMs.
Implications: The PML test (with and without manual pressure) should not be used in clinic to investigate PM shortness. Because the main scapular motion that
occures during the PML test is a posterior tilt, our findings suggest that the impact of the PM on a restricted scapular posterior tilt might be smaller than believed.
Funding Acknowledgements: none
Ethics Approval: The permission of the Ethics Committee of the Canton of Zurich was granted (KEK-ZH:2013-0349).
Keywords: Muscle length test, Pectoralis minor, Validation

PO2-LB-037
MEASUREMENT PROPERTIES OF PERFORMANCE BASED OUTCOME MEASURES ASSESSING LUMBAR SPINE ENDURANCE: A SYSTEMATIC REVIEW
S. Haslam*, N. Heneghan 1, A. Wolf 2, G. Lynch 3, R. Hair, L. Martin 3, A. Rushton 3
1
University of Birmingham, Birmingham, Timor-Leste, 2EIS - English Institute of Sport, 3University of Birmingham, Birmingham, United Kingdom
Background: Low back pain is a common problem with evidence suggesting that a reduction in lumbar spine endurance (LSE) may contribute to its onset. A number
of performance based measures assessing LSE are described in the literature and may be valuable to inform clinical evaluation. Clinicians should carefully consider the
measurement properties of ameasure before using in practice.
Purpose: To systematically review the measurement properties of LSE outcome measures in participants with and without low back pain
Methods: A systematic review was conducted according to a pre-defined protocol and is reported in line with PRISMA. Two independent reviewers searched the
Cochrane Library, EBSCO (CINAHL plus, AMED, Medline, SPORTDiscus) from inception to 30th January 2015 screening all articles by title and abstract, and then
potentially relevant articles by full text. A manual search of articles reference lists was also conducted. Contact was made with recognised and already published
authors in this area to identify unpublished work. Studies that evaluated measurement properties of at least one field based LSE outcome measure in a population of
adults over 18 years of age were included. Population disease status did not affect eligibility. Studies published in languages other than English were excluded. Data
were extracted and methodological quality evaluated using COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments)
independently by two reviewers. At each stage, a third reviewer mediated any disagreement. GRADE (Grading of Recommendations Assessment, Development and
Evaluation) was adapted to enable a qualitative synthesis of results across studies and measures
Results: Twenty five studies evaluating 22 outcome measures were included following an initial retrieval of 568 citations. Measures were catagorised into 14 groups
according to common terminology. Five measurement properties were evaluated (test-retest, inter and intratester reliability; criterion and content
validity).Reliability - Static and dynamic, flexion based measures demonstrated strong/very strong reliability. Static and dynamic, extension based measures revealed
the Ito extensor test had consistently stronger magnitudes of reliability than the Biering Sorensen (BS) and prone double straight leg raise test although
methodological quality ranged from poor to fair. The side bridge and flexion rotation trunk test explored reliability and reported very strong magnitudes. Criterion
Validity -Electromyography and isokinetic dynamometry were used as gold standards for a number of the measures. Changes were found in physiological markers of
fatigue across all the studies with further detail on the exact muscle groups tested also documented for example, median frequency slope decrease in lumbar
paraspinal muscles was more than in glute max or bicep femoris muscle groups for biering sorensen test or physiological markers of fatigue, most significantly in the
ipsilateral external oblique and contralateral erector spinae for the lateral hold on roman chair. Content Validity - The ITFT, abdominal static endurance test, BS and
Ito extensor test found correlation between performance and measures of psychosocial components; both of which were rated excellent.
Conclusion: A number of measures require further research to evaluate the essential measurement properties more comprehensively. Measures that assess the
lateral flexors statically and rotators dynamically should evaluate the criterion and content validity, measurement error and responsiveness.
Implications: The ITFT is recommended in practice however this measure requires criterion validation. The Ito extensor and BS test were the most comprehensively
evaluated measures in relation to the essential measurement properties with the Ito extensor test the recommended test when wanting to assess the extensors
statically, with regards to LSE.
Funding Acknowledgements: Nil
Ethics Approval: Nil
Keywords: lumbar spine rehabilitation, performance based outcomes, Systematic review

PO2-LB-045
AN AUDIT OF THE ADHERENCE TO THE NICE GUIDELINES FOR LOW BACK PAIN IN WESTERN SUSSEX HOSPITALS NHS TRUST OUTPATIENT DEPARTMENT
A. Kemp*
Background: Back pain costs the UK National Health Service an estimated 481 million (Office of National statistics, 2013). The NICE guidelines for the early
managment of persistent non-specific low back pain (NSLBP) (2009) were developed as UK national guidance by a panel of experts including doctors, physiotherapist,
chiropractors, nurses and psychologists. The guidelines recommended that all patients with NSLBP should be offered one of the following treatment options; advice
and reassurance; an exercise programme (either group or individual); manual therapy or a course of acupuncture. Previous audits in the same department had shown
that physiotherapists were not always recording all treatments that had been offered, especially advice and exercise. Previous audits had shown that staff were not
offering therapies that were not recommended in the guidelines such as electrotherapy or traction.
Purpose: As a result of previous audits, new notes were designed to facilitate recording of treatment interventions set against NICE guidance. This audit was
undertaken to measure the effect of introducing the new paperwork on compliance with NICE guidelines. Standards were set, with the expectation that 100% of
patients would have been offered treatment in line with the guidelines and that this would have been recorded in 100% of the patients notes.
Secondary objectives included using this audit as part of the wider hospital Trust's audit profile, and part of the body of evidence of governance and quality within the
physiotherapy service.
Methods: A total of 60 sets of notes with a diagnosis code of LBP were randomly selected for auditing. After completing previous audits a simple audit sheet had
been developed using a tick list of the audit categories which was placed on the reverse of the front sheet in the notes to make the auditing process easier.
Results: 100% of patients were offered at least one of the recommended treatments. 68% of patients audited were offered more than one of the recommended
treatments.
Conclusion: One hundred percent of the patients audited had been offered at least one of the treatment options recommended in the 2009 NICE guidelines. This
showed a vast improvement on the previous audit figures, supporting the decision to change the physiotherapy notes.
The 2009 guidelines are currently being updated and are due to be pulished in September 2016. After reviewing the new guidelines it will be determined if our
departmental standards will need to change and whether the focus of future audits will need to be adapted after any changes in practice have had a reasonable time
frame to become embedded in practice. The focus of the physiotherapy department on audit related to the national guidelines has helped raise the profile of the
department within the trust in terms of quality and governance and has helped to establish a leading role for staff in audit within the organisation.
Ethics Approval: Not required.
Keywords: None

PO2-LB-046
TO INVESTIGATE PATIENT BELIEFS REGARDING LOW BACK PAIN (LBP) FOLLOWING CONSERVATIVE PHYSICAL REHABILITATION: A SYSTEMATIC REVIEW
J. Hurley 1,*, M. O'Keeffe 1, A. Synnott 1, S. Bunzli 2, W. Dankaerts 3, P. O'Sullivan 2, K. O'Sullivan 1
1
Clinical Therapies, University of Limerick, Limerick, Ireland, 2Physiotherapy and Exercise Science, Curtin University, Perth, Australia, 3Rehabilitation Sciences, KU
Leuven, Leuven, Belgium
Background: Several studies have demonstrated that negative patient beliefs are closely related to current and future LBP disability. Therefore, it has been proposed
that a key component of rehabilitation should be targeting inaccurate beliefs about LBP. This would include challenging beliefs such as; exercise and activity are
dangerous; advanced radiological imaging is useful for LBP; the prognosis for LBP is bleak. Studies have discovered that healthcare professionals sometimes struggle
with the challenge of positively altering patients beliefs. Therefore, it is unclear if negative beliefs are altered following conservative physical rehabilitation.
Purpose: This systematic review aimed to examine patients LBP beliefs following conservative physical rehabilitation and determine if they were positive or negative.
Methods: Six electronic databases were searched by two authors independently. The search strategy used keywords relating to; (i) qualitative research, (ii) LBP, (iii)
beliefs and (iv) rehabilitation. Studies were included where the beliefs of patients with non-specific LBP were examined qualitatively after physical rehabilitation. Data
regarding patient characteristics, description of rehabilitation, sample size, data collection methods, study aims and key findings were extracted by two authors
independently. Two authors independently assessed methodological quality using the Critical Appraisal Skills Programme. Themes were identified using a three-stage
inductive thematic analytic process by two authors independently and cross-checked to ensure accuracy.
Results: Three themes emerged; (1) Beliefs about exercise and activity most patients believed that exercise was helpful. However, most moved more carefully than
normal, and some activities were still deemed unsafe; (2) Beliefs about nature of the condition while not as focused on finding a cure, LBP was still mostly
considered to reflect spinal tissue damage; (3) Beliefs about future of the condition patients were quite pessimistic about their future prognosis.
Conclusion: Patient beliefs regarding the benefit of activity over rest are positive after physical rehabilitation. However, many patients are still fearful of normal
movement, the extent of damage to their spine and their future prognosis, which may be important targets for rehabilitation. Future studies need to investigate why
some, but not all, beliefs are changed following an intervention.
Implications: The study highlights that patients maintain some negative beliefs following rehabilitation, and these beliefs may require greater emphasis during
rehabilitation.
Keywords: Beliefs, low back pain, qualitative research

PO2-LL-048
DO PARTICIPANTS WITH MEDIAL TIBIAL STRESS SYNDROME HAVE PLANTARFLEXOR MUSCLE WEAKNESS?
A. Swani*, S. O'Neill
Background: Medial tibial shin splints (MTSS) is one of the most common lower limb injuries amongst athletes. Muscle weakness and fatigue is an identified risk
factor but there is a significant lack of research on this topic.
Purpose: To compare the Plantarflexor muscle strength between subjects with MTSS and healthy controls.
Methods: The isokinetic Plantarflexor strength of 12 subjects with MTSS and 12 healthy control subjects was measured using 3 different tests. Tests were completed
using concentric speeds of 90/s and 225/s, and an eccentric speed of 90/s. Plantarflexor strength of each participant, peak torque represented as percentage of
body weight (%BW) was recorded.
Results: The results show a clear difference between the MTSS and control group for all test speeds. Concentric 90/s MTSS group 53.92%BW versus control group
88.33 %BW (p = <0.002), 225/s MTSS group 36.50 %BW versus control group 67.00 %BW (p = <0.001) and for the eccentric speed of 90/s MTSS group 78.59 versus
control group 177.42 (p = <0.001). Participants with MTSS displayed weaker plantarflexors compared to an age matched group of controls.
Conclusion: The study has highlighted a significant difference in plantarflexor power between subjects with MTSS and age matched controls. In order to rehabilitate
subjects with MTSS it will be important to improve plantarflexor strength. Plantarflexor strength may play an integral part in shock absorbing capacity of the limb
during locomotion. Further research is required to investigate the cause:effect relationship between plantarflexor strength and MTSS.
Implications: This study has highlighted areas for further research. Therapists need to consider Plantarflexor strength when rehabilitating MTSS patients.
Plantarflexor strength warrants further research using longitudinal study designs.
Funding Acknowledgements: This project was not funded.
Ethics Approval: Approved by Coventry University Ethics and the University of Leicester Research Ethics committees.
Keywords: Medial Tibial Stress Syndrome, Plantarflexors, Weakness

PO2-LL-049
BLOOD FLOW RESTRICTION TO LOWER BODY INDUCES ANALGESIA IN PATIENTS WITH ANTERIOR KNEE PAIN
V. Korakakis 1 2,*, R. Whiteley 2, K. Epameinontidis 2
1
HOMTD, Hellenic Orthopaedic Manipulative Therapy Diploma, Athens, Greece, 2Orthopaedic and sports medicine hospital, Aspetar, Doha, Qatar
Background: Exercise is seen to be an effective intervention for anterior knee pain (AKP) however pain can be a significant barrier to its application. Mounting
evidence supports that blood flow restriction (BFR) combined with low-load exercise training can induce muscle morphological changes, enhance strengthening
responses, and attenuate muscle atrophy after immobilization. Anecdotally we noticed a reduction in AKP after application of BFR. To our knowledge this effect has
not been examined formally.
Purpose: The primary objective of this study was to determine if a single acute BFR-exercise bout would induce immediate significant pain reduction in patients with
AKP. The secondary objective was to assess the short-term effect of BFR on pain after a physiotherapy/rehabilitation session (45 minutes).
Methods: This single-blinded, cross sectional study assessed the effect on pain of a BFR-exercise bout, immediately after application, and after a single physiotherapy
session aiming motor control and muscle strength exercises in AKP patients. BFR pressure used was set at 50% of complete blood flow occlusion. The protocol used
included four sets of low-load open kinetic chain knee extensions and the parameters were individualized in terms of resistance according to tolerance. Outcome
measures were pain during bilateral and single-leg squat (0-10), and step-down test (0-10). To estimate the patient rating of clinical effectiveness, previously
described thresholds for change in pain were used, with appropriate adjustments for baseline levels of pain. Data were analysed using repeated measures analysis of
variance (ANOVA). The level of significance after Bonferroni adjustment was set at 0.017.
Results: 25 patients with AKP participated. Significant effects were found with greater pain relief immediate after BFR in two different tests of bilateral leg squat and
single-leg squat (p<0.017), as well as after step-down test (p<0.017). Time analysis revealed that pain reduction, although decreased in mean difference, was
sustained after the physiotherapy session at 45 minutes post-BFR application (p <0.017). The reduction in pain effect size was found to be clinically significant in both
post-BFR assessments.
Conclusion: A single BFR-exercise bout immediately reduced AKP with the effect sustained for at least 45 minutes. Further studies are needed to assess the optimum
parameters of BFR-exercise bout and to evaluate the long-term effect not only in pain reduction, but in the clinical improvement of symptoms with
physiotherapy/rehabilitation.
Implications: Interestingly, we found no non-responders to BFR-exercise bout in any case of symptoms duration, type of pathology and severity of pain. The most
important clinical implication is that BFR-exercise bout can be used to reduce pain and provide a window of opportunity for clinicians to work with AKP patients in
terms of motor control and muscle strengthening.
Funding Acknowledgements: none
Ethics Approval: This pilot study was conducted in accordance with the Declaration of Helsinki (2013). Blood flow restriction exercise is a standard clinical practice in
our hospital. Patients give an informed consent for practices used in our organization. Ethics application has been submitted and is ongoing with a decision expected
on 30th of December.
Keywords: analgesia, anterior knee pain, blood flow restriction

PO2-LL-050
THE EFFECT OF PATELLAR MOBILISATION ON PATELLAR POSITION, PAIN AND KNEE EXTENSOR STRENGTH IN PATELLOFEMORAL PAIN PATIENTS
L. Herrington*
Background: Historically, it has been generally agreed that the main cause of patellofemoral pain is altered tissue loading stresses created by patellofemoral joint
mal-tracking and position which alters internal tissue homeostasis of this joint creating pathology and pain. The cause of the mal position-tracking of the patella has
been described as multi-factorial, influenced proximally from the thigh and pelvis and distally from the foot. Little recent research attention has been focused locally
on patella position itself or how treatment of patella position influences patients symptoms.
Purpose: The aim of this study was to focus on the effect of local treatment of patella position on patellofemoral pain and knee extensor strength. Specifically, to
examine the effects of patella mobilisation on pain, knee extensor strength and patella position
Methods: 12 females with patellofemoral pain (aged 24+/-3.2 years) participated. All subjects had their patellar position measured using real time ultrasound
scanning using a previously established method prior to and following patella mobilisation. All subjects also had their knee extensor strength tested using a handheld
dynamometer at 90 degrees knee flexion prior to and following mobilisation. Whilst undertaking maximal isometric quadriceps contraction a pain score was recorded
using a 10cm visual analogue scale. The patellar mobilisation technique applied was a medial tilt, with the knee supported in 20 flexion. Pressure applied through the
thenar eminence to the medial side of the patella, so tilting the patella medially until resistance was felt , small amplitude oscillations were then undertaken
continuously for 2 minutes keeping the movement into tissue resistance the whole time.
Results: Patella position changed significantly (p=0.003) average position pre intervention was 6.2+/-1.3mm post intervention 9.2+/-0.9mm. Knee extensor strength
changed significantly following the intervention (p=0.025) average strength improving from 53.3+/-5.1kg to 63.5+/-9.1kg. The pain score during isometric contraction
also improved following intervention (p=0.001) with pain reducing from on average 5+/-1.3cm to 1.1+/-1.1cm.
Conclusion: A single intervention of patella mobilisation had a significant effect on subjects with patellofemoral pain, and caused knee extensor strength and pain
during quadriceps contraction to be significantly improved. This may have been caused by the significant change in patella position also reported within this study
Implications: As patellofemoral pain is often characterised by patients having quadriceps weakness and pain an intervention which is able to ameliorate these is
obviously of significance in the management of this condition
Funding Acknowledgements: Work was unfunded
Ethics Approval: Ethical approval was granted by the University of Salford research ethics committee
Keywords: mobilisation, patella, strength

PO2-LL-051
VALIDITY OF CLINICAL ASSESSMENT COMPARED WITH PLANTAR FASCIA THICKNESS ON ULTRASOUND FOR PLANTAR FASCIITIS: A CROSS-SECTIONAL STUDY
R. Fagan 1, V. Cuddy 2, J. Ashton 2, M. Clarke 2, H. French 1,*
1
School of Physiotherapy, Royal College of Surgeons in Ireland, 2Physiotherapy Department, Beaumont Hospital, Dublin, Ireland
Background: Plantar fasciitis (PFS) is a degeneration of the plantar aponeurosis in the foot. Ultrasound (US) can be used as a diagnostic imaging technique for this
condition, with similar diagnostic accuracy to Magnetic Resonance Imaging (MRI). Common factors associated with plantar fasciitis include increased Body Mass Index
(BMI), reduced ankle dorsiflexion and increased foot pronation.
Purpose: This study aimed firstly to determine the diagnostic utility of the clinical diagnosis of PFS compared with US examination, and secondly, to determine the
relationship between a range of symptom-related and physical examination items and US-diagnosed PFS.
Methods: This cross-sectional study was approved by the Ethics (Medical Research) Committee Beaumont Hospital (REC 14/54). Patients referred from orthopaedic
and rheumatology clinics were screened for eligibility and informed consent was obtained. Clinical criteria were based on presence of medial heel pain for a minimum
of six weeks, aggravated by rising or initial weight bearing after inactivity (1). Study participants underwent clinical and US examination by two independent blinded
assessors. PFS was determined on US by measuring plantar fascia thickness. The following characteristics were recorded: BMI, foot type (pronated, supinated,
neutral) and ankle dorsiflexion range (prssence of equinus). Diagnostic accuracy was determined by estimating sensitivity and specificity of clinical criteria against US
measurement (gold standard). Mann-Whitney U tests and Chi-squared analyses were used to compare differences in symptom-based and physical examination
variables between those with and without PFS. All statistical analyses were undertaken in SPSS v22 (IBM corp).
Results: Fourteen participants (28 feet) were recruited. Sensitivity and specificity of clinical diagnosis compared to US was 62.50% (95% Confidence Interval
(CI):35.43-84.80%) and 58.33% (95% CI:27.67-84.23%), respectively. Increased body weight was significantly associated with PFS (p=0.04). 75% of those with USdiagnosed PFS had altered biomechanics compared to 92% of those negative for PFS by US. Equinus was present in 87.5% of US-diagnosed PFS patients, and 83.3% of
participants with a negative diagnosis of PFS (p=0.27).
Conclusion: Clinical diagnosis demonstrated only moderate diagnostic accuracy for PFS compared with PF thickness as measured with US. Weight was significantly
associated with PFS. Foot type and reduced dorsiflexion may have an association with foot pain, but not PFS alone. The small sample size may partially explain the
results
Implications: Clinical assessment alone may not be sufficient in ruling in or ruling out PFS. Further clinical criteria may have to be investigated to aid in identification
of PFS for both targeted treatment clinically, and to aid recruitment in future research.
References
(1) McPoil TG et al. Heel pain-plantar fasciitis: clinical practice guildelines linked to the international classification of function, disability, and health from the
Orthopaedic section of the APTA. J Orthop Sports Phys Ther. 2008; 38(4):A1-a18.
Funding Acknowledgements: This research was funded by a Health Research Board (HRB), Ireland Undergraduate Summer Student Research grant.
Ethics Approval: Ethics approval was obtained from Beaumont Hospital Medical Research Ethics Committee.
Keywords: diagnostic accuracy, plantar fasciitis, Ultrasound Imaging

PO2-LL-052
CAN ULTRASOUND TECHNOLOGY PREDICT THE DEVELOPMENT OF ACHILLES AND PATELLAR TENDINOPATHY?: A SYSTEMATIC REVIEW OF THE LITERATURE
S. Mc Auliffe*, K. Mc Creesh, K. O'sullivan, H. Purtill, F. Culloty
Background: Ultrasound is commonly used to visualise tendon dimensions. In many athletes ultrasound imaging of the patellar or Achilles tendons will reveal
morphological abnormalities, typically localized tendon thickening with hypoechoic areas and increased vascularity. It is not clear whether the presence of ultrasound
changes in asymptomatic tendons precede (and predict) future tendon problems or just a normal physiologic response or necessary adaption by athletes to sport
specific loading demands.
Purpose: To systematically assess the evidence regarding the ability of ultrasound technology to predict future symptoms of patellar or Achilles tendinopathy.
Methods: Eight electronic databases (Academic Search Complete, AMED, Biomedical Reference Collection, Cinahl, Medline, Sportsdiscus, Web of Science and
Embase) were searched using an agreed set of keywords. Prospective studies that performed ultrasound measurement of tendon dimensions at baseline and at a
follow up in addition to a clinical measure of pain and/or function were included.
Results: 20 studies were included for final review. All participants in the review were sporting populations. Athletes with tendon abnormalities in the form of
hypoechoic areas are more likely to develop symptoms than normal tendons. In tendons with hypoechoic areas, 1236% of these tendons with abnormalities go on
to become symptomatic, while 0-7% of normal tendons in athletic populations develop symptoms.
Conclusion: Results of this review indicate tendon abnormalities in the form of hypoechoic areas using ultrasound imaging are weakly predictive of the development
of patellar or achilles tendinopathy in sporting populations.
Implications: Findings of this review may have potentially important implications for management of sporting populations at risk of developing achilles or patellar
tendinopathy. Identification of at risk athletes using screening tools such as ultrasound may allow preventative programs to be implemented. However these findings
should be interpreted in light of an athletes complete clinical presentation.
Funding Acknowledgements: No funding has been received for this study.
Keywords: Prediction, Tendinopathy, Ultrasound Imaging

PO2-LL-054
PATIENTS EXPERIENCES OF PARTICIPATING IN AN EXERCISE GROUP AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION (ACLR)
F. Poget*
Background: Anterior cruciate ligament reconstruction (ACLR) has a high incidence and results in significant costs for healthcare. Despite reported successful physical
outcomes, such as knee range of motion, strength and stability, only half of patients are able to return to their preinjury level of sport participation. While suboptimal
physical outcomes may partially explain these less than satisfactory results, there is growing evidence that social and contextual factors contribute to patients
achieving their preinjury level of activity (Lee et al, 2008). Motivation, adherence to rehabilitation, social support, fear of re-injury and self-efficacy seem to be
essential to attain successful recovery following ACLR. Group therapy has been suggested to provide physical and these psychosocial benefits to individuals affected
by other pathologies such as osteoarthritis and peripheral neuropathy (McCarthy et al., 2004; Powell-Cope et al., 2014). This project explores how physiotherapists
can address these factors in an ACLR group setting.
Purpose: The aim of this study was to explore the patients perceptions and experiences of participating in a weekly exercise group following ACLR and to investigate
the impact on their rehabilitation. The research was carried out as a Master degrees dissertation and as part of the service development of the clinic where the ACLR
group took place.
Methods: Hermeneutic phenomenology was used to explore the experience of nine participants, recruited from the clinic where the ACLR exercise group took place.
Two focus groups, following a semi-structured outline and facilitated by a moderator and an independent observer occurred in summer 2015. Data was transcribed
and analysed using thematic analysis.
Results: Three males and six females aged 21 to 57 years old (median: 30) engaged in the study. Four considered themselves as sedentary, the other six reported
participating in sports, such as handball or running, at a preinjury rate of two to five trainings per week. Three major themes emerged from the data: psychosocial
factors, identity of the ACLR group and physical outcomes. The group influenced the participants motivation, enjoyment and commitment to exercise during the
rehabilitation. Social support and reassurance were mostly gained. The participants taking part in sport experienced the ACLR group as a substitute for sport trainings.
The group was further suggested to enhance speed of recovery and facilitate the return to normal life, especially for participants with lower reported motivation and
adherence to home-exercises. The challenging role of the physiotherapist was highlighted as well as the promotion of shared accountability between patients and the
groups therapist. Moreover, the ACLR groups identity was questioned within the rehabilitation process, and the need for more transparency about roles was
suggested for all stakeholders, including patients, physiotherapists, surgeons and health insurers in order to promote group therapy in the Swiss healthcare context.
Conclusion: Participating in an exercise group therapy is perceived as increasing motivation, self-confidence, social support and helps enhance a faster successful
recovery and return to normal life following ACLR. Our findings indicate that participants with a lower reported adherence to home-exercises especially benefit from
it. For future research, a quantitative or mixed methods approach would be appropriate to assess the cost-effectiveness and the benefits of an exercise group
therapy.
Implications: The ACLR exercise group can help participants to overcome difficulties with regard to motivation and exercise adherence encountered during their ACLR
rehabilitation. Better transparency of roles and information should be provided to all stakeholders to facilitate its implementation.
Funding Acknowledgements: No funding was involved in this study.
Ethics Approval: The research proposal was approved by the ethics and governance committee of the University of Brighton and by the relevant organisation in
Switzerland.
Keywords: anterior cruciate ligament reconstruction (ACLR), group therapy, hermeneutic phenomenology

PO2-LL-055
VALIDATION OF THE LATERAL ANTERIOR DRAWER TEST FOR EXAMINING POSTERIOR CRUCIATE LIGAMENT INTEGRITY IN CADAVERIC KNEES
G. Seeber 1, M. Wilhelm 2, O. Matthijs 2, G. Windisch 3, P. Sizer 2, B. Reichert 4,*
1
Orthopedics, Carl von Ossietzky University Oldenburg, Oldenburg, Germany, 2Texas Tech University Health Science Center, Lubbock, Texas, United States, 3Praxis f.
Manuelle Medizin, Graz, Austria, 4Carl von Ossietzky University, Oldenburg, Germany
Background: Clinicians are often unable to identify posterior cruciate ligament (PCL) ruptures through common clinical tests. This leads to undetected tears and
potential degenerative changes within the knee joint (e.g. irreversible cartilage damage). The lateral-anterior drawer (LAD) test is distinguished from the more
common clinical tests by its lateral-anterior testing force direction and has been proposed for the diagnosis of PCL-ruptures. However, it has not yet been validated.
Purpose: To assess the construct and concurrent validity of the LAD test.
Methods: Eighteen cadaveric knees (36-94 years old; mean = 79 years), embalmed according to the method of Thiel, were sectioned from pelvis to foot. With skin
and subcutaneous tissue removed, threaded markers were inserted into the distal femur and proximal tibia. Each femur was stabilized and the tibia was translated in
lateral-anterior direction for the LAD, versus straight posterior for the posterior sag sign (PSS). Each test was repeated three times with the PCL both intact and cut in
that order. Digital images were captured at start and finish positions during each trial. Tibial marker translation during each trial was digitized using the MATLAB
Program. Means and standard deviations were established for each condition. The PSS values were used as a reference standard for establishing LAD concurrent
validity.
Results: Tibial translation was significantly greater with the PCL cut versus intact during the LAD (u=-3.680; p<0.002) and PSS (u=-3.724; p<0.002) tests. There was no
significant difference between the changes in tibial translation after the PCL was cut during the LAD versus PSS tests (t=2.029; p=0.07).
Conclusion: The LAD test detected changes in tibial translation corresponding with changes in PCL integrity, supporting test construct validity. The LAD test was at
least as effective for assessing PCL integrity as the PSS test, supporting test concurrent validity. The use of the LAD test may be best suited when: (1) joint end-feel is
important to the diagnosis; (2) increased muscle tone accompanies the knee injury and hinders an accurate PSS test use; and (3) the tester is rather inexperienced.
Furthermore, positive LAD and PSS tests could be clustered to strengthen PCL tear diagnostic suspicions. Further studies are needed to determine intra- and intertester-reliability of the LAD test.
Implications: Adding the LAD test to the diagnostic algorithm in PCL tear diagnostic suspicions may be conducive to detect PCL tears more precisely and hence
preserve patients from subsequently developing irreversible cartilage damage due to knee laxity.
Funding Acknowledgements: This project was unfunded.
Ethics Approval: Medical ethical approval has not been necessary to conduct this trial.
Keywords: Clinical Diagnostic, Drawer Test, Posterior Cruciate Ligament

PO2-MT-060
THORACIC MANIPULATION AND ADJUVANT EXERCISE AS A COMPONENT OF POSTOPERATIVE ROTATOR CUFF REPAIR REHABILITATION: A CASE REPORT
E. Chaconas 1,*, B. Mcintosh 2
1
Doctor of Physical Therapy, University of St. Augustine, St. Augustine, 2Active Life and Sports Physical Therapy, Towson, United States
Background: Compromised movement of the scapulae and thoracic spine are considered to be impairments associated with rotator cuff pathology. Outcomes
following rotator cuff repair vary with up to 90% of surgical repairs subsequently failing. Interventions targeting potential causative impairments such as decreased
thoracic spine mobility and poor periscapular motor control can be beneficial.
Purpose: The purpose of this case report is to describe the physical therapists management of a patient after rotator cuff repair, utilizing thoracic spine manipulation
and periscapular motor control, to restore function of the shoulder complex.
Methods: A 62-year-old female presented to the physical therapist with a complete tear to the supraspinatus tendon that was surgically repaired. The patients
limitations included inability to perform overhead reaching, limited shoulder function as measured by a score of 35% on the shoulder pain disability index (SPADI) and
8/10 pain measured with the numeric pain rating scale (NPRS). Thoracic spine manipulation and periscapular motor control exercises were initiated during postoperative week 3 and progressed over the course of eight weeks.
Results: Results indicated improved mobility, strength, and motor control of the shoulder complex. The SPADI improvement to 35% and NPRS improvement to 2/10
pain both exceed reported values of minimal clinical important difference.
Conclusion: Integrating thoracic manipulation and periscapular motor control exercise aided in the restoration of function and reduced pain during post-operative
rotator cuff repair rehabilitation. Further research is needed to establish the cause and effect relationship for interventions targeting the thoracic spine and scapulae
in cases of post-operative rotator cuff repair rehabilitation.
Implications: The benefit of thoracic manipulation for subacromial pain syndrome has been established and clinicians should consider investigating the use of these
techniques for patients recovering from rotator cuff repair surgery.
Funding Acknowledgements: No fudnging support was provided for this project.
Ethics Approval: Ethics approval was not required for this retrospective case report but the patient did provide consent for the use of clinical data.
Keywords: Manipulation , Rotator cuff, Shoulder pain

PO2-PA-063
I KNOW WHAT I WANT BUT IM NOT SURE HOW TO GET IT-EXPECTATIONS OF PHYSIOTHERAPY TREATMENT OF PERSONS WITH PERSISTENT PAIN
T. Calner 1,*, G. Isaksson 1, P. Michaelson 1
1
1Division of Health and Rehabilitation, Department of Health Science, Lulea University of Technology, Lulea, Sweden
Background: Expectations of physiotherapy treatment of patients with persistent pain have been shown to influence treatment outcome and patient satisfaction, yet
this is mostly explored and described in retrospective.
Purpose: The aim of the study was to explore and describe the expectations people with persistent pain have prior to physiotherapy treatment.
Methods: Ten participants with persistent musculoskeletal pain from the back, neck, or shoulders were included in the study. Data were collected by interviews using
a semi-structured interview guide and were analysed with qualitative content analysis.
Results: The analysis resulted in one main category: The multifaceted picture of expectations and four categories: Standing in the doorway: curious and uncertain;
Looking for respect, confirmation and knowledge; Expecting treatment, regular training, and follow up; and Having dreams, being realistic, or feeling resigned.
The main category and the categories describe a multifaceted picture of the participants expectations, gradually developed and eventually encompassing several
aspects: good dialogue and communication, the need to be confirmed as individuals, and getting an explanation for the pain. The results also show that the
participants expected tailored training with frequent follow-ups and their expectations of outcome ranged from hope of the best possible results to realistic or
resigned regarding pain relief and activity levels.
Conclusion: The results show a multifaceted picture of the participants expectations, which encompass several different aspects: good dialogue and communication,
the need to be seen and confirmed as an individual, and a desire to receive an explanation for the pain. The result also shows that the participants expect individually
tailored training programs with frequent follow ups as part of the treatment and that they have ideal as well as realistic expectations regarding the outcome in terms
of pain relief and increased activity.
Implications: he initial question tell me about your expectations needs to be followed by additional questions to gain a more thorough insight of patients
expectations, which could be regarded as a beneficial start of the physiotherapy treatment process. Our findings emphasize the clinical benefits of giving each patient
the best and most comprehensive information regarding their problems. Our findings suggests that the participants wanted individually tailored training programs.
They emphasized the importance of regular follow ups to training and adjustments of exercise and they were aware of their own responsibility to do the presumed
exercises. Taking this into account makes way for a good foundation in establishing the treatment contract between patient and physiotherapist. If the patients
desired and acceptable expectations of treatment outcome are addressed early in the first interview, it might be possible to make these expectations clear to the
patient and the physiotherapist, which eventually can be useful in establishing treatment goals (ideal) and sub goals (desired, acceptable).
Ethics Approval: The study was approved by the regional ethics review board in Umea, Sweden (reference DNR 2013-11-31M).
Keywords: expectations, persistent pain, physiotherapy treatment

PO2-PA-067
CLINICAL PRACTICE GUIDELINES FOR THE MANAGEMENT OF CHRONIC MUSCULOSKELETAL PAIN IN PRIMARY HEALTH CARE: A SYSTEMATIC REVIEW
D. Ernstzen 1,*, S. Hillier 2, Q. Louw 1
1
Physiotherapy, Stellenbosch University, Cape Town, South Africa, 2School of Health Sciences, University of South Australia, Adelaide, Australia
Background: Chronic Musculoskeletal (CMSK) pain and its management present a challenge to patients, clinicians and communities. The prevalence of chronic pain is
high and increasing and a large proportion of patients are managed in primary health care (PHC). Up-to-date, high quality, evidence-based clinical practice guidelines
(CPGs) that are applicable for PHC are vital to assist clinicians in making decisions about the care process of patients with CMSK pain. When considering the
development of a CPG for the management of CMSK pain in PHC, it is important to consider the option to adopt, adapt or contextualize existing CPGs. These options
are important to limit duplication of effort and use of resources.
Purpose: The aim of this systematic review was to systematically identify and appraise the available evidence-based CPGs for the holistic management of adults with
CMSK pain in PHC settings. This process was needed to inform further guideline development.
Methods: A systematic review was conducted. Twelve guideline clearinghouses and six electronic databases were searched during May 2015 for eligible CPGs
published between years 2000 to October 2014. The CPGs meeting the inclusion criteria were appraised by four reviewers using the Appraisal of Guidelines Research
and Evaluation (AGREE) II. The content analysis of CPGs was limited to those with good methodological quality. The principle investigator extracted the
recommendations into a matrix. The process was verified by a research assistant and audited by the co-authors.
Results: Of the 1081 CPG records identified, 32 were eligible, and 12 CPG were included based on the inclusion and exclusion criteria. The median for the domain
methodological rigour of CPGs was 66% on the AGREE II. Six CPGs were eligible for content analysis, while six CPGs were excluded based on a methodological quality
score <50% and/or indistinct recommendations. A total of 171 recommendations were extracted. Content analysis revealed recommendations about a wide variety
of strategies for CMSK namely: 9% (n=15) about general assessment; 3.5% (n=6) about a care approach, 16% (n=27) focussed on non-pharmacological management,
72% (n = 123) recommendations were made about pharmacological management of which 17% (n=29) were for non-opioid management and 55% (n=94) for opioid
management. Recommendations made were consistent across CPGs.
Conclusion: Several CPGs for CMSK pain exist, some which are of high quality. The focus of the CPGs were on opioid prescription. Non-pharmacological management
options such as behavioural, cognitive and physical rehabilitation strategies were limited.
Implications: CPGs are important to guide clinical decision making about care, and may influence health care policy about CMSK pain. Due to the existence of high
quality CPGs for CMSK pain, future actions can focus on adapting or contextualising existing high quality CPGs to the local context, instead of de novo CPG
development. Resources can be used to develop implementation strategies which include rehabilitation strategies. The inclusion of rehabilitation strategies in CPGs
may facilitate interdisciplinary management and address the multiple dimensions of CMSK pain, to optimise care for the large and growing population with CMSK
pain.
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: This study is part of a systematic review and is thus exempt from ethical approval.
Keywords: Chronic musculoskeletal pain, Clinical practice guidelines, Interdisciplinary management

PO2-SP-070
TRUNK LATERALITY RECOGNITION TASKS AND MOTOR IMAGERY: DOES TRUNK POSTURE AFFECT PERFORMANCE?
L. Alazmi 1,*, R. Kirmond 1, N. Heneghan 1, D. Punt 1
1
School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
Background: The value of laterality recognition tasks in clinical practice relies on the assumption that completing the task is an embodied process requiring actual
motor simulation of the postures presented. For limb-based LRTs, there is substantial evidence supportive of such a process. For example, altering the posture of a
limb has a significant impact on LRT performance for images of the corresponding limb indicative of individuals using online kinaesthetic information to complete the
task; i.e. they use motor imagery. Related evidence is lacking for trunk-based LRTs and this has contributed to uncertainty as to whether they also elicit motor
imagery in a similar manner.
Purpose: The study investigated whether the trunk posture of participants modulates performance on a trunk-based LRT. If trunk-based LRTs depend on actual motor
simulation of the postures presented, different participant postures should modulate performance.
Methods: Thirty unimpaired participants completed a computerised trunk laterality recognition task. Images used showed human figures with the trunk rotated or
side-flexed to the left or right. Images were also orientated to different degrees (0, 45, 90, 135, 180) and around different axes (X, Y, Z). Additionally, participants
completed the task while assuming three different standing postures; neutral, left trunk rotation and right trunk rotation. Stimulus characteristics were randomised
across experimental trials and participant posture was randomised across experimental blocks. Accuracy and response time data were analysed via two separate 3 x 2
x 2 (Participant posture: left, neutral, right x Stimulus posture: side-flexion, rotation x Stimulus laterality: left, right) ANOVAs.
Results: Accuracy data showed a 3-way interaction. Participants responding while standing in right trunk rotation were significantly more accurate (p<0.005) for
images showing right trunk rotation than images showing left trunk rotation. Response time data revealed a Participant posture x Stimulus posture interaction
(p<0.01); participants were faster to respond to rotated stimuli (but not side-flexed stimuli) when standing in a neutral posture compared to a left (p=0.017) or a right
(p<0.01) rotated posture.
Conclusion: The findings show that participant posture can modulate performance on a trunk-based LRT in a manner that is at least partially suggestive of them using
online kinaesthetic information to make their judgments. However, the postural effects shown are incomplete or weak when considered against those demonstrated
previously for limb-based LRTs.
Implications: Trunk-based LRTs have been introduced into clinical practice in a similar way to limb-based LRTs. However, whereas the latter have a wealth of
evidence to support their ability to elicit motor imagery, the former have not. Further research using different methodologies should explore this issue before trunkbased LRTs are recommended in clinical practice.
Funding Acknowledgements: LA is supported by a scholarship from the State of Kuwait Government.
Ethics Approval: The study was approved by the University of Birmingham's Research Ethics Committee.
Keywords: Laterality Recognition Tasks, Motor Imagery, Back Pain

PO3-AP-001
MOTOR CONTROL IN MUSCULOSKELETAL PHYSIOTHERAPY: A CONCEPT ANALYSIS
M. Low 1,*, N. Petty 1, C. Hebron 1
1
Health Sciences, University of Brighton, Eastbourne, United Kingdom
Background: The term motor control is used commonly in physiotherapy research and clinical practice however the meaning of the term is unclear. A review of the
literature revealed variation in the use of the concept of motor control within and between the specialties of the physiotherapy profession. In addition, the literature
identified that motor control is used interchangeably with terms such as neuromotor control and neuromuscular control. The ambiguity of the term may cause
miscommunication and misunderstanding in physiotherapy education, research and clinical practice.
Purpose: To clarify the concept of motor control and its use in musculoskeletal (MSK) physiotherapy practice.
Methods: The evolutionary method of concept analysis was used to investigate the socially constructed concept of motor control. Literature between 2009 to 2014
was selected from CINAHL, AMED and Medline databases to provide contemporary, peer reviewed and relevant data on the concept. Two hundred and ten abstracts
were reviewed from which 50 studies were included in the analysis due to their relevance to physiotherapy practice. An inductive process of analysis was used to
collect the attributes, antecedents, consequences and related terms of the concept of motor control.
Results: Forty-one different attributes of motor control were identified in the literature that included musculoskeletal, neurological and paediatric physiotherapy
specialty areas. The highest number of research articles that used motor control was within the musculoskeletal literature (n=35).
The term motor control was used interchangeably with neuromuscular control, neuromotor control and core stability.
The MSK literature tended to focus on the balance between movement production and motion stability whereas the neurological physiotherapy literature tended to
focus on the function and purpose of movement. The paediatric physiotherapy literature had a tendency to focus on individuals interactions with the environment.
The majority of the MSK literature focused on spinal rehabilitation (n=26/35). Eighteen of the 26 spinal rehabilitation research papers used Panjabi's spinal stability
model as a fundamental basis for this research.
Conclusion: Motor control is a broad, vague and ambiguous concept that is open to interpretation. There is inconsistency in its meaning within and between
physiotherapy specialities. The use of the concept of motor control is determined by the context in which it is delivered, including its underlying theoretical model
and when the research was conducted.
Implications: The lack of clarity of the concept of motor control could be problematic in clinical practice, education and research resulting in an inappropriate
application or interpretation of the concept. A recommendation from this research paper is that a Delphi study may be helpful to bring consensus to the meaning of
motor control within physiotherapy.
Ethics Approval: None required.
Keywords: Concept Analysis, Motor Control, Physiotherapy Theory

PO3-AP-003
CAN THE HAND LATERALITY RECOGNITION TASK BE PERFORMED WITHOUT USING MOTOR IMAGERY?
I. Grigoriadis*, D. Punt
Background: When presented with a picture of a hand and asked to determine its laterality (i.e. is it a left or a right hand?), it is typical for individuals to mentally
rotate their own limbs in orderto solve the task, therefore performing motor imagery in the process. Resulting data from the so-called hand laterality recognition task
(HLRT) reflects characteristics of actual movement; responses are faster for images corresponding with natural versus awkward postures (awkwardness effects) and
with the dominant versus the non-dominant hand (dominance effects). The ability of the task to implicitly elicit motor imagery has been exploited in recent years as
an assessment and intervention for patients with chronic pain and it is increasingly prevalent in clinical practice. However, clinical studies have revealed inconsistent
data and the suggestion that patients may not use motor imagery to complete the task, threatening the basis for its use.
Purpose: The study investigated whether it was possible to prevent motor imagery during a HLRT in unimpaired individuals by providing simple instructions that
encourage visual imagery rather than motor imagery.
Methods: Thirty-three unimpaired right-handed participants (16 female) completed a HLRT. Fifteen participants (7 female) completed the task in the normal way
without any specific instructions (Motor group). Eighteen participants (9 female) were given simple instructions requiring them to imagine each image in a fingers
up position and then judge laterality according to the relative position of the thumb (Vision group). Following the experiment, participants in the Vision group were
asked to rate how well they had been able to follow the instructions. Response time data were analysed to allow comparison between groups,and also within groups
for awkwardness and dominance effects.
Results: Across all participants, overall performance was comparable with significant main effects of Awkwardness and Dominance supportive of a motor
strategy. However, splitting the Vision Group according to participants self-report of compliance with instructions (one third of this group reported being unable to
follow the instructions) revealed a number of interactions. Awkwardness effects were confined to the Motor group and Non-compliant Vision group, while the
Compliant Vision group were unaffected by this factor. Additionally, only the Motor group showed a dominance effect.
Conclusion: Although unimpaired individuals demonstrate a strong propensity to use motor imagery when completing the HLRT, it is possible for them to use
alternative strategies without affecting their general performance. For patients, where motor imagery may be more difficult or may even evoke pain, it is likely that
alternative strategies could be used.
Implications: Carefully examining data from the HLRT, particularly for awkwardness effects, provides a method of probing whether motor imagery has been
performed or not.
Funding Acknowledgements: None.
Ethics Approval: The study was approved by the University of Birminghams Research Ethics Committee.
Keywords: hand laterality, motor imagery, visual imagery

PO3-AP-007
CAPTURING THE EXPERIENCE OF CHRONIC LOW BACK PAIN THROUGH PERSONAL VISUALISATIONS OF SIGNIFICANT WALKS AN ART AND HEALTH PROJECT
A. Moore 1,*, K. Saber-Sheikh 1, S. chubb 2, N. Bryant 2
1
Centre for Health Research, University of Brighton, Eastbourne, 2Fine Art , University of Chichester, Chichester, United Kingdom
Background: This study was developed from a collaboration between a musculoskeletal therapist and researcher,a fine artist,a media specialist and an engineer.All
the team had an interest in Chronic Low Back Pain from a range of perspectives and shared a range of skills and knowledge which had never before been combined
and utilised in this area of study. In context,Chronic Low Back Pain is an invisible problem that affects 80% of the UK population at some time in their lives.It is
however a largely misunderstood which is an issue that individuals who experience it sometimes have difficulty communicating.
Purpose: The purpose of the study was to capture participants' maeningful experiences of Chronic Low back pain in everyday life focusing on a personal significant
walk. The aim of the project was to produce a series of visualisations with each of the participants which would enhance health professionals and members of the
Publics understanding of the difficulties faced by individuals with chronic Low back pain.
Methods: Twelve participants with Chronic Low Back Pain chose a walk of personal significance to them, either Positive or negative. Demographic data were collected
at the start of the process as well as details regarding the extent and position of their pain.Prior to their walk Inertial sensors were attached to their Lumbar spine (L1S1)and a head mounted video camera was fitted to their forehead to capture a video of their walk. Pain levels were monitored every 2 minutes during their 20
minute walk and qualitative data were collected prior to ,during and after their walk using a range of approaches.
Results: Using the data gathered ,visual representationsof each of the significant walks have been co-produced by the researchers and the participants. Key elements
of the video footage and data have been selectedand combined in a seriesof audio visual exhibitions. Each participant used their own movement data to manipulate
special effects applied to the original video footage and data was synchronised to create hybrid footage that the participant felt represented their personal
experience.
Conclusion: Low Back Pain is a complex issue that creates significant personal challenges for those affected. This combined arts science and health approach to this
work has demonstrated a range of outcomes that may be helpful in building a range of visualisations of a range of Musculoskeletal conditions.
Implications: These very personal and valid expressions of Chronic Low Back Pain syndromes are now available for exhibition purposes. More public knowledge of the
impact of Chronic Low Back Pain on individuals who experience the problem could create a greater understanding of the challenges faced by these people. The
outcomes of the project will also be useful for teaching purposes in relation to health professional students. The more understanding members of the public and
health professionals have of the personal impact of chronic low back pain the more likely it is that individuals with back pain will meet with more positive
understanding from their family their friends and their colleagues.
Funding Acknowledgements: This Project was funded by The Welcome Trust in the UK
Ethics Approval: The research project was approved by the Un iversity of Brighton,Faculty of Health's Ethic and Governance committee
Keywords: Art and Health , Chronic low back pain, Patient experiences

PO3-CS-010
IS DEEP CERVICAL NECK FLEXORS TRAINING MORE EFFECTIVE THAN GENERAL NECK EXERCISES OR ADVICE IN PATIENTS WITH CHRONIC NECK PAIN? A
PROSPECTIVE RANDOMIZED CONTROLLED TRIAL
P. Bobos 1, T. Papanikolaou 2, C. Koutsojannis 2, J. MacDermid 1, E. Billis*
1
Faculty of Health Sciences,Health and Rehabilitation Sciences in Physical Therapy field, , University of Western Ontario, Ontario, Canada, 2Dept of Physical Therapy,
TEI of Western Greece, Dept of Physical Therapy, Aigio, Greece
Background: Specific training of the deep cervical neck flexor muscles has been found to improve pain, disability, quality of life (QoL) and psychosocial status in
patients with neck pain. However it is not well established if it is more effective than a general neck muscles training or advice.
Purpose: To investigate the effects of deep cervical flexor muscles training on pain, disability, QoL and psychosocial status of patients with chronic neck pain.
Methods: Adults suffering from chronic neck pain (>3 months) with a Neck Disability Index (NDI) of over 5/50 were eligible to participate. Subjects were randomly
assigned in 3 intervention groups; deep neck flexor training (specific group), general neck exercise training (general group) & advice (control). All groups received
instrutions and advice. The two intervention groups received a graded progressive exercise programme for 7 weeks, performed by a physiotherapist twice a week for
40 minutes/per session. Outcome measures involved 4 self-reported measures, NDI (disability), Numeric Pain Rating Scale (NPRS), SF-12 for QoL and Hospital Anxiety
and Depression Scale (HADS); and 2 clinician-based ones, cervicothoracic angle and craniocervical flexion test (CCFT). The latter two measurements yielded excellent
reliability (ICCs >0,83) on the pilot. One-way and repeated measures 2-way ANOVAs with tukey post hoc analysis were utilised.
Results: Out of 67 participants, 60 (47 men, mean age: 39,4512,67) completed the programme (retrospective power analysis of 0.80). Statistically significant
differences (p<0.05) across groups were yielded on pain, disability, QoL (mental subscale) and on CCFT performance. Post hoc analysis revealed significant
improvements (p<0,05) on the specific group on pain (against general group), disability (against the control) and on CCFT (against both other groups) at 7 weeks. CCFT
performance was superior to all other interventions. Pain and disability decreased however, across groups and, QoL (physical subscale), depression and anxiety did
not yield statistical differences between groups, indicating some lack of effectiveness of the exercise groups on addressing these issues.
Conclusion: All chronic neck pain patients showed great reduction in pain, disability, and on CCFT performance; particularly the specific group, which performed the
deep neck flexor training. However, no statistically significant changes were yielded on QoL, anxiety, depression, and on cervicothoracic angle measurements.
Implications: A 7 weeks physiotherapy programme of progressive deep cervical flexor muscle training showed reduction in pain, disability and better performance
on craniocervial flexion test compared to general neck exercises or advice for chronic neck pain patients. However, neck flexors training was not superior to general
exercises or advice for affecting QoL, depression or anxiety.
Funding Acknowledgements: No funding provided for this work.
Ethics Approval: Ethical approval was given by the Scientific Committee of the Technological Educational Institute (TEI) of Western Greece, School of Health &
Welfare, Department of Physical Therapy.
Keywords: Chronic neck pain, deep neck flexor training

PO3-CS-012
INVESTIGATING STIFFNESS OF CERVICAL ARTERIES WITH ULTRASOUND ELASTOGRAPHY: A PROOF OF CONCEPT STUDY
L. Thomas 1,*, J. Low 1
1
School of Health and Rehabilitation Sciences, University of Queensland, St Lucia, Australia
Background: Cervical arterial dissection (CAD) is a common cause of stroke in people under 55 years who are usually otherwise healthy. It has in rare cases been
associated with cervical manipulative therapy. Neck pain is commonly effectively treated with physiotherapy or chiropractic manipulative therapy. However, in rare
cases complications may arise, most seriously dissection of the cervical arteries which supply blood to the brain. This can lead to stroke or even death. The causes are
unclear but appear to involve an underlying arterial susceptibility plus exposure to an external trigger such as minor trauma or neck manipulation. Current premanipulative screening protocols are limited in their ability to identify those with susceptible arteries who might be at greater risk.
Measurement of arterial stiffness has been shown to be a reliable indicator of some arterial diseases and could provide a method of evaluating underlying arterial
susceptibility in dissection. Recently, ultrasound elastography has been used to measure and map the stiffness of various tissues including the carotid arteries. This
could perhaps provide a useful way to screen the cervical arteries prior to manipulative treatment. Previous studies have investigated the association of altered blood
flow to risk of CAD but not arterial wall stiffness.
Purpose: The aim of the study was to investigate the feasibility of using ultrasound elastography to image the cervical arterial walls and assess their mechanical
properties. A secondary aim was to determine whether wall stiffness changed between the neutral and contralateral head positions.
Methods: This was a proof of concept study examining the cervical arteries of 10 healthy individuals. Participants were scanned with scanned with ultrasound for Bmode, Doppler, and elastography of their internal carotid (ICA) and vertebral arteries (VA) proximally around C3-4 and distally at C1-2, in the neutral head position
and contralateral rotation Arterial wall thickness (mm), blood flow velocities (cms-1), and wall stiffness (cms-1) were captured with the Acuson/Siemens S3000
ultrasound system using a 9mHz linear transducer. Data was compared between neutral and contralateral rotation positions with paired t-tests.
Results: The cervical arteries of 10 healthy participants (4 males, 6 females), mean age 25.5 years were successfully scanned with ultrasound. The VA wall was stiffer
than ICA in the neutral head position. The ICA walls appeared less stiff following contralateral neck rotation and the change was significant distally (p=0.014). The VA
walls appeared to be stiffer in contralateral neck rotation but this was not significant proximally (p=0.472) and distally (p=0.381).
Conclusion: Ultrasound elastography can be utilised to measure arterial wall stiffness in the cervical arteries in both neutral and rotated head positions. Stiffness
appears to be different between ICA and VA which may have implications for relative arterial susceptibility when exposed to cervical manipulative therapy.
Implications: Ultrasound elastography has potential to provide insight into cervical arterial compliance and the effect of different head positions. This could suggest
future potential for use as a clinical screening tool prior to cervical manipulative therapy.
Funding Acknowledgements: The study was funded by an internal grant from the University of Queensland
Ethics Approval: Ethical approval was granted by the Medical Research Ethics Committee of the University of Queensland
Keywords: Cervical artery dissection; Cervical manipulation; Ultrasound elastography; pre-manipulative screening

PO3-CS-017
PHYSICAL THERAPIST MANAGEMENT OF A 54-YEAR-OLD MALE WITH CHRONIC NECK PAIN UTILIZING AN EMPHASIS ON NEUROSCIENCE EDUCATION: A CASE
REPORT
T. Bourgeois*, J. Schexnayder 1
1
University of St. Augustine-Doctor of Physical Therapy, University of St. Augustine for Health Sciences, Saint Augustine, United States
Background: Chronic neck pain is the fourth most common condition leading to disability and affects approximately 22% of women and 16% of men.
Purpose: The purpose of this case report is to demonstrate how a physical therapists management of chronic neck pain emphasizing therapeutic neuroscience
education (TNE) for treatment interventions can decrease pain, improve range of motion, improve outcomes, and improve functional ability with daily activities in a
middle aged man with chronic neck pain.
Methods: A 54-year-old retired Caucasian male presented to the clinic with complaints of chronic neck pain of greater than 2 years with an increase severity over the
past three months. Patient reported pain in his lower cervical region with symptoms spreading to his posterior shoulders and hands. Clinical examination revealed
no identifiable mechanical pattern of symptom reproduction or signs of central spinal cord issues. Other findings include: Visual Analog Scale (VAS) 7/10 at rest,
bilateral grip/pinch strength weakness, limited cervical AROM in all directions, Quebec Back Pain Disability Scale (QBPDS) 63/100, and the Patient-Specific Functional
Scale (PSFS) reported at 2/10 for mowing lawn, 3/10 for lifting, and 1/10 for driving.
Therapeutic neuroscience education (TNE) was administered after the initial examination and during 4 subsequent treatment sessions in the form of the educational
cards that helped teach the patient about pain pathways, chronic pain, fear avoidance, and central sensitization. Supportive movements were utilized to facilitate
graded progressive pain-free movements and diaphragmatic breathing as a home exercise program.
Results: Significant improvements were seen in all outcomes exceeding the minimal detectable change. These include: VAS 0/10, improved grip/pinch strength,
improved cervical AROM, Quebec Back Pain Disability Scale (QBPDS) 13/100 and the Patient-Specific Functional Scale (PSFS) 10/10 for mowing lawn, 10/10 for lifting,
and 10/10 for driving.
Conclusion: This case demonstrates the effectiveness of emphasizing TNE for the successful treatment of non-mechanical chronic neck pain. Future research utilizing
randomized controlled trials to assess the effectiveness of this approach is needed.
Implications: TNE with the addition of diaphragmatic breathing and graded pain free movements could be a viable treatment option when looking to improve
motion, reduce fear, improve the understanding of pain, and improve participation restrictions in patients with chronic neck pain.
Funding Acknowledgements: This case was not financially funded, yet was piloted as a capstone project for University of St. Augustine for Health Sciences.
Ethics Approval: There is no need for an ethical committee to approve this case project. Informed consent was approved by the patient prior to treatment services.

Keywords: Chronic Neck Pain, Diaphragmatic Breathing, Therapeutic Neuroscience Education

PO3-CS-019
THE EFFICACY OF MANUAL THERAPY AND EXERCISE FOR TREATING NON-SPECIFIC NECK PAIN: AN UPDATE OF SYSTEMATIC REVIEWS
B. Hidalgo 1,*, T. Hall 2, B. Cagnie 3, L. Pitance 4
1
Physiotherapy / Manual Therapy, Faculty of Motor Sciences / Parnasse ISEI, Bruxelles, Belgium, 2School of Physiotherapy and Exercise Science, Curtin University,
Perth, Australia, 3Department of Rehabiliation Sciences and Physiotherap, Ghent University, Ghent, 4Physiotherapy / Manual Therapy, Faculty of Motor Sciences ,
Bruxelles, Belgium
Background: Neck pain (NP) is the poor cousin to low back pain in terms of research investigations. In most cases a specific diagnosis cannot be made and NP is
labelled non-specific, because of the multifactorial etiology. Manual therapy (MT) is also an increasingly popular treatment available to people with NP and many
countries include MT in national guidelines for treating musculoskeletal disorders.
Purpose: Our systemic review (SR) updates previous reviews and presents new findings regarding MT validity for efficacy on NP.
Methods: A SR of MT covering a period from January 2000 to December 2014 was conducted by two independent reviewers according to Cochrane and PRISMA
updated guidelines. 178 studies were evaluated using qualitative criteria. Two stages of NP were categorized; acutesubacute (ASNP) or chronic (CNP). Further subclassification was made according to MT intervention: MT1 (manipulation); MT2 (mobilization); and MT3 (MT1+MT2). In each sub-category, MT could be combined or
not with exercise or usual medical care (UMC). Consequently, quantitative evaluation criteria were applied to 57 eligible randomized controlled trials (RCTs), and
hence 30 low-risk of bias RCTs were identified for review. Only studies providing new updated information (21/30 RCTs) are presented here.
Results: This SR confirmed previous evidence ranged from limited to moderate in favor of MT1-3 for greater improvements in pain and function for patients with NP
when compared to other common treatments such as UMC (e.g. ultrasound or anti-inflammatory drugs). Moreover, combined MT with exercise is better than MT or
exercise alone.
New evidence is found for ASNP: LIMITED evidence in favor of cervical MT1 + exercise when compared to thoracic MT1 + exercise for NP and function in the shortterm. LIMITED evidence to support MT3 + exercise in comparison to MT2 + exercise for pain and function improvements in the short-term.
New evidence is found for Chronic NP: MODERATE to STRONG evidence for no difference between MT2 at the symptomatic or random cervical level for pain and
function. MODERATE evidence showing no difference between MT1 and MT2 for pain in the intermediate term. LIMITED evidence of similar effectiveness for NP
when comparing thoracic MT1 to cervical MT1.
Conclusion: This SR updates the evidence for MT combined or not with exercise and/or UMC for different stages of NP and provides recommendations for future
studies.
Implications: Combining manipulation with mobilization may provide greater benefits to subjects with acute/subacute and chronic disorders, particularly in subjects
who respond more favorably to a combined intervention of exercise and manipulation.
Funding Acknowledgements: no funding sources
Ethics Approval: not required
Keywords: Manual Therapy, neck pain, systematic review

PO3-CS-027
THE EFFECT OF INCLUSION/EXCLUSION CRITERIA FOR A SHOULDER REHABILITATION CLASS ON OUTCOME SCORES FOR SHOULDER PAIN AND FUNCTION-AN AUDIT
M. Shaw*, J. braid 1
1
MSK Outpatients, Worthing and Southlands Western Sussex Hospitals Trust, Worthing, United Kingdom
Background: Western Sussex Hospitals Trust has run a shoulder rehabilitation class for 6 years. In the first 3 years it was impossible to determine the number of
patients who were entering the class fulfilled the inclusion and exclusion criteria set at the time as we had no set standards. Equally there was no record of pre and
post class outcome scores. It was therefore difficult to assess whether we were targeting the correct patient group for rehabilitation in a class environment.
Purpose: An audit was developed to ensure that 100% of patients entering the class fulfilled the inclusion and exclusion criteria and that 75% of patients achieved a
clinically meaningful improvement in the outcome measures.
Methods: An excel database was created to capture the number of patients entering the class who fulfilled the inclusion and exclusion criteria and outcome
scores. Shoulder conditions and compliance in the form of class attendance, patient demographic, handedness and number of 1:1 sessions prior to the class was also
recorded. A paper booklet was created with an inclusion and exclusion tick sheet, VAS (Visual Analogue Score), PSFS (Patient Specific and Functional Score) and SPADI
(Shoulder Pain and Disability Index) pre and post class outcome forms and an exercise booklet. The inclusion and exclusion forms and exercises were filled out by the
referring Physiotherapist. The pre and post class outcome measures were completed. The data was analysed and presented in graph form over a two year period
from November 2013 to November 2015.
Results: Data were collected for 122 people. 97.6% of all patients who entered the class fulfilled the inclusion and exclusion criteria over a two year period. 72 (59%)
had a significantly positive change (2 and above) in their VAS score. 90 (74%) had a significantly positive overall change in their PSFS score (2 and above), 55 (45%) had
a significantly positive change in SPADI. 87% of all patients who completed the class achieved a significantly positive change in either their VAS, PSFS or SPADI scores.
Conclusion: Nearly all patients who entered the Shoulder rehabilitation class fulfilled the inclusion/exclusion criteria. Patients who completed the class demonstrated
a positive change in their outcome scores. The PSFS outcome measure gave the nearest score to 75%. The number of people who achieved a significant change in
their VAS was lower than expected but on further investigation, the majority of those who did not achieve a significant change already started with a low score. These
patients usually achieved a significant PSFS change. Since there is conflict in the literature over what constitutes a significant change in SPADI ( 8-13% or 18% ) 18%
was selected. This may explain the low (45%) SPADI score. However, when comparing this data to old data where SPADI scores were recorded on day one of
physiotherapy and then after a shoulder class, the percentage of positive change was greater. This may imply that the SPADI may not be a suitable outcome measure
for higher functioning people later on in their rehabilitation. This is something which requires further investigation.
Implications: Further data is required for the use of the VAS as an outcome measure and the SPADI may not be the most appropriate outcome tool for a shoulder
class. There can be no inference between the effect of the inclusion / exclusion criteria into a shoulder class on the outcomes scores, but this warrants further
investigation.
A research study would determine whether there is any correlation between the inclusion/exclusion criteria and the outcomes of patients in the shoulder
rehabilitation class which may help develop national guidelines for a shoulder rehabilitation class.
Ethics Approval: N/A
Keywords: Pain, Rehabilitation, shoulder

PO3-EX-032
RETURNING TO SPORT POST ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: A QUALITATIVE EXPLORATION
N. Gill 1,*, S. Nagi 2
1
Coventry University, Coventry, 2University of Leicester, Leicester, United Kingdom
Background: It is thought that fewer than half of the individuals who have undergone anterior cruciate ligament (ACL) reconstruction return to their pre-injury
sporting level, in spite of research suggesting physical capability of the knee joint as having been restored. Quantitative studies of the subject have not considered
factors affecting resumption of sport for this client group and have tended to record a patients return to sport as an outcome measure of rehabilitation success.
What remains unclear are the elements within the rehabilitation process which may prevent a client from reaching their pre-operative sporting levels.
Purpose: The purpose of this qualitative study was to explore the experiences of individuals returning to sport following ACL reconstruction. The aim was to gain
knowledge of individuals thoughts and feelings through the rehabilitation process and identify the barriers and opportunities that might affect post-operative
participation in sport.
Methods: This phenomenological study was conducted using a focus group method. A purposive sample included students from the University of Leicester who had
previously undergone an ACL reconstruction. Narrative data from the focus group was then transcribed verbatim and analysed thematically.
Results: Two overarching themes were identified from the data; Fear and Rehabilitation. Fears included those of possible re-injury, the long-term consequence of the
injury and of the knees reduced physical capabilities. Rehabilitation included opinions of physiotherapy, NHS vs private rehabilitation, the role of education,
participation in sports and timescale.
Conclusion: This study highlights a need for rehabilitation programmes to consider physical and psychological strategies following ACL reconstruction. Whilst multiple
barriers to the return to sport have been identified, ensuring goals are patient-centred, encouraging participation in alternative sports, combined with educating
individuals on the realistic time-frames for recuperation, can help to maximise the potential for resuming pre-injury sport. It is evident that fear of re-injury is present
in this client group and the wait for surgery may heighten this concern. Additional research into the effect of delaying surgical intervention for ACL deficiency would
be of interest.
Implications: Rationale for rehabilitation programmes to integrate physical and psychological interventions such as motivational interviewing and cognitive
behavioural therapy to assist in managing patients fears of returning to sport post ACL reconstruction is advocated by the findings of this study.
Patient-centred goals remain a priority within rehabilitation and the post-operative phase could be better used for motivating and informing individuals of a realistic
period for recovery and encouraging participation in alternative sports.
Ethics Approval: Ethical approval for this study was granted by Coventry University and the University of Leicester.
Keywords: Anterior cruciate ligament reconstruction, Qualitative research, Return to sport

PO3-EX-033
THE DEVELOPMENT AND PEER EVALUATION OF
A SCREENING TOOL FOR CERVICOGENIC DIZZINESS
P. Vaes*, G. Bus 1, C. Van Den Broeck 1, V. Vijverman 1, S. Malone 1, R. A. B. Oostendorp 2

1
Manual Therapy, Vrije Universiteit Brussel-Belgium, Brussels, Belgium, 2Allied Health Sciences, Radboud University, Nijmegen, Netherlands
Background: Cervicogenic dizziness, is insufficiently investigated. Ther seems to be an need for a tool to evaluate how manual therapy management for cervicogenic
dizziness can be screened, diagnosed and managed in daily practice.
Purpose: The three objectives were to determine the need for a new screening tool for cervicogenic dizziness, to investigate how such a tool could be developed and
finally to evaluate how it could be improved, taking into account content and applicability in daily practice.
Methods: A cross-sectional online survey was conducted among 124 manual therapists regarding the need for a new tool. Next, a screening tool was developed
based on current research. A second online survey was conducted among 78 manual therapists concerning the anamnestic data and clinical tests that might be
excluded from or added to the tool and its applicability in daily practice. Additionaly, eleven university educators were surveyed by phone using a semi-structured
interview.
Results: Manual therapists (81%) believe there is a need for a new screening protocol. Every item given in the tool would be included by more than 80% of the
manual therapists, except for the test of Babinski Weil and the Whisper test (61-80%). Respondents agreed that C0-C1 (92%), C1-C2 (96%) and C2-C3 (81%) are most
important in vertebral functioning?
Conclusion: A majority of manual therapists conclude that the cervicogenic dizziness screening tool is necessary for daily practice. They also indicate the the tool is
too time-consuming (58%). Twenty-four percent of the therapists find the clinical examination necessary but too extensive as it was presented in this study.
Implications: A cervicogenic dizziness screening tool is necessary for daily practice of the manual therapist. It however should be redesigned to make is more suitable
and less time consuming for daily practice.
Funding Acknowledgements: Universiteit Brussels Research group in physiotharapy and manual therapy.
Ethics Approval: Ethics Committee of the University of Brussels Academic Hiospital approved the study protocol.
Keywords: cervical, dizziness, differential diagnosis, manual therapy, survey

PO3-EX-034
EFFECTS OF MASSAGE BEFORE STRETCHING ON MUSCLE HARDNESS AND RANGE OF MOTION
Y. Miura 1,*, H. Kuruma 1, M. Kashiwagi 1, M. Tomioka 1, J. Oike 1, O. Funami 1, H. Nakajima 1, M. Tamura 1
1
Division of Physical Therapy, Tokyo Metropolitan University, Tokyo, Japan
Background: Soft tissue mobilization, including friction massage, functional massage, and stretching, is a treatment for the dysfunction of the muscles or fascia.
However, few studies have reported regarding the effects of the combination of these techniques.
Purpose: This study aimed to investigate the effects of massage before stretching on muscle hardness and range of motion (ROM).
Methods: The participants were 44 healthy males who had no history of traumatic injury. The aims of the study were explained to the participants, and each provided
written informed consent. The medial head of gastrocnemius muscle (GM) was studied in each participant. The participants were randomly divided into four groups,
control, static stretching (SS), friction massage (friction), and functional massage (functional) groups. The participants in the control group lay supine for 8 min, while
the participants in SS group lay supine for 4 min and received SS for 1 min in three sets. The participants in the friction or functional group received massage for 3 min
and lay supine for 1 min, after which they received SS for 1 min in three sets. Active, passive ROM, and muscle hardness were measured before and after
intervention. Muscle hardness was measured by real-time tissue elastography (RTE) using an ultrasound (Hitachi Medical Corporation, EUB-7500, Japan). RTE was
performed by free-hand manipulation of a 10-MHz linear probe and an attached reference bag. After performing RTE, stain ratio was used to measure muscle
hardness and to calculate the amount of distortion of GM divided by the amount of distortion of the reference bag. Incidentally, the amount of distortion increases in
the soft tissue, whereas it decreases in the hard tissue. Muscle hardness was measured in two layers (superficial: depth 1 cm, deep: depth 3 cm). The significance of
the differences between measurements before and after intervention and differences between the different groups were evaluated using two-way analysis of
variance and multiple comparison testing (Bonferroni). P<0.05 was considered as significant.
Results: Superficial and deep muscle hardness demonstrated the main effects and interactions. Active and passive ROM demonstrated only the main effects. After
the intervention, superficial muscle hardness was significantly decreased in the friction group (mean: 87.0) compared with that in the SS group (73.6) and in the
functional group (88.2) compared with the control group (76.9) and the SS group. After the intervention, deep muscle hardness was significantly decreased in the
friction group (88.2) and functional group (89.4) compared with that in the control group (73.9). Furthermore, in the friction group, both superficial and deep muscle
hardness were significantly decreased after the intervention compared with those before the intervention (superficial: 71.1, deep: 77.4). Similarly, in the functional
group, both superficial and deep muscle hardness were significantly decreased after the intervention compared with those before the intervention (superficial: 69.5,
deep: 70.0). In the friction group, active and passive ROM (active: 16.6, passive: 22.2) were significantly increased after the intervention compared with those
before the intervention (active: 13.0, passive: 18.2). Similarly, in the functional group, both active and passive ROM (active: 16.5, passive: 22.5) were significantly
increased after the intervention compared with those before the intervention (active: 13.0, passive: 18.5).
Conclusion: Performing massage before stretching significantly improved muscle flexibility and ROM compared with performing stretching alone.
Implications: As a treatment for the dysfunction of the muscles or fascia, our results suggest that performing pre-treatment massage in addition to stretching is
effective.
Funding Acknowledgements: We don't get any fund for this study.
Ethics Approval: This study was approved by the Tokyo Metropolitan University Ethical Review Board.
Keywords: muscle hardness, soft tissue mobilization, ultrasonography

PO3-LB-035
PORTUGUESE INDIVIDUALS` EXPERIENCES AND PERSPECTIVES OF NON-SPECIFIC CHRONIC LOW BACK PAIN: AN INTERPRETATIVE PHENOMENOLOGICAL ANALYSIS
C. Caeiro 1,*, A. Moore 2, L. Price 3
1
School of Health Care, Polytechnic Institute of Setbal, Setbal, Portugal, 2Centre for Health Research, 3School of Health Sciences, University of Brighton, Eastbourne,
United Kingdom
Background: Considering the complexity inherent in the experience of non-specific chronic low back pain (NSCLBP), where personal and cultural contexts play an
important role, research has highlighted the need to study this phenomenon from a cross-cultural perspective.
Purpose: Based on the assumption that understanding the individuals` experiences and perspectives about NSCLBP may facilitate the design of therapeutic
approaches closer to their needs, and considering the low volume of research produced in Portugal within this area, this study aimed to explore the experiences and
perspectives of Portuguese individuals with NSCLBP.
Methods: The study was conducted through the lens of the interpretivist paradigm, which means that the researcher was focused on developing a deep
understanding about the interactions between participants with NSCLBP and their contexts in making sense of their disorder. The constructionism view of knowledge
as well as realism and relativism were adopted respectively as epistemological and ontological positions. An interpretative phenomenological analysis (IPA) was
employed as methodological approach to explore the experiences of eight participants, who were recruited purposefully from three Portuguese health sites. Semistructured one to one interviews were carried out in order to collect data. The interviews were audio-recorded and transcribed verbatim.
Results: Following an inductive process of data analysis, five themes emerged. The first theme discussed the disruptive nature of the NSCLBP experience. The second
theme discussed the participants` meaning making of NSCLBP, while highlighting their need to understand it. The third theme highlighted the clinical encounters,
particularly regarding their contribution in maintaining the lack of participants understanding about NSCLBP. The fourth theme discussed the meaning making of
NSCLBP contribution in reshaping the participants` social interactions. Finally, the fifth theme highlighted the participants` definition of their sense of self through the
meaning making of NSCLBP. The emergent themes reflected both the participants` shared experiences of the phenomenon under investigation as well as the
particular way in which each participant experiences it.
Conclusion: These findings pointed to the impact of NSCLBP on the restriction of everyday life, reshaping of social interactions and redefinition of the participants`
sense of self. They highlighted the participants` need to understand their disorder in order to have some control over it. Finally, they called attention to health
professionals` role on perpetuating both the participants` struggle to understand their disorder and their dependency on health care services.
Implications: This study offered insights into the Portuguese individuals experiences of NSCLBP disorder, which may help clinicians in transferring this knowledge to
the therapeutic approach to patients with similar experiences. The knowledge produced may be used to inform recommendations for NSCLBP management.
Funding Acknowledgements: This study was supported by the Polytechnic Institute of Setbal (PhD Grant reference: SFRH/PROTEC/67839/2010).
Ethics Approval: Ethical approval was obtained from the Faculty of Health and Social Science Research Ethics & Governance Committee of the University of Brighton.
Keywords: non-specific chronic low back pain, patients`experiences, qualitative research

PO3-LB-036
THE EFFECTIVENESS OF MATCHED SUBGROUPING FOR MANUAL THERAPY, EXERCISE THERAPY AND PSYCHOSOCIAL INTERVENTIONS FOR NON-SPECIFIC LOW BACK
PAIN. A SYSTEMATIC REVIEW.
M.-A. Jess*
Background: Evidence on the best treatments for nonspecific low back pain (NSLBP) remains inconclusive, with emphasis pointing towards subgrouping improving
the effectiveness of treatments, due to the proposed heterogeneity of this group of patients. This systematic review was undertaken to establish if
matched subgrouping improves the outcome of treatments in NSLBP.
Purpose: The purpose of this review was to establish if the efficacy of manual therapy, exercise therapy and psychosocial interventions are improved for pain,
disability and psychosocial factors (such as anxiety, depression and fear avoidance behaviours), when matched to the appropriate subgroups of patients with NSLBP.
Methods: Cochrane CENTRAL, EMBASE, MEDLINE, PEDro and WoK were electronically searched, with additional studies identified through reference lists. Studies
eligible for inclusion were randomized controlled trials (RCT) of subgrouping matched to manual therapy, exercise therapy or psychosocial interventions for NSLBP.
Studies needed to ensure prognostic factors were accounted for and robust information on treatment effect modification was obtained. They had to be a hypothesis
testing or a validation study, published in English. Studies were evaluated for their methodological quality using the criteria recommended by the Cochrane Back
Review Group.
Results: Five RCTs, all with high methodological quality were included. A meta-analysis was not performed due to the heterogeneity of the studies. The only study in
this review to have assessed a psychosocial matched intervention was based on the STarT Back screening tool (Hill et al. 2011). Results favoured subgroup matched
intervention with significant improvements in pain, disability and a number of psychosocial factors. The Delitto treatment-based classification system (Brennan et al.
2006), demonstrated improvements in disability, as did a study using the McKenzie directional-preference based classification (Long et al. 2004). It also showed
significant improvement in pain in the short term. The results from the two studies (Childs et al. 2004; Hancock et al. 2008) classifying patients according to a clinical
prediction rule for manipulation (Flynn et al. 2002) were equivocal.
Conclusion: This review found that there is some evidence to suggest that outcomes are improved when interventions are matched to subgroups for NSLBP patients.
However, based on robust subgrouping principles, the only subgrouping design that would be recommended into clinical practice is the classification approach using
the STarT Back screening tool. Further validation studies are required for the other subgrouping rules.
Implications: The emphasis of future work should be on vigorous subgrouping methodology, including study designs that enable prognostic factors to be
differentiated from treatment effect modifiers, prior to the application of the results into clinical practice.
Keywords: Non-specific low back pain, Stratified care, subgrouping

PO3-LB-040
GERMAN PHYSIOTHERAPISTS VIEWS ON A SINGLE APPOINTMENT FOR LOW-RISK PATIENTS WITHIN THE START-BACK APPROACH
P. Kuithan 1 2,*, K. Krug 3, J. C. Hill 4, J. Szecsenyi 3, J. Steinhaeuser 5, S. Joos 6, S. Karstens 7 8
1
Department of Therapeutic Sciences, SRH Hochschule Heidelberg, Heidelberg, 2M.Sc. Sport Physiotherapy, German Sport University Cologne, Cologne, 3Department
of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany, 4Institute of Primary Care and Health Sciences, Keele
University, Keele/Stoke-on-Trent, United Kingdom, 5Institute of Family medicine, University Hospital Schleswig-Holstein Campus Luebeck, Luebeck, 6Department of
General Practice, University of Tuebingen, Tuebingen, 7Department of Computer Science; Therapeutic Sciences, Trier University of applied Science, Trier, 8formerly
Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
Background: The STarT-Back-Tool (Subgroups for Targeted Treatment) classifies patients with low back pain depending on their risk of a poor prognosis into low-,
medium- and high-risk subgroups in order to deliver matched targeted treatment pathways. Implementing stratified care in Germany may require modifying aspects
of the treatment pathways. In the original UK trial testing this approach, the low risk matched treatment pathway consisted of patients receiving a minimal
intervention involving a single physiotherapy session with standardised examination, reassurance, advice on activity promotion, and no further treatment.
Purpose: The objective of this project was to identify potential obstacles and opportunities of implementing the STarT-Back stratification approach in Germany. This
abstract focuses on German physiotherapists perceptions of delivering the low-risk treatment pathway.
Methods: Three two-hour workshops were conducted with physiotherapists, starting with an introduction about the STarT-Back low-risk treatment pathway,
followed by focus group discussions guided by a semi-standardised interview guideline. The discussions were digitally recorded, transcribed verbatim and coded using
a content analysis approach.
Results: In total 19 physiotherapists (4 male, 15 female, mean age=41 years, SD=8.6) from different clinical settings participated. The results identified four themes;
patient information, clinical framework/settings, physiotherapists qualifications, and the application of media to support patient education.
Participants highlighted the following obstacles to the low risk pathway; the fact it was very different to their usual approach, that a single session might adversely
affect the therapeutic relationship as patients might have opposing views about minimal treatment, that it might decrease diagnosis-based decision making, that one
session could be insufficient for some patients, and the need for additional support to enable them to sign-post patients to local exercise services. Finally,
heterogeneous current physiotherapy clinical standards and qualifications were stated as possible obstacles to being able to implement the low-risk pathway.
Participants voiced opportunities from the low-risk pathway including; potential to gain new clients, that German physiotherapists were appropriately qualified to
deliver the pathway, that the use of media to support patient education was positive, that allowing the provision of a follow-up appointment or optional telephone
consultation might help maintain some patients trust, and that the pathway might facilitate inter-professional networking with healthcare partners.
Conclusion: The findings demonstrate German physiotherapists are interested in the STarT-Back low-risk treatment pathway. However, its implementation would
lead to a significant change in current practice and professional identity, particularly promoting self-management treatment option. Inter-professional networks
would have to be established and further expanded and patients compliance and perceptions carefully evaluated.
Implications: Overall, physiotherapists and GPs, as previously reported, agree that STarT-Back implementation has potential to improve patient care and optimise
cost-effectiveness. However, modifying the low-risk pathway to better align with current physiotherapy practice in Germany, e.g. follow-up contact, might foster
implementation.
Ethics Approval: Ethical approval was obtained from the Medical Faculty of the University of Heidelberg (registration ID= S-414/2013).
Keywords: focus groups, low back pain, patient education

PO3-LB-041
RELIABILITY OF TOOLS MEASURING LUMBAR SPINE PROPRIOCEPTION IN ATHLETIC POPULATION: A SYSTEMATIC REVIEW
C. Pazaridis 1,*, S. Spencer 2, A. Rushton 3, N. Heneghan 3
1
University of Birmingham, Birmingham, 2Lilleshall NSC, English Institute of Sport, Shropshire, 3School of Sport, Exercise and Rehabilitation Sciences, University of
Birmingham, Birmingham, United Kingdom
Background: Low Back Pain (LBP) is a common musculoskeletal disorder with 30% prevalence in an athletic population. Proprioception deficits contribute to
development or maintenance of LBP thus it is imperative that reliable instruments for measuring lumbar spine proprioception are available for use in clinical practice.
The results could assist clinical assessment, implementation of therapeutic interventions and enhance an athletes recovery, reducing play time loss.
Purpose: To evaluate the scope and nature of tools measuring proprioception of people within athletic population. A second aim is to identify the clinical applicability
of the tools used in this review.
Methods: Designed and reported based on CRD guidelines and PRISMA. Human participants with mean age (18-40) were included, while studies with patients having
specific LBP causes were excluded. At least one component of RE as a measure of proprioception was selected as outcome. The included study design was
prospective reliability studies. An electronic search was conducted up until September 2015. The terms back pain, proprioception and reliability as well as
synonym terms were used. A quality appraisal tool (QAREL) was used to assess the risk of bias. Results were summarized.
Results: 5 studies were included and analysed, with each study using a different tool. All assessed intra-observer reliability and had 2 to 5 positive items in QAREL
tool indicating high risk of bias with many conduct or reporting faults, especially in rater representativeness and blinding. Sample sizes varied from 14 to 292 and the
follow-up period varied from 15 minutes to 2-3 years. Power calculation was performed in 1 study only. Intra-observer reliability agreement varied from 0.20-0.89,
indicating poor to excellent reliability and errors of measurement varied from 0.34 to 3.90 indicating small to large errors. 2 studies presented tools with easier
clinical applicability regarding low weight and ease of application, making them relevant to an athletic setting.
Conclusion: There is limited evidence to suggest that tools assessing lumbar spine proprioception present acceptable reliability to be used widely in clinical practice.
Most tools reported moderate reliability and only two instruments were considered clinically applicable, with the studies presenting methodological shortcomings.
Further studies on the inter-rater reliability of tools measuring lumbar proprioception are needed, that are conducted and reported appropriately. Furthermore
studies of similar methodology are needed in order to be able to generalize the results of the reliability studies.
Implications: The higher female to male ratio reflects the athletic population where LBP affects more female athletes than men. The mean age of subjects included in
the studies is 24 which is representative of a young aged athlete in a majority of sports. Due to the apparent lack of athletes in reliability studies, the results of the
general population used on this review can aid athletic rehabilitative programs.
Funding Acknowledgements: This project was not funded
Keywords: lumbar spine, Proprioception, review

PO3-LL-049
DO LOWER LIMB KINEMATICS DIFFER BETWEEN RUNNERS WITH AND WITHOUT PATELLOFEMORAL PAIN SYNDROME? A SYSTEMATIC REVIEW AND METAANALYSIS
M. James 1, K. Gill 1, L. Kedroff 1,*
1
Academic Department of Physiotherapy, King's College, London, London, United Kingdom
Background: Running is a popular activity and over 2 million people run on a weekly basis in the United Kingdom. Although running provides many health benefits, it
is also associated with a high incidence of injury and Patellofemoral Pain Syndrome (PFPS) is the most common lower limb disorder. A lack of consensus persists
regarding the precise aetiology of PFPS but it is likely to be multi-factorial, and altered lower limb kinematics may be a contributing factor.
Purpose: The aim of this study is to (i) perform a systematic review of the current literature to determine if lower limb kinematics differ between runners with and
without PFPS; and (ii) whether any differences can be quantified via Meta-analysis.
Methods: A search was conducted for studies published between 01 Jan 1950 and 13 May 2015 using MEDLINE, CINAHL, Embase, Cochrane Library and Web of
Science. A grey literature and hand search were also performed. Keywords linking running kinematics at the hip, knee, ankle and foot joints in subjects with PFPS
were used and the PRISMA checklist protocol was followed. 6231 potential titles and abstracts were revealed and 32 studies were extracted for full text review. Study
quality was assessed using a modified Downs and Black Scale, external validity and inclusion and exclusion criteria for PFPS diagnosis were measured via a
customised checklist. Intraclass correlation coefficient were conducted in STATA software version 12 (Texas,USA) to determine intra-rater reliability. Fourteen studies
were included in qualitative analysis, 10 of these studies measured peak angles during the stance phase of running and therefore appeared sufficiently homogeneous
for inclusion in the Meta-analysis. The mean and standard deviations for peak angles of hip adduction (HADD), hip internal rotation (HIR), knee flexion (KF), knee
abduction (KABD), knee adduction (KADD) and internal rotation (KIR), tibial internal rotation (TIR) and rear foot eversion (R-EVER) of the PFPS and control groups
were inputted into RevMan (Review Manager) Version 5.3 (Cochrane, London, UK) and forest plots were generated.
Results: Both checklists demonstrated a high level of agreement between authors for all individual items and total scores. Study quality varied due to omissions in the
reporting of methodological detail and the heterogeneity of outcome measures used. We found that subjects with PFPS demonstrated a statistically significant
pooled effect of mean increased HIR (1.57), and HADD (1.79) which concurs with commonly accepted theories and previous research. We also found decreased KF
(3.63) and rear foot eversion (1.96) in PFPS subjects compared to healthy controls. The pooled results for KADD,KABD,KIR and TIR were not statistically significant.
Heterogeneity was low in studies examining the knee and ankle (0%), but high in those assessing the hip ( 72% and 82% for HIR and HADD respectively).
Conclusion: Subjects with PFPS demonstrated increased HIR and HADD and reduced KF and R-EVER. It must be noted that these differences are small, and fall within
the considered accepted range of measurement error associated with multi centre kinematic assessment. The lack of large prospective studies with large sample sizes
impacts on the ability to infer causation of running kinematics on PFPS. Future studies examining the entire kinetic chain are required in order to provide more global
information regarding the lower limb rather than evaluating individual joint(s).
Implications: Clinicians are advised to acknowledge these small alterations lower limb kinematics; in particular increased HADD, but should appreciate the variability
in results found and should choose treatments based on an individualised patient assessment.
Funding Acknowledgements: No funding was received for this project.
Ethics Approval: No ethics approval was required.
Keywords: Patellofemoral pain, running, kinematics

PO3-LL-052
THE EFFECT OF ADDING MYOFASCIAL TECHNIQUES TO AN EXERCISE PROGRAMME FOR PATIENTS WITH ANTERIOR KNEE PAIN - A RANDOMIZED CLINICAL TRIAL
G. Telles 1, D. Cristovo 1, F. Belache 1 2, M. Santos 3, R. Almeida 1 4, L. C. Nogueira 2 3,*
1
Hospital Universitrio Gaffre e Guinle, 2UNISUAM, 3IFRJ, 4UNIFESO, Rio de Janeiro, Brazil
Background: Anterior knee pain is a common complaint and can cause difficulty with its inability to bear weight. Previous studies in patients with anterior knee pain
showed that strengthening hip muscles can lead to knee pain relief . However, it has already been shown that myofascial techniques for the rectus femoris muscle
reduce anterior knee pain. There are studies that combine different approaches in the same intervention group to improve knee pain and function. To the best of our
knowledge, no study has examined the effect of combining hip muscles strengthening and myofascial techniques for reducing pain and improving function in patients
with anterior knee pain, despite this being a common clinical practice.
Purpose: The aim of the study was to analyse the effect of adding myofascial techniques to an exercise programme for patients with anterior knee pain.
Methods: A clinical trial with 18 patients with a clinical diagnosis of anterior knee pain was conducted. One group (E) with nine individuals was treated with hip
muscle strengthening exercises; another group (EM), with nine individuals, had myofascial techniques added. To quantify the results, the Numerical Pain Rating Scale
(NPRS) and the Lower Extremity Functional Scale (LEFS) were used.
Results: The E group showed an improvement in pain (p = 0.02), but not in the mean degree of disability. The EM group showed an improvement in pain (p = 0.01), as
well as the degree of disability (p = 0.008). The effect size analysis showed that participants of the EM group had a greater impact on clinical pain and disability
(Cohen`s d = 0.35 and 0.30, respectively).
Conclusion: The addition of myofascial techniques should be considered to improve the functionality of the lower limbs and reduce pain in patients with anterior
knee pain.
Ethics Approval: Gaffre and Guinle University Hospital Ethics Committee
Keywords: anterior knee pain, Patellofemoral pain syndrome, Physiotherapy and Muscle Strengthening

PO3-LL-054
EFFECTIVE THERAPY TO REDUCE EDEMA AFTER TOTAL KNEE ARTHROPLASTY
MULTI-LAYER COMPRESSION THERAPY OR STANDARD THERAPY WITH COOL PACK
A RANDOMIZED CONTROLLED PILOT TRIAL
B. Stocker, C. Babendererde, M. Rohner-Spengler, U. W. Mueller, A. Meichtry, H. Luomajoki*
Background: After total knee arthroplasty (TKA) efficient control and reduction of postoperative edema is of great importance.
Purpose: The aim of this study was to investigate the effectiveness of multi-layer compression therapy (MLCT) to reduce edema in the early period after surgery
compared to the standard treatment with Cool Pack.
Methods: In this randomized controlled pilot trial, sixteen patients after TKA were randomized into a intervention group (IG) or a control group (CG). Circumferential
measurements were used to assess edema. Secondary outcomes were range of motion (ROM), pain (numeric rating scale, NRS) and function as measured with the
fast Self Paced Walking Test (fSPWT).
Results: Clinically relevant and statistically significant interaction effects were measured in postoperative edema reduction in favor of the IG, in the early
postoperative period and on the follow-up at six weeks. Six days postoperatively, the interaction effects in edema reduction between the groups was -3.8 cm (KI:-5.1;
-2.4, p<0.001) when measured 10 cm proximal to the joint space and -2.7 cm (KI:-4.1; -1.3, p<0.001) measured 5 cm proximal. We further observed minor, nonsignificant interaction effects in secondary outcomes in favor of the CG. Six days postoperatively the interaction effect for knee flexion was -8.3 (KI:-22.0; 5.4, p=0.27)
and for fSPWT it was 12.8 seconds (KI:-16.4; 41.3, p=0.46). Six weeks postoperatively these differences diminished.
Conclusion: MLCT is an efficient method in reduction of postoperative edema in patients with TKA, though at the expense of less early knee flexion and function.
From the current state of our findings we recommend the use of MLCT when edema is severe and may delay postoperative rehabilitation.
Implications: By patients after TKA we recommend the use of MLCT when the edema is the main problem and may delay postoperative rehabilitation.
Ethics Approval: Ethikkommission Nordwest- und Zentralschweiz (EKNZ 2014-225)
Keywords: cryotherapy, knee arthroplasty, multilayer compression bandage

PO3-MT-057
PREMANIPULATIVE TESTING AND BENIGN ADVERSE EVENTS WITH CERVICAL MANIPULATION: A MODIFIED EXTENSIVE LITERATURE REVIEW
B. Harper, C. Heldman 1,*
1
Radford University, Roanoke, United States
Background: Cervical spine manipulation (CSM) is controversial due to potentially serious adverse events; thus the orthopedic manual physical therapist (OMPT)
should be well versed in evaluating the hemodynamic system prior to CSM and, once screened for safety, the patient should be informed of the most common benign
post CSM adverse events.
Purpose: To investigate through a review of literature the current premanipulative (PM) tests performed to identified cervical artery dysfunction
(CAD)/vetebrobasilar insufficiency (VBI), to determine which PM tests are used to identify CAD due to spontaneous arterial dissection (SAD) compared to those used
for mechanical arterial compromise (MAC), and to discus the most common benign adverse events (BAE).
Methods: An inductive analysis of literature addressing vertebral artery (VA) PM assessments, including internal carotid artery (ICA) and VA turbulence, and vascular
compromise. The analysis also revealed patient risk factors related BAE.
Results: Higher risk for SAD is associated with atherosclerosis, hypertension, diabetes mellitus, and a history of smoking. A genetic defect can lead to increased levels
of amino acid homocysteine creating fragility of the arterial wall. The PM SAD exam includes blood pressure, heart rate, cranial nerve examination, general eye
examination, auscultation of bruits, and laboratory testing for elevated amino acid homocysteine. Current MAC PM tests have not been validated as hemodynamic
patency assessments, thus, these blood flow dynamic assessments do not identify CAD/VBI risk. MAC is assessed using cervical rotation, deKleyns test, premanipulative hold, and a hand held Doppler velocimeter. If symptoms are associated with a spontaneous event, then mechanical tests have little value; in fact, they
may provoke a vascular event. Fifty percent of patients will experience mild to moderate severity BAE such as local discomfort, headache, stiffness/soreness,
aggravation of chief complaint, fatigue, radiating discomfort, dizziness/nausea, and hot skin within four to eight hours after CSM, dissipating within 1-3 days.
Individuals between the ages of 30-39 years, women, and those with a history of smoking, migraines, or regular medication usage are most likely to experience BAE.
Conclusion: This study offers an evidence-based compilation of literature providing a set of various subjective and objective testing which can assist the OMPTs
clinical decision process for PM tests and BAE. Screening for hemodynamic spontaneous CAD involves a combination of assessing co-morbidities, investigating patient
historical events, evaluating subjective complaints, and providing appropriate physical examination procedures. Once CAD from SAD events have been screened as
negative for vascular co-morbidities, then PM screening for MAC can be performed, not to assess arterial patency in terms of CAD, but to gauge for potential vascular
intolerance during mechanical forces which may occur during CSM.
Implications: Despite the lack of support for mechanical vascular assessments for MAC CAD, there remains some clinical value in MAC PM screening tests. Mechanical
tests cannot identify risk for spontaneous CAD and may cause a vascular event. Mechanical PM tests are not employed when the clinician has any suspicion that SAD
is in process. MAC PM vertebral artery screening may be useful in patients who have blood flow compromise due to biomechanical disruption of blood flow,
secondary to multiple factors including both normal and abnormal anatomy. In doing so, the clinician is not using MAC PM tests to assess risk for CAD, but is assessing
vascular tolerance through the range CSM will occur. Due to co-morbidities of multiple systems associated with SAD, PM tests used in isolation will not eliminate the
risk of vascular adverse events, but, when used judiciously, may assist in the decision for the application of CSM.
Funding Acknowledgements: Work was unfunded.
Ethics Approval: No ethics approval was required as this was a modified extensive literature review article.
Keywords: Premanipulative Testing, Cervical Manipulation, Spontaneous Vascular Events, Cervical Artery Dysfunction

PO3-MT-058
THE ADJUNCTIVE BENEFIT OF MANUAL THERAPY IN ADDITION TO THERAPEUTIC EXERCISE FOR SHOULDER IMPINGEMENT SYNDROME: A SYSTEMATIC REVIEW
X. Konstantakis 1,*, C. Pazaridis 2, N. Heneghan 3
1
Physiotherapy, Queen's Hospital-Burton Hospitals NHS Foundation Trust, Burton upon Trent, 2School of Sport and Exercise Sciences, University of Birmingham,
Birmigham, 3School of Sport and Exercise Sciences, University of Birmingham, Birmingham, United Kingdom
Background: Shoulder impingement syndrome (SIS) constitutes the most common diagnostic subgroup of shoulder problems, for which therapeutic exercise (TE) is
considered as an effective treatment intervention. Existing evidence suggests that its efficacy may be augmented when is combined with manual therapy (MT).
However, the evidence regarding the effectiveness of this combined therapeutic approach is inconclusive.
Purpose: To investigate whether TE combined with MT is superior to TE alone in improving patient reported outcomes of pain and shoulder function in patients with
SIS.
Methods: A systematic review was designed in accordance to published guidelines and reported in line with PRISMA. Key databases were searched until November
2015. Studies were included if they were RCT study designs, comparing TE with MT to TE alone and included measures of pain and disability. The Cochrane risk-of-bias
tool was used to evaluate the quality of the included studies. Searching, data extraction and quality assessment was undertaken by 2 independent reviewers.
Heterogeneity in key characteristics precluded meta-analysis.
Results: From 1.469 articles 15 full text articles were evaluated, resulting in 7 included RCTs. Methodological deficits found in the majority of the studies, conduct of
the studies; unclear randomisation methods; inadequate allocation concealment, raising doubts for the accuracy of the results. Thus 3 studies were classified as
having high risk of bias while 3 had unclear risk of bias. Only one study (n=90) had low risk of bias, in which, the intervention group (TE with MT) reported a minor
decrease of mean pain, measured by the visual numeric rating scale, at five weeks (RR of 1.46; 95% CI 1.01-2.10), indicating a minor additional effect of MT in a single
TE programme.
Conclusion: Limited evidence suggests that MT may enhance the effectiveness of a single TE programme in improving pain and shoulder function in SIS in the short
term. Poor quality coupled with heterogeneity of both interventions precludes strong conclusions to be drawn.
Implications: More methodologically high quality studies are required to evaluate further this combined therapeutic approach and establish the optimal TE
programme and MT regimen, thus allowing clinicians to take an evidence-based practice approach when treating patients with acute, subacute and chronic SIS.
Keywords: Exercise, Manual therapy, Shoulder impingement syndrome

PO3-MT-059
THE EFFECT OF SPINAL MOBILISATION ON KNEE EXTENSOR STRENGTH
L. Herrington*
Background: Arthrogenic inhibition of the quadriceps muscle has been found to occur following a variety of knee pathologies, a number of reasonably successful local
strategies have been used to reduce the impact of this problem and bring about improvements in recruitment and strength of quadriceps. There may though be the
possibility that more centrally directed (spinal cord level) interventions may also have positive benefits. Suter et al (2000) found sacroiliac joint manipulation
decreased quadriceps inhibition, whilst Hart et al (2010) found fatiguing the back extensors increased inhibition and decreased strength of the quadriceps.
Purpose: The aim of this study was to investigate the acute effects of passive mobilisation of the lumbar spine on quadriceps strength
Methods: Six male and 6 female subjects (age 20.4+/-1.0 years) participated, all were currently uninjured and physical active with no previous history of knee or spine
injury or pain. They all had on passive mobility testing (posterior-anterior pressure) at L3 an hypo-mobile stiff joint. Prior to lumbar spine mobilisation all subjects
had their knee extensor strength of their right leg tested concentrically at 60 deg/sec on a isokinetic dynamometer. All subjects then received 5 continuous minutes
of passive mobilisation to the lumbar spine, specifically a unilateral posterior-anterior mobilisation at L3 grade III (Maitland classification; large amplitude oscillation
moving constantly in and out of tissue resistance). After the mobilisation all subjects strength was retested. Smallest detectable difference values had already been
established for the strength test and were for peak torque 27.2Nm and for total work 20.5Nm.
Results: There was a significant change in strength (both peak torque (PT) and total work (TW)) between the pre and post mobilisation scores (PT p=0.002; TW
p=0.0001). The mean change in PT was 25(+/-22)Nm and for TW 29(+/-18)Nm.
Conclusion: In subjects with hypo-mobile L3 motion segments of the spine, mobilisation would appear to significantly increase the ability of the knee extensors to
generate force throughout the range of movement tested (total work). Mobilisation would also appear to increase the ability of the knee extensors to generate
maximal force (peak torque). But this change though statistically significant failed to exceed the reported value for SDD so the change seen could have been due to
chance or measurement error and so should be viewed with caution.
Implications: In patients with weak or inhibited quadriceps and if they also have reduced movement at L3, it may be worth considering mobilising the spine as this
might provide a significant adjunct to local means of regaining quadriceps strength and reducing inhibition.
Funding Acknowledgements: Nofunding was recieved
Ethics Approval: The project was approved by the University of Salford research ethics committee
Keywords: knee, spine mobilisation, strength

PO3-PA-068
WHAT IS IMPORTANT IN PAIN NEUROSCIENCE EDUCATION? THE EXPERIENCE OF PATIENTS WITH CHRONIC PAIN
A. Wijma 1,*, C. Speksnijder 2, A. Crom- Ottens 3, C. Knulst-Verlaan 4, D. Keizer 5, J. Nijs 6, P. van Wilgen 7
1
Faculty of Physical Education and Physiotherapy, Pain in Motion research group (www.paininmotion.be), 2. Transcare, Transdisciplinary Painmanagement Center,
the Netherlands, Vrije Universiteit Brussel, Brussel, Groningen, Belgium, 2Physical Therapy Science, Clinical Health Sciences. Scientific Institute for Quality of Health
Care. Department of Oral and Maxillofacial Surgery and Special Dental Care, University Medical Center Utrecht, 6.
Radboud University Nijmegen Medical
Center, Utrecht, Nijmegen, 3Department of Child Rehabilitation, Schepers Hospital, Emmen, 4Department of Physical Therapy, Lelie Healthcare, Capelle aan den IJsel,
5
Transdisciplinary Painmanagement Center, Transcare, Groningen, Netherlands, 6Faculty of Physical Education and Physiotherapy, Pain in Motion research group
(www.paininmotion.be), , Vrije Universiteit Brussel, Brussel, 7Faculty of Physical Education and Physiotherapy, Transcare, Transdisciplinary Painmanagement Center
,Pain in Motion research group (www.paininmotion.be), Vrije Universiteit Brussel, Brussel, Groningen, Belgium
Background: There is a large number of studies examining the effect of PNE in chronic pain disorders, these studies have found multiple positive influences, among
which: improved pain perceptions, decreased pain, improved functioning, diminished kinesiofobia and catastrophizing. However, the experiences of patients
regarding PNE are unknown. In a treatment that addresses patients perceptions it is important to know what these patients experiences (thoughts, emotions,
beliefs) are.
Purpose: The purpose of this study was to understand how patients experience pain neuroscience education.
Methods: Fifteen patients with chronic pain at a transdisciplinary treatment center were interviewed.
These patients first have a three hour intake (physiotherapist, psyhologist, GP). Followed by a consult with the Gp one week later where they receive short verbal PNE
and a booklet. One week later the patient receives PNE by both the psychologist and the physiotherapist. Afterwards, treatment options are discussed and if
necessary deployed.
Member checks were performed, furthermore a focus group with healthcare professionals from the transdisciplinary treatment center was conducted. Interviews
were transcribed verbatim. Analysis was done according to Grounded Theory and the QUAGOL.
Results: Four interacting topics emerged: 1) the pre-PNE phase, involving the primary needs in order to provide PNE, with the subthemes: a broad intake and the
healthcare professionals; 2) a comprehensible PNE containing understandable explanation and interaction between the physical therapist and psychologist; 3)
outcomes of PNE including the subthemes awareness, finding peace of mind and fewer complaints; 4)scepticism containing doubt towards the diagnosis and
PNE, disagreement with the diagnosis and PNE and PNE can be confronting.
Conclusion: This study is the first to gain insight in the experiences of patients with nonspecific chronic pain with PNE. The results of this study, with cautiousness
about generalization, provide information for healthcare professionals (physical therapists, psychologists) when giving PNE and can be used to facilitate healthcare
professionals in providing PNE.
Future work should focus on studying the experiences of PNE in different settings. To develop a holistic understanding of PNE, future research should also focus on
observing PNE in practice.
Implications: Even though one should be cautious when generalizing this study to clinical practice, there are some clinical implications. When providing PNE the
perceptual changes of patients with chronic pain will improve in a cognitive behavioral manner. However, this takes a thourough biopsychosocial intake, good
interpersonal skills of the healthcare professionals (among which physiotherapists)and a repetative, clear PNE. This all takes time, involvement and a biopsychosocial
view on pain. Whereby a team interaction enhances the outcomes of PNE.
Ethics Approval: This study was conducted complying with the Dutch law and international principles on research involving human subjects.
Keywords: chronic pain, Pain Neuroscience Education, Qualitative Research

PO3-SP-070
IS THORACIC MANIPULATION EFFECTIVE IN MANAGING SHOULDER DYSFUNCTION - A SYSTEMATIC REVIEW
P. Sanzo*, E. Yeung 1, L. Levesque 2, E. Maheu 3, T. Woodard 4, S. Michels 5, L. Bouin 6
1
Department of Physical Therapy, University of Toronto, Toronto, 2Western University, London, 3Physiothrapie Maheu Killens, Montreal, 4University of Manitoba,
Winnipeg, 5Therapeutic Mobility, Barrie, 6Clinique de physiothrapie de la Mauricie, Shawinigan, Canada
Background: Shoulder pain is a commonly reported disorder for which thoracic spine manipulation is an effective intervention. The therapeutic benefits of
manipulation have been attributed to an interaction between neurophysiological and biomechanical mechanisms as described by the Regional Interdependence
Model. Despite the increasing body of evidence examining the effectiveness of thoracic spine manipulation in the treatment of shoulder dysfunction, it has yet to be
summarized to inform clinical practice and future research.
Purpose: To summarize the evidence regarding the effectiveness of thoracic, cervicothoracic, or rib manipulation (TSM) for improving pain, range of motion (ROM),
and function in adults with shoulder dysfunction.
Methods: A comprehensive literature search was performed in five electronic databases from inception to November 2015. Using predetermined criteria, initial
abstract and title selection was performed by two independent investigators. Final article selection and data extraction was performed by two other
investigators. Methodological quality of the randomized trials (RTs) and non-RTs was assessed using the PEDro scale and the Quality Assessment Tool for Studies of
Diverse Designs (QATSDD), respectively. The body of evidence was synthesized using the Centre for Evidence Based Medicine 2009 and the Best Evidence Synthesis
guidelines.
Results: Five RTs and seven non-RTs met inclusion criteria. Scores ranged from 3-8/10 on PEDro and 52-92% on QATSDD. One excellent quality non-RT showed
changes in pain, ROM, and function. One RT and two non-RTs of good quality reported changes in pain scores. One RT of good quality demonstrated change in
shoulder ROM. One RT and one non-RT of good quality showed improvement in functional measures. Changes considered were statistically significant.
Conclusion: There appears to be weak evidence (grade C) to support the use of TSM for shoulder dysfunction. Synthesis of the current evidence using Best Evidence
Synthesis guidelines resulted in a practice consideration for the use of TSM in the management of pain, mobility, and functional limitations for adults with shoulder
dysfunction. Further efforts to publish quality evidence would be beneficial to further advance this recommendation.
Implications: Promising results related to manipulation of the thoracic spine, cervicothoracic junction region, or ribs for the treatment of shoulder dysfunction are
available. Future research should include more studies with larger sample size, longer follow-up periods, more detailed and explicit descriptions of the techniques,
consistent use of outcome measures, and the integration of psychosocial factors.
Funding Acknowledgements: No funding was received for this research project.
Ethics Approval: Ethics approval was not obtained for this systematic review.
Keywords: Cervicothoracic, rib, costal, thrust, glenohumeral

PO4-AP-003
EFFECT OF ATTENTIONAL FOCUS ON THE MOTOR SYSTEM EXCITABILITY ASSESSED BY SINGLE PULSED TRANSCRANIAL MAGNETIC STIMULATION IN HEALTHY
SUBJECTS: A PILOT STUDY.
G. Rossettini*, M. Testa 1, M. Vicentini 2, P. Manganotti 3
1
Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Campus of Savona, Italy, Master in
Musculoskeletal Rehabilitation Disorders, Savona, 2Private practice, Verona, 3Department of Medical Science, Surgery and Health, University of Trieste, Clinical
Neurology Unit, Trieste, Italy
Background: Recently therapeutic exercise has gained much attention in physiotherapy. The achievement of an effective learning and motor performance represents
an everyday challenge in clinical setting. This goal is pursued by different cognitive facilitations such as verbal instructions and feedbacks that direct attentional focus
of performer to the body (Internal Focus of Attention IFA) or the movements outcome (External Focus of Attention EFA). While several studies showed EFA to be
more effective than IFA to improve motor performance on healthy subjects and patients with musculoskeletal disorders and neurological dysfunctions, the cortical
excitability of motor system related to IFA or EFA was much less studied.
Purpose: The objective of this study was to investigate motor performance, patients preference and motor system excitability induced by IFA and EFA.
Methods: A within-subjects pilot study was executed. 10 healthy right-handed participants (28.1 2.64 years; 4 women, 6 man) performed a finger movement task
with right hand in a counterbalanced order (control, EFA, IFA conditions). Motor performance errors and patients preference were recorded. Cortical and spinal
motor evoked potentials (MEPs) were assessed by a single pulsed transcranial magnetic stimulation (TMS) applied over left and right primary motor cortex (M1) and
cervical spinal cord. The repeated ANOVA, and the Wilkcoxon test for paired data were adopted.
Results: EFA determined a better motor performance (3.4 1.35 errors) compared to control (8.2 2.20 errors) and IFA (9.9 1.60 errors) (p < 0.01). No differences
were found between control and IFA conditions. Participants preferred EFA (60%) against IFA (20%) and control (20%). TMS stimulation in left M1 caused a higher
response compared to stimulation in right M1 and spinal cord (p < 0.001). Although not statistically relevant, it was detected an incremental trend for the three
conditions MEPs (EFA > IFA > control) under left M1 hot spot stimulation (EFA: 1853 1156 millivolts, IFA: 1575 1104 millivolts, Control: 1084 799 millivolts).
Conclusion: Our results confirm that EFA positively influences motor performance and participants preference more than IFA and control. Their effects are evident
on behavioural data and on motor excitability as revealed by MEPs amplitude and seem located more at cortical level than at spinal level. Due its clinical relevance,
the interaction between attention and motor system has to be further investigated in trials with a large sample size and in subjects with musculoskeletal disorders.
Implications: EFA instruction helps learners to achieve sooner a more advanced level of performance. Physiotherapists and instructors should consider this cognitive
strategy when they administer instructions and feedbacks to their patients or athletes during therapeutic exercises.
Funding Acknowledgements: The authors declared no potential conflicts of interest and received no financial support for the research.
Ethics Approval: The Institutional Review Board approved the study.
Keywords: Attention, Motor Skills, Transcranial Magnetic Stimulation

PO4-CS-011
MUSCULOSKELETAL BIOMECHANICAL FEATURES OF THE UPPER CERVICAL SPINE AND 3D ANATOMICAL MODELING: REAPPRAISAL OF MANUAL TECHNIQUES?
B. Beyer 1, S. Sobczak 2, V. Feipel 3, P.-M. Dugailly 4,*
1
Department of Anatomy, Faculty of Medicine - Universit Libre de Bruxelles, Brussels, Belgium, 2Dpartement d'Anatomie, Universit du Qubec Trois-Rivires,
Trois-Rivires, Canada, 3Department of Anatomy, 4Department of Osteopathy, Faculty of Motor Sciences - Universit Libre de Bruxelles, Brussels, Belgium
Background: Several studies have focused on kinematics analysis and musculoskeletal modeling of the upper cervical spine (UCS) during manual mobilisation
techniques. However, integration of motion, suboccipital ligaments and muscles data into specimen-specific 3D UCS models is not reported yet.
Purpose: The aims of the present study were (1) to assess alterations of length and moment arm of UCS anatomical structures (i.e. muscles and ligaments) and (2) to
develop 3D modeling with motion representation including musculoskeletal biomechanical features.
Methods: Based on a previous in-vitro experimental study, UCS anatomical modeling and kinematics data were processed for 8 specimens. Identification of
suboccipital ligaments and muscles was carried out using a virtual palpation method of anatomical landmarks. Length and moment arm data were computed for 5
discrete positions of UCS in both axial rotation and flexion extension. Data reliability and error propagation on outcomes were also analysed.
Results: In general, a significant effect of UCS position was observed either for both analysed motions.
Regarding axial rotation, outcomes showed three categories of length and moment arms alterations: (1) with both negligible length and moment arm variations, (2)
with simultaneous length and moment arm variations of an identical sign and (3) with length and moment arm variations of an opposite sign. Greater changes were
demonstrated for atlantoaxial ligaments, tectorial membrane, rectus capitis posterior major and obliquus capitis inferior muscles. Concerning flexion extension,
length alteration was greater than 15% for most structures. Larger moment arms were observed for posterior ligaments and muscles such as occipito-atlanto-axial
membranes and rectus capitis posterior muscles (i.e. major and minor), respectively.Based on data outcomes, UCS positioning should be considered to involve length
and moment arm of the structures of interest depending on the technique objective. As an example, when an operator intends to use MET focused on OCI muscle,
homolateral axial rotation positioning of UCS (C1-C2) should be recommended to provide a greater moment arm during contraction of the latter.
Conclusion: Biomechanical features of UCS ligaments and muscles were analysed for axial rotation and flexion extension. Musculoskeletal modeling was achieved for
both anatomical structure types including motion representation. Considering these outcomes, manual approaches such as muscle energy technique may be
reappraised and further investigations are needed.
Implications: The present data may be considered for clinical use and further development of cervical spine manual approaches. Pedagogical application is available
for better understanding of manual techniques and their biomechanical implications.
Funding Acknowledgements: The present work was unfunded
Ethics Approval: The present study was based on cadaveric investigations that does not require ethics approval.
Keywords: cervical biomechanics, manual techniques, upper cervical spine

PO4-CS-012
UPPER CERVICAL SPINE MOBILIZATION IN PATIENTS WITH CERVICOGENIC HEADACHE: CLINICAL PREDICTION RULES
M. Malo-Urris*, J. M. Trics, C. Hidalgo, S. Prez, E. Bueno, A. Ruiz de Escudero, P. Fanlo, E. Estbanez, A. Carrasco, S. Cabanillas
Background: Manual therapy has a important role on headache treatment. Nevertheless, the responsiveness of each patient to manual therapy techniques can differ.
Purpose: To design Clinical Prediction Rules for upper cervical mobilization treatment in patients with cervicogenic headache.
Methods: A clinical trial with 82 patients with cervicogenic headache was performed. Initially, patients were assessed to determine their clinical characteristics.
Patients received 3 sessions of manual therapy treatment of the upper cervical spine. One month later, the Global Perceived Effect was assessed using a -5 to +5
scale. Participants were considered as Responders if presented +4 or +5, and Non-Responders if presented less than +4. Clinical characteristics of Responders
were analyzed using a Multivariate Regression Analysis.
Results: Two different models of prediction were designed. The first model, using all examination variables, include hypomobility of C0-C1, presence of active
myofascial trigger points in suboccipital muscles and a level of headache intensity less than 750. This model presents a probability of improvement of 47% if one
variable is present, 61% if two variables are present and 90% if three variables are present. The second model, using only variables obtained by Anamnesis, include a
minimum VAS of 0, a duration of headache less than 12 hours and the absence of nausea associated to headache. This model presents a probability of improvement
of 47% if one variable is present, 58% if two variables are present and 82% if three variables are present.
Conclusion: Two models of prediction have been designed, allowing identify patients with cervicogenic headache that present a greater probability of success after
manual therapy treatment of upper cervical mobilization.
Implications: Identification of a clinical prediction rule benefit the physical therapist decision making.
Ethics Approval: Comit tico de Investigacin Biomdica de Aragn
Keywords: Cervical manipulation, Headache, Manual Therapy

PO4-CS-013
GLOBAL POSTURAL RE-EDUCATION AND EXERCISE THERAPY IN THE TREATMENT OF INTERNAL DISORDERS OF THE TEMPOROMANDIBULAR JOINT. A CASE
SERIES.
L. Henriquez 1,*, L. Palomer 2, J. Leppe 2, K. Evans 3
1
Physical Therapy, Universidad San Sebastin, 2Physical Therapy, Universidad del Desarrollo, Santiago, Chile, 3Physiotherapy, School of Allied Health Sciences, Griffith
University, Gold Coast, Australia
Background: The most common reason people with temporomandibular disorders (TMD) seek treatment is persistent, and often severe, orofacial pain that affects
their activities of daily living and quality of life. Given the recalcitrance of many TMDs, and the subsequent associated health care costs, identifying patients at the
acute stage of the disorder and implementing effective treatment strategies may help prevent the development of chronic pain and disability.Signs and symptoms of
TMD include craniofacial pain, altered jaw mobility, changes in the ability to occlude the teeth fully, tinnitus and joint clicking. Physical therapy, either independently
or with other interventions, is commonly used for treating TMDs. Global Posture Re-education (GPR) is an approach that is based on the assumption of two muscle
chains, divided into posterior and anterior chains, and the theory that alterations in the relationship between these chains can produce pain and dysfunction.As an
intervention, GPR involves all muscles of the same chain being simultaneously stretched. Both GPR and static stretching have been found to be similarly effective for
reducing pain and EMG activity in people with TMD with a muscular component but the effect of GPR for people with TMD with internal derangement has not yet
been evaluated.
Purpose: To determine the effectiveness of a physical therapy treatment based on Global Postural Re-education (GPR)and exercise therapy in patients with
temporomandibular joint (TMJ) internal disorder,discal displacement with reduction.
Methods: Sixteen participants (12 females; mean age = 20.5 years, range 18-24 years) were recruited. Joint sounds (click score) with six jaw movements were given a
value of two points if audible but one point if only audible with a stethoscope. TMJ pain with movement and pain on palpation was rated on a visual analogue scale.
Participants also completed the Spanish version of the Hospital Anxiety and Depression Scale(HADS). Treatment consisted of re-positioning skull-cervical-jaw and
adding functional movements and exercises for the tongue, lip and jaw. Participants received six sessions of one hour of treatment for six weeks. Pre and postintervention scores and correlations between the variables were evaluated using the Wilcoxon statistic and Spearman correlation with significance p<0.05.
Results: Following the intervention, there was a significant decrease in the click score (p<0.01) and pain on opening (p<0.01) but no change with pain on palpation
(p=0.29).There was also a significant reduction in HADS scores following the intervention(p <0.01) but there was no correlation between HADS scores and clinical
signs and symptoms.
Conclusion: In this case series, the combination of GPR and exercise therapy reduced clinical signs and symptoms in patients with TMD in a relatively short period of
time. The improvements in clinical variables were independent of improvements reported by participants in levels of anxiety and depression.
Implications: The results of this study support the use of this combined therapeutic approach in the management of people during initial stages of internal disorders
of the TMJ. Findings from this study will inform future, larger studies investigating optimal treatment approaches for patients with TMD.
This study shows that this therapeutic approach could help reverse internal disorders of the temporomandibular joint in early grades, and potentially can help to
prevent more serious diseases.
Funding Acknowledgements: The study was supported by internal funds of Universidad San Sebastian (number 5006 ) .
Ethics Approval: Approval for the project was granted by the physiotherapy school of San Sebastian University.
Keywords: Global Postural Reeducation, pain management, Temporomandibular Joint

PO4-CS-019
ADVERSE EVENTS AFTER CERVICAL SPINAL MANIPULATIVE THERAPY: CONSENSUS BASED CLASSIFICATION AND DEFINITIONS
R. Kranenburg 1 2,*, S. Lakke 1, M. Schmitt 1, C. Van der Schans 1 2
1
Research group Healthy Ageing, Alied Health Care and Nursing, Hanze University of Applied Sciences, 2Department of Rehabilitation, University Medical Center
Groningen, Groningen, Netherlands
Background: Cervical spinal manipulations (CSM) are frequently used techniques to alleviate neck pain and headache. Minor and major complications following CSM
have been described, though clear consensus on definition and the classification of the complications had not yet been achieved. As a result, incidence rates may be
underestimated.
Purpose: The aim of this study was to develop a consensus-based classification of adverse events following cervical spinal manipulations for registering adverse
events (AE) in clinical practice and research.
Methods: The Delphi-method was applied. Dutch medical specialists (n=10), manual therapists (n=11), and patients (n=9) participated in an online survey. In Round 1,
potential complications were inventoried and detailed in accordance with the ICF and the ICD-10. In Round 2, panel members categorized the potential complications
in their selected classification. During the third round, participants were asked if they could agree with the proposed classification, as stated by the majority of the
participants.
Results: Thirty-four complications of CSM were defined. Consensus was achieved for 29 complications for all durations [hours, days, weeks]. For the remaining five
complications, consensus was reached for two of the three durations [hours, days, weeks].
Conclusion: A consensus-based classification system of adverse events after cervical spinal manipulation was developed which comprises patients and clinicians
perspectives, and has only a small number of categories. The classification system includes a precise description of potential adverse events and is based on
international accepted classifications (ICD-10 and ICF). This classification system may be useful for registering adverse events in both clinical practice and research.
Implications: It is recommended to further study the feasibility of this framework for daily use and that new adverse events are added to the list.
Ethics Approval: The Medical Ethical Committee of the University Medical Center Groningen, The Netherlands, provided a waiver for this study.
Keywords: adverse events, Cervical manipulation, Delphi

PO4-CS-022
PATIENT AND PUBLIC INVOLVEMENT IN THE DESIGN OF A CLINICAL TRIAL TO INVESTIGATE THE ROLE OF POSTERIOR SHOULDER TIGHTNESS IN PATIENTS WITH
SHOULDER IMPINGEMENT
K. Hall*, D. Barron 1, C. Ridehalgh 2, A. Moore 3
1
Patient and Public Involvement, Sussex Research and Development , Brighton, 2Senior Lecturer, 3Professor of Physiotherapy, University of Brighton, Eastbourne,
United Kingdom
Background: Patient and Public involvement (PPI) refers to the process of engaging patients or members of the public in the design and conduct of research. The aim
is that research is conducted with and by patients and not only on them. The Department of Health Research Governance Framework recommends that patients
should be involved wherever possible in the design, conduct, analysis and reporting of research (DoH 2005).
Dudley et al. (2015) explored researchers and PPI contributors account of the impact of PPI on 28 separate trials and found that many reported little benefit of
involvement of the PPI contributors. They identified several factors that predicted the beneficial involvement of the public in the design of clinical trials. Our account
will describe its finding in the context of these recommendations.
Purpose: The purpose of this project was to engage patients and the public in the early design stages of a clinical trial entitled,
"The effectiveness of treatment for posterior shoulder tightness in combination with exercise compared with exercise alone in individuals with shoulder impingement
syndrome: a feasibility study."
This project will describe the perceived benefits of early engagement of PPI contributors and the impact this had on the design of trial interventions.
Methods: Six patients with shoulder impingement syndrome (SIS) attended a discussion relating to the design of a research trial investigating the impact of treating
posterior shoulder tightness in patients with SIS. Discussion was facilitated around the groups experience of physiotherapy prior to their listing for surgery in an
attempt to improve physiotherapy interventions. Of particular interest were patients understanding of how physiotherapy might help in the management of SIS, their
experience of therapeutic exercise and the level of engagement with physiotherapy.
Results: Several themes emerged from the discussion. Firstly there was a lack of clarity relating to instructions on the parameters of exercise, in addition patients
could not offer any explanation for the potential beneficial effects of therapeutic exercise and instead raised concerns about how physiotherapy might cause further
damage to their shoulders, demonstrating a high degree of fear avoidance and catastrophising:
- if its torn wont the exercises tear it more
- How do you know you are not doing more damage or [causing] more injury?
Conclusion: Our conclusions were that in order to promote engagement and adherence with the physiotherapy treatment a thorough educational intervention would
be required. This educational intervention will present the evidence relating to the therapeutic effect of exercise for SIS, the rational for the mechanisms of efficacy
and challenge patients beliefs relating to any pathoanatomical diagnosis, fear avoidance and catastrophising.
Outcomes before and after intervention will include an evaluation of patients beliefs relating to the perceived benefits of physiotherapy and a measure of their selfefficacy.
Implications: The Health Belief Model (HBM) suggests that people are more likely to take health-related action if they believe that by doing so they can avoid a
negative health condition. The aim of the educational intervention was to provide patients with clear mechanisms of benefit in terms of published research, but also
to explain potential mechanisms of recovery in the presence of structural pathology and the beneficial physiological processes such as mechaotransduction that can
be derived from therapeutic exercise. It is believed these processes will promote self-efficacy and adherence with the rehabilitation strategy. The outcomes were
redesigned in an attempt to capture this change in cognitions.
Funding Acknowledgements: A successful application was submitted to the Research Design Service South East (RDS SE) for a Public and Patient Involvement Grant.
The main study received NIHR Clinical Doctoral Research Fellowship (NIHR CDRF) funding in February 2015. NIHR will fund the ongoing involvement of PPI
contributors through the study. NIHR reference; CDRF-2014-05-003
Ethics Approval: Our engagement of patients and the public was coordinated throughout by Duncan Barron (Senior Research Fellow specializing in PPI with the
Research Design Service South East) and in accordance with INVOLVE guidelines.
Ethical approval for the main study has been provided by the University of Brighton Health and Social Science, Science and Engineering Research Ethics and
Governance Committee - Decision on Manuscript ID REGC-15-061.R1: Approved 02/11/15.
Keywords: Glenohumeral joint, Patient and public involvement

PO4-CS-025
THE EFFECTIVENESS OF NEURAL TISSUE MANAGEMENT STRATEGIES IN THE TREATMENT OF NERVE-RELATED NECK AND ARM PAIN: A STRUCTURED LITERATURE
REVIEW.
L. Galvin*, M. Grant
Background: Nerve-related neck and arm pain is a common condition that can have a significant impact on a persons physical and mental well-being. Neural tissue
management (NTM) strategies may include the use of a cervical contralateral lateral glide (CCLG) and/or nerve mobilisation. These strategies have been advocated as
a way of treating this condition. To date, there has been no structured literature review examining the effectiveness of this treatment.
Purpose: To systematically review and evaluate the evidence for the effectiveness of NTM strategies for the treatment of nerve-related neck and arm pain. Secondary
aims were to assess for common baseline characteristics of patients across studies and to evaluate the consistency of terminology used to describe this population
and intervention.
Methods: A database search for randomised controlled trials (RCTs) or randomised clinical trials from 01/01/1979 to 30/04/2015 was conducted using keywords
relating to nerve-related neck and arm pain/cervical radiculopathy/cervicobrachial pain or similar conditions. The primary intervention was required to include a NTM
strategy (CCLG and/or nerve mobilisation). A primary outcome measure for pain was also required. Data extraction was performed by LG relating to the primary and
secondary aims and each study was quality appraised using the Cochrane Collaboration Risk of Bias (RoB) tool by LG.
Results: 61 records were retrieved and data extraction and assessment of RoB was performed on 5 randomised clinical trials and 2 RCTs comprising 315 participants.
Five studies reported positive outcomes using a NTM strategy with four achieving clinically significant reductions in pain with follow-up of 3-8 weeks. Two studies
with conflicting results were rated as having a low RoB, 2 studies with an unclear RoB favoured NTM strategies while 2 of the remaining 3 studies with a high
RoB also favoured NTM strategies. Only 2 of the studies collected baseline data thoroughly regarding duration, distribution and quality of symptoms. Terminology for
the population varied across studies.
Conclusion: There is some evidence from the studies assessed that NTM strategies may provide short term pain relief. The results should be interpreted with caution
due to methodological flaws and small numbers within studies. If applied judiciously these techniques may be used to relieve pain in the short-term to facilitate
rehabilitation. In 2 methodologically sound studies adverse events from NTM strategies were reported as minor and short lived (<24 hours). Future studies should
seek to identify sub-groups of patients that may benefit from NTM strategies in addition to a self-management program with education, advice and exercise. Future
studies need to collect baseline data regarding duration, distribution and quality of symptoms to allow for analysis of subgroups within participants. Consistent use of
agreed terminology for this population across future studies will allow researchers and clinicians to more readily interpret and apply research findings.
Funding Acknowledgements: This work was unfuded
Keywords: Cervical radiculopathy, Manual Therapy, neurodynamics

PO4-EX-032
INABILITY TO PERFORM DUE TO MUSCULOSKELETAL PAIN AND INJURY IN ELITE ADULT IRISH DANCERS: A PROSPECTIVE INVESTIGATION OF CONTRIBUTING
FACTORS
R. Cahalan*, K. O'Sullivan 1, H. Purtill 2, N. Bargary 2, O. Ni Bhriain 3, P. O'Sullivan 4
1
Clinical Therapies, 2Mathematics and Statistics, 3Irish World Academy of Music and Dance, University of Limerick, limerick, Ireland, 4Physiotherapy, Curtin University,
Perth, Australia
Background:
Previous research in Irish dancing (ID) has reported high levels of pain and injury in this cohort. Screening protocols in other genres have been developed to identify
and address the needs of at-risk dancers. No prospective studies to support existing screening protocols or confirm retrospective findings have been conducted in ID.
Purpose: The purpose of this study was to prospectively examined the factors which relate to musculoskeletal pain and injury in ID, to inform guidelines for the
development of an evidence-based screening protocol.
Methods: Baseline subjective data (n=85) and physical data (n=84) were collected by experienced physiotherapists. Subjects completed a monthly online
questionnaire for one year providing data on general physical and psychological health and rates of pain/injury. Subjects were allocated to a More Injured (MI) or
Less injured (LI) category depending on their duration of absence from performance over the year.
Results: Eighty-four subjects completed the year-long follow up (MI: n= 32, LI: n=52). 278 complaints of pain/injury were recorded with only 15(17.9%) subjects
recording no dance absence throughout that period. Factors significantly associated with membership of the MI group included lower mood (anger-hostility subscale)
(p=0.003), more severe previous injury(s) (p=0.017), a higher level of general everyday pain (p=0.020), a higher number of subjective health complaints (p=0.026),
more body parts affected by pain/injury (p=0.028), always or often dancing in pain (p=0.028) and insufficient sleep (p=0.043). No physical factors were significantly
associated with membership of the MI group.
Conclusion:
Pain/injury in ID is commonplace. Several inter-related biopsychosocial factors appear to be associated with higher rates of pain/injury in this population. Screening
protocols should examine an extensive range of biopsychosocial factors to best identify at-risk dancers.
Implications:
Clinicians must be cognisant that Irish dancers may be at greater risk of pain/injury if suffering from numerous general health problems.
Taking a detailed history of previous pain intensity, impact and chronicity, as well as an assessment of psychological and general health complaints is vital.
Clinicians should record and monitor incidences of illness as well as injury under clearly defined parameters.
Funding Acknowledgements: One author (RC) is supported by a scholarship from the Faculty of Education and Health Sciences, University of Limerick, Ireland.
Another author (KOS) is supported by a research fellowship from the Health Research Board of Ireland.
Ethics Approval: Ethical approval was granted by the research ethics committee of the University of Limerick, Ireland.
Keywords: Dance, Injury, Pain

PO4-EX-033
STRENGTH DEFICITS IN ACHILLES TENDINOPATHY?: A SYSTEMATIC REVIEW OF THE LITERATURE.
S. Mc Auliffe*, K. Mc Creesh, K. O'sullivan, H. Purtill, A. Tabunea, S. O'Neill
Background: Tendinopathy is a term commonly used to describe the clinical presentation of tendon symptoms which includes localised tendon pain with loading,
tenderness to palpation and impaired function. Strengthening exercises are regarded as an effective intervention for achilles tendinopathy, but the specific
mechanisms behind its effects have not yet been fully elucidated. Thus, it is important to firstly establish the exact strength deficits present in those with achilles
tendinopathy.
Purpose: To systematically review the evidence regarding baseline differences in strength parameters between individuals with Achilles tendinopathy and healthy
controls.
Methods: Eight electronic databases were searched using an agreed set of keywords. Cross sectional studies that compared baseline strength measures preoperatively/pre-intervention between subjects with achilles tendinopathy and healthy controls or between injured and non-injured sides within an achilles
tendinopathy population were included.
Results: 16 studies were included for final review. All studies but one selected active athletes as their subjects. The mean ages of the participants were very similar
between studies, ranging from 20 to 58 years. The majority used isokinetic dynamometry to assess strength deficits, while a small number of studies compared
hopping/jumping type activities. Overall, the majority of the studies reported that the non-injured side/healthy controls were significantly stronger than the injured
side/individuals with AT. Eccentric PF PT was found to be the most consistent and sensitive as significant findings were reported for all velocities(p<0.05). A consistent
significant difference in hopping distance in favour of the healthy/uninjured group was found in three studies (p<0.05).
Conclusion: Based on the studies included in this review, it appears that patients/legs with achilles tendinopathy display deficits in strength parameters compared to
those without achilles tendinopathy.
Implications: The results in this review may help inform us of which strength measures are consistent and are sensitive enough to distinguish between injured and
non-injured legs/population. Furthermore identification of strength deficits in achilles tendinopathy may inform tailored rehabilitation to address deficits.
Keywords: Isokinetic, Plyometric, Plyometric

PO4-EX-034
AN APPLIED STUDY OF WHIPLASH IN A SPORTING CONTEXT: FINDINGS AND IMPLICATIONS
A. Clough 1,*, P. Clough 2, F. Earle 3, J. Horne 3
1
Physiotherapy, Hull & east Riding Hospital Trust, Hull, 2Psychology, Manchester Metropolitan University, Manchester, 3Psychology, University of Hull, Hull, United
Kingdom
Background: Whiplash associated disorders are frequently presented to medical professionals, often as a results of RTA's. However, they are rarely reported by
athletes, despite the rigours of an involvement in this type of activity. The reasons for this dispartity are explored and discussed.
Purpose: The lack of WAD injuries in sports people is perplexing. It is important to understand why this occurs and to try and identify if this is a diagnostic or labelling
issue, or whether it is a 'real' difference. This information will allow for better treatment outcomes and the greater sharing of knowledge and best practice.
Methods: Six professional Super League level, rugby players (UK) participated in this study. Impacts/collisions were measured over a season, using Global Positioning
Sports SPI-Pro X 15 Hz (GPSports) units .
In addition, squad players and physiotherapy staff were interviewed during the season and injury records examined.
Results: One of the key findings of the current research was the large number of impacts experienced by players, including many severe ones. The results show that
the impact forces within rugby league are similar to those reported in studies focussing on RTAs where WAD has been reported.
Contrary to these objective findings, Whiplash Associated Disorders were not reported by players or clinicuians within the club during the season.
There were differences in the number and extent of impacts depending on the payer positions. Fowards experiencing more physical trauma.
Conclusion: Previous research has shown that the types of impact experienced by the players in the present study are sufficient to produce WAD. However, none
were prsented in this sample.
The results of this study, showed that the back row Forwards had the highest number of total impacts per match, the Backs experienced the highest number of
severe impacts and the front row Forwards had the fewest number of impacts, demonstrating that, whilst all players experience significant impacts, this was
particularly noticeable in second row forwards and was least common in front row forwards.
The lack of WAD's could be the result of many factors including (a) diagnostic varitions between sport clinicians and non sport clinicians (b) the training and
physiology of players and/or (c) the actual forces experienced.
Implications: It is hoped that the findings from this study may be of value to clinicians working within and outside sport. There are three key recommendations: (a)
Failure to treat this type of injury correctly and in a timely manner may have negative consequences on the health of players, both in the short term and throughout
their lives (b) There should be an acknowledgement and awareness in the therapy community that there are objective measures available to help support subjective
measures and (c) There should be a widening/broadening of the bio-psychosocial yellow flags to include sports related issues.
,
Ethics Approval: This study was approved by the Ethics Committee of the Department of Psychology at the University of Hull, according to the British Psychological
Society's guidelines for research with human participants
Keywords: Whiplash Associated Disorders sport

PO4-LB-036
ARE DEEP AND SUPERFICIAL REGIONS OF THE LUMBAR MULTIFIDUS DIFFERENTIALLY ACTIVATED DURING WALKING AT DIFFERENT SPEEDS AND INCLINATIONS?
R. Crawford 1 2, L. Gizzi 3, A. Ni Mhuiris 1,*, D. Falla 3
1
Centre for Health Sciences, Zurich University of Applied Sciences, Winterthur, Switzerland, 2Faculty of Health Professions, Curtin University, Perth, Australia,
3
Institute for Neurorehabilitation Systems, University Medical Centre, Gttingen, Germany
Background: Lumbar multifidus is a complex muscle with multi-fascicular morphology shown to be differently controlled in healthy individuals during sagittal plane
motion. However, only a modest literature describes activation patterns within multifidus during common functional activities like walking, even though walking is
commonly promoted as beneficial in optimising low back health.
Purpose: To determine activation patterns for deep and superficial multifidus and superficial lumbar erector spinae (ES) in young adults during walking under various
conditions.
Methods: Ten healthy volunteers in their twenties (3F, 7M) walked on a treadmill in eight conditions; at 2km/h and 4km/h, each 0, 1, 5 and 10 inclination. Subjects
walked continuously for 2min/condition, with 45-60s rest between each. Intramuscular electromyography (EMG) was recorded from the deep and superficial
multifidus unilaterally at L5 using bipolar Teflon-coated stainless steel fine wire electrodes inserted under ultrasound guidance according to an established method.
Surface EMG was recorded from the ES at the level of L3. Activity was characterised by: amplitude of peak of activation (normalized to maximal activity at slow
speed/0% inclination), position of peak activity within the gait cycle (0-100%), and duration of muscle activity as a percent relative to the full gait cycle. Peak
amplitude, peak position, and activity duration were computed for each of the central 41 gait cycles considered for each condition; average values were retained for
statistical analysis by ANOVA.
Results: Across all conditions superficial fibres of multifidus showed higher normalized EMG amplitude compared to deeper fibres (p<0.01); relative to average
amplitude during walking at slow speed without inclination, superficial multifidus peak amplitude was 232115% higher when walking at the faster speed with 10 of
inclination, versus only 17277% higher for deeper multifidus (p<0.01). Peak ES activity was dependent on condition (F=2.7, p=0.02) with higher activity observed at
the faster speed/10 condition compared to the slow speed/1 condition (p<0.05). The percentage of the gait cycle where peak EMG amplitude was detected
(multifidus (both): 4913%; ES 4816%) did not differ with speed or inclination. Deep multifidus duration of activation was longer when walking at all inclinations at
the faster speed compared to the slow speed (p<0.01); this finding was not evident for superficial multifidus or ES (both p<0.05). Thus, a significantly longer activation
of deep multifidus was observed compared to superficial multifidus and ES when walking at faster speed (p<0.05).
Conclusion: Differential activation of deep and superficial lumbar multifidus was shown in young healthy volunteers with varied walking conditions. The prolonged,
more tonic, activation of the deep relative to superficial regions of multifidus during gait supports a postural function of the deeper fibres.
Implications: Further studies are warranted to examine the influence of factors such as age or pain on activation within lumbar paravertebral muscles during
common functional activities.
Funding Acknowledgements: No external or third party funds were recieved.
Ethics Approval: Ethical approval was granted by the Universittsmedizin Gttingen, Germany.
Keywords: Electromyography, Multifidus, Walking

PO4-LB-038
DOES CERVICAL LORDOSIS CHANGE AFTER SPINAL MANIPULATION FOR NECK PAIN? A PROSPECTIVE COHORT STUDY
J. Branney 1,*, M. Shilton 2, B. Penning de Vries 2, A. Breen 3
1
Faculty of Health and Social Sciences, Bournemouth University, 2Anglo-European College of Chiropractic, Bournemouth, United Kingdom, 3Institute of
Musculoskeletal Research & Clinical Implementation, Anglo-European College of Chiropractic, Bournemouth, United Kingdom
Background: The Global Burden of Disease (2010) study suggests that the prevalence of neck pain-related disability is higher than previously estimated and that the
burden it places on society and healthcare can be expected to rise with an ageing world population. Most neck pain is considered to be mechanical in nature but no
treatments directed at mechanical neck pain show clear superiority or large effect sizes. It has been proposed that the amount of lordosis (sagittal alignment) in the
cervical spine is important for treatment and prognosis. However, the importance of cervical lordosis in relation to neck pain is controversial and has yet to be
substantiated by high quality prospective research. Further, there is a paucity of evidence investigating the ability of spinal manipulative therapy (SMT) to alter spinal
alignment.
Purpose: The objectives of this study were:
1.
To determine the intra-observer and intra-subject repeatability (measurement error and reliability) for cervical lordosis measurement (posterior tangent
method) in healthy volunteers
2.
To determine whether cervical lordosis changes after a course of spinal manipulation for non-specific neck pain
Methods: Posterior tangents of C2 and C6 were drawn on the lateral cervical fluoroscopic images of 29 patients with subacute/chronic non-specific neck pain and 30
healthy volunteers matched for age and gender, recruited August 2011 to April 2013. The resultant angle was measured using Image J digital geometric software.
The intra-observer repeatability (measurement error and reliability) and intra-subject repeatability (minimum detectable change (MDC) over 4 weeks) were
determined in healthy volunteers. A comparison of cervical lordosis was made between patients and healthy volunteers at baseline. Change in lordosis (greater than
or equal to the MDC) between baseline and follow-up was determined in patients receiving a 4-week course of spinal manipulation.
Results: Intra-observer measurement error for cervical lordosis was acceptable (SEM 3.6) and reliability was substantial ICC 0.98, 95 % CI 0.9620991). The intrasubject MDC however, was large (13.5). There was no significant difference between lordotic angles in patients and healthy volunteers (p =0.16). The mean (SD)
cervical lordotic increase over 4 weeks in patients was 2.1(9.2) which was not significant (p = 0.12). In only four patients was cervical lordosis increased by at least
the MDC.
Conclusion: This study found no difference in cervical lordosis (sagittal alignment) between patients with mild to moderately-disabling neck pain and matched healthy
volunteers. Furthermore, there was no significant change in cervical lordosis in patients after 4 weeks of cervical spinal manipulation.
Implications: The determination of whether or not to apply cervical SMT to a patient with neck pain, or to assess the outcome of SMT, cannot currently be based on
the sagittal alignment of the cervical spine. Rather, as recommended in the literature, this should be determined via a process of clinical reasoning that seeks to rule
out non-mechanical causes of neck pain, takes account of the risks and benefits of treatment, the practitioners experience and the preferences of patients.
Funding Acknowledgements: Funding for this study was provided by the EAC European Chiropractors Union Research Fund and the AECC TAM Club.
Ethics Approval: Ethical approval for the parent study from which the radiographic images were acquired was granted by the UK National Research Ethics Service
South West Cornwall & Plymouth (11/SW/0072).
Keywords: Cervical manipulation, cervical spine, neck pain

PO4-LB-040
ASYMMETRIC TRUNK RANGE OF MOTION IN COLLEGE FEMALE STUDENTS WITH LOW BACK PAIN
K. Akasaka 1 2,*, A. Tamura 2 3, T. Otsudo 1 2, Y. Sawada 1, Y. Okubo 1 2, H. Igarashi 1, S. Yoshida 1
1
Physical Therapy, 2Graduate School of Medicine, Saitama Medical University, Saitama, 3Rehabilitation, Sekishindo Hospital, Kawagoe, Japan
Background: Low back pain (LBP) is one of the major causes of disability during activities of daily living or working. According to reports, the rate of complaints related
to LBP is approximately 15 to 25% of the Japanese population. Previous studies have suggested that heavy physical work with bent or twisted position of trunk
associates the development of LBP. In addition, overloads of working or daily living tasks may cause asymmetric trunk motion by occurring some physical changes
with repetitive mechanical stress. However, the asymmetric of trunk rotation angle of the subjects with a history of LBP has not been clarified.
Purpose: The purpose of this study was to investigate the asymmetry of trunk side-flexion and rotation angle of the subjects with history of LBP during active trunk
movements by three-dimensional motion analysis system.
Methods: Thirty-four college females (age: 21.10.9 years old; height: 160.95.6 cm; weight: 53.65.4 kg) volunteered to participate in this study. All participants
gave written informed consent for participation prior to testing. They were required to have no history of orthopedic trunk surgery and no current symptoms of LBP.
They were dichotomously categorized into either LBP group (n=14, the subjects with a history of LBP within the last 5 years) or non-LBP group (n=20, the subjects
with no history of LBP within the last 5 years). Three-dimensional motion analysis system with eight cameras (Vicon MX, 120Hz) was used to record trunk angle data.
All participants performed the trunk flexion, extension, rotation and side-flexion to right and left by active range of motion (ROM) test on sitting. Each ROM was
measured as angles between thorax and pelvis segments. Trunk ROM () of each motion were calculated. Absolute values of the differences were calculated for each
rotation and side-flexion. Rotation and side-flexion asymmetries (%ROM) were also calculated as a ratio of the absolute value of the differences to the sum of each
bilateral ROM, respectively. Un-paired T test was used to identify differences in these variables between each group.
Results: Trunk flexion, extension and side-flexion ROM had no differences between LBP group and non-LBP group. Trunk rotation ROM in the LBP group was
significantly smaller than one in the non-LBP group (LBP; 59.9 10.1 , non-LBP; 68.2 9.1 , P<0.05). Trunk rotation asymmetry in the LBP group was significantly
larger than one in the non-LBP group (LBP; 8.3 4.9%, non-LBP; 5.1 3.7 %, P<0.05), while trunk side-flexion asymmetry had no difference between each group (LBP;
6.1 5.4%, non-LBP; 5.8 5.4 %, P>0.05).
Conclusion: In the situation of daily living or working, most tasks include asymmetric movement for the specific direction and impose excessive rotational motion. The
limited ROM and the asymmetry of trunk rotation may cause by being imposed repetitive mechanical stress on the habitual excessive motion. From our results, the
subjects with a history of LBP had small trunk rotation ROM and large asymmetry in comparison with the subjects with no history of LBP. Our findings indicated that
the asymmetric or limited rotation ROM might effect to the development of LBP.
Implications: These results indicated that asymmetry of trunk rotation may be one of the considerable parameter in the prevention of LBP.
Ethics Approval: This study followed the Declaration of Helsinki and was approved by the Ethics Committee at the Saitama Medical University, Saitama, Japan (M-65).
Keywords: low back pain, range of motion, symmetry

PO4-LB-043
CONSIDERATIONS FOR TREATING PATIENTS WITH LOWER LIMB AMPUTATION FOR LOW BACK PAIN
K. Taylor 1,*
1
School of Physical Therapy & Rehabilitation Sciences, University of South Florida, Tampa, United States
Background: Approximately 50-90% of all people will experience low back pain (LBP) at some point in their lifetime. A 2002 survey found that 26.4% of U.S. adults
reported LBP lasting at least 1 day within the previous 3 months. Overall prevalence of LBP among individuals with lower limb amputation (LLA) is reported at 52-71%.
More specifically, LBP prevalence has been reported at 62% for those with transtibial LLA and 81% for those with transfemoral LLA.
Purpose: The purpose of this presentation is to provide clinicians with an updated review of evidence regarding LBP in persons with LLA: development, treatment,
and implications of post-LLA changes on treatment.
Methods: Literature regarding LBP in individuals with LLA was collected using databases available through the U.S. Department of Veterans Affairs. Article titles and
abstracts retrieved from searches were reviewed for relevance. Full-text versions of relevant articles were obtained, read, and summarized. Information is presented
in this presentation/abstract.
Results: One quarter of persons with LLA and LBP rate their average pain as moderate and 31% severe. LBP interferes with daily activities in 85% of those with LLA to
some degree (minimal, moderate, or severe). Persons with LLA rate their LBP as more bothersome than residual limb pain and phantom limb pain (PLP). After LLA,
physical changes can include increased insulin levels, increased risk of abdominal aortic aneurysm (AAA), and increased risk of cardiovascular disease (CVD) even
when compared to to people of equal physical activity. There are observable biomechanical changes following LLA that can have significant effect at the lumbar spine.
Both movement asymmetries and muscle work asymmetries should be considered with regard to the development of LBP. Psychological and social changes after LLA
include increased depression prevalence, decreased social interaction, and higher levels of pain correlated with decreased socialization and decreased functional
activity. Greater psychosocial overlay (e.g. traumatic brain injury and post-traumatic stress disorder) in U.S. military personnel may contribute further to Veterans and
Active Duty individuals developing LBP after LLA. Furthermore, there is an evident correlation between poor quality of life and LBP in U.S. Veterans after LLA that is
stronger than presence of PLP or more proximal LLA levels.
Conclusion: LBP is a multifactorial problem that is further complicated by physical, psychological, social, and quality of life changes following LLA. Development of LBP
cannot be explained solely by the presence of biomechanical differences. Individuals with LLA are at higher risk of developing CVD and LBP that may be nonmusculoskeletal (MSK) in nature compared to those without LLA with similar activity levels. The validity of utilizing conservative evaluation and intervention
approaches such as treatment-based classifications has not been established and there is currently no clinical practice guideline that offers clinicians guidance to
treating LBP specific to this population. Further research must be performed to establish the validity of treatment approaches commonly used by physiotherapists to
prevent and alleviate LBP in people with LLA.
Implications: LBP is a common occurrence in individuals with LLA that is often overlooked. Individuals with LBP and LLA are likely to benefit most from a multidisciplinary approach to treatment of LBP based on the multi-factorial nature of LBP that is further complicated by limb loss. Clinicians should ensure vigilant
screening and review of systems with this population secondary to increased risk of developing non-MSK diseases that may present as LBP (e.g. AAA, CVD).
Funding Acknowledgements: No funding acknowledgements required. Part of this project was undertaken by the author as part of the Orthopaedic Physical Therapy
Residency Program at the James A. Haley Veterans' Hospital in Tampa, Florida, USA. The contents do not represent the views of the Department of Veterans Affairs or
the U.S. Government.
Ethics Approval: No ethics approval required.
Keywords: amputation, Evidence informed management, Low Back Pain

PO4-LB-046
PATIENTS BELIEFS ABOUT THE INFLUENCE OF ACTIVITY ATTENUATES THE IMPROVEMENT IN PAIN AND DISABILITY AFTER A CONSERVATIVE TREATMENT IN
CHRONIC LOW BACK PAIN PATIENTS
R. Cabral 1, F. Belache 2, M. Santos 3, A. C. Magalhes 3, N. Meziat 1, L. C. Nogueira*
1
UNISUAM, 2Gaffre and Guinle University Hospital, 3IFRJ, Rio de Janeiro, Brazil
Background: Fear avoidance beliefs can influence at baseline pain intensity and lumbar disability. However, there is a lack of information about the fear avoidance
beliefs influence on the improvement of the pain and disability of the chronic low back pain patients who underwent conservative treatment.
Purpose: The study aimed to analyze this relationship between the influence of the patient`s beliefs about activity on the improvement of the pain and disability of
the chronic low back pain patients who underwent a conservative treatment.
Methods: A single-subject experimental study was performed where, initially, the participants filled out a form with demographic, clinical data and completed selfadministered questionnaires to measure pain intensity (Numeric Pain Rating Scale), low back disability (Oswestry Disability Index), and the patients beliefs about the
influence of activity (Fear-Avoidance Beliefs Questionnaire). Then, the participants underwent a physiotherapy clinical examination. The treatment performed was a
combination of modalities of manual therapy and therapeutic exercises.
Results: The study consisted of 8 patients who performed 6 sessions of conservative treatment on average.The analysis of descriptive characteristics of the sample
showed an average of 59.2 years (11.5) with a predominance of women (62.5%). Patients had an average of pain duration of 4.8 (4.0) years. The average initial pain
intensity assessed by the Numerical Pain Scale was 6.5 (2.3), and the initial lumbar disability average scored by ODI was 43.5 (18.6). The average of the initial FABQ
score was 28.7 ( 15.3). After the intervention, the values obtained for pain intensity and lumbar disability was an average of 2.6 (p <0.01) and 33.3 (p= 0.1),
respectively. It was observed a very high correlation between FABQ total score and the improvement of pain (Rho = -0.74; p = 0.04). A high correlation was observed
between the FABQ total score and the improved of lumbar disability (Rho = -0.67; p = 0.07). There was no correlation between the subdivisions of FABQ and changes
in pain intensity and disability.
Conclusion: Higher levels of negative beliefs about the influence of activity attenuated the improvement in pain and disability of chronic low back pain patients. The
conservative treatment was effective to reduce pain in all of the patients, although the disability was reduced in a few patients. The fear and avoidance beliefs
evidenced more influence in pain intensity than lumbar disability of patients presented here.
Ethics Approval: Gaffre and Guinle Univerty Hospital Ethics Comitee.
Keywords: Beliefs, Chronic low back pain, Musculoskeletal Pain

PO4-LL-050
CAN ULTRASOUND RELIABLY MEASURE TENDON DIMENSIONS?: SYSTEMATIC REVIEW AND CLINICAL IMPLICATIONS.
S. Mc Auliffe*, K. Mc Creesh, K. O'sullivan, H. Purtill
Background: Ultrasound (US) is a commonly used imaging modality for visualising tendon pathology. In comparison to MRI, US is perceived to have a higher risk of
error when evaluating tendon dimensions. To date, there is no systematic review on the reliability of US measurement of tendon dimensions.
Purpose: To systematically assess the evidence regarding the intra and inter-rater reliability of US measurements of tendon dimensions and to interpret the clinical
relevance of findings.
Methods: Eight electronic databases (Academic Search Complete, AMED, Biomedical Reference Collection, Cinahl, Medline, Sportsdiscus, Web of Science and
Embase) were searched using an agreed set of keywords. Studies which investigated the reliability of tendon dimensions (Thickness or cross sectional area (CSA)) of
the upper and lower limb using ultrasound in asymptomatic or symptomatic populations were eligible.
Results: 22 studies were included for final review. Intraclass correlation coefficient (ICC) values for the thickness of 15 tendons ranged from 0.45-0.99 (Inter-rater)
and 0.58-0.99 (intra-rater). ICC values for tendon CSA ranged from 0.58-0.92. Percentage coefficient of variation (CV%) for tendon thickness and CSA ranged from 035%. Percentage standard error of the mean (SEM%) values ranged from 3-7%.
Conclusion: Ultrasound is reliable in the measurement of tendon size, with findings comparable with ultrasound measures of muscle dimensions.
Implications: The degree of error using ultrasound in measuring tendon dimensions is small and is less than the difference reported between symptomatic and
asymptomatic tendons. This may have potentially important clinical implications regarding the identification, monitoring and management of tendinopathy.
Keywords: Reliability, Tendon, Ultrasound

PO4-LL-053
DETERMINATION OF PROOF OF PRINCIPLE OF THE STAR EXCURSION BALANCE TEST AS A
REHABILITATION TOOL POST ANKLE FRACTURE
C. Brennan*
Background: Ankle fractures are one of the most common fractures of the lower limb and contribute significantly to mortality, morbidity and costs to the patient,
hospital and healthcare system. Ankle fractures account for approximately 9% of all fractures with a rate of prevalence of 187 per 100,000 of population. Complaints
of ongoing stiffness, swelling and pain with walking, as well as chronic deficits in balance are common outcomes post ankle fracture.
Purpose: The aim of this study was to determine proof of principle that the Star Excursion Balance Test (SEBT), when used as a rehabilitation tool, would show
positive results compared to the widely used Single Leg Stance (SLS) in balance measures post ankle fracture. A secondary outcome of this study was to determine if a
correlation existed between a change in score in the SEBT when compared to a change in score on the Lower Extremity Functional Scale (LEFS).
Methods: The study design employed was a cohort study (of 60 subjects) with two cohort groups; the SEBT treatment group and the SLS treatment group. Subjects
were assessed at one week and six weeks after removal of immobilisation, post ankle fracture. Outcome measures used were the SEBT, SLS, measured using the
Balance Error Scoring System, and the LEFS.
Results: Preliminary results indicate statistically significant positive effects in favour of the SEBT treatment programme. SEBT scores, SLS scores and LEFS scores at one
week and six weeks after removal of immobilisation will be presented.
Conclusion: A SEBT treatment programme, when used as a rehabilitation tool, shows positive results compared to the SLS treatment programme. Future work will
involve follow-up assessment at twelve weeks and six months.
Implications: This study offers a novel approach for musculoskeletal physiotherapists that may guide and develop the implementation of balance rehabilitation
programmes, specifically in optimising dynamic postural stability, post ankle fracture.
Funding Acknowledgements: CB acknowledges support from the Centre for Learning Development, St. Jamess Hospital.
Ethics Approval: Ethics approval has been obtained from Tallaght Hospital/St. Jamess Hospital Joint Research Ethics Committee.
Keywords: balance; ankle fracture

PO4-LL-054
PILOT STUDY OF THE RELATIONSHIP OF TIBIAL ANGLE AND POSTERIOR GLIDE WITH DEEP KNEE FLEXION
VERIFICATION OF IMMEDIATE EFFECT OF MANUAL PHYSICAL THERAPY USING X-RAY IMAGING
K. Masui*, T. Sato, S. Taniguchi, K. Miyazaki
Background: Deep knee flexion produces posterior displacement of meniscus by excessive posterior glide of the tibia. It increases the load to the joint surface and is
considered a cause of osteoarthritis of the knee. However, physical therapists often use the posterior tibial glide technique to increase the range of motion of the
knee flexion.
Purpose: The aim of this study is to determine the immediate effect of a method of manual physical therapy (MPT), which is designed to improve the knee flexion
with the controlled angle of tibia.
Methods: 5 Subjects without a history of the knee pathology participated in this study. Using X-ray picture, the femoro-tibial angle and the femoro-tibial distance was
measured in supine with the knee deeply flexed so that the heel touches the buttock. The measurement was conducted under 2 controlled and 3 therapeutic
conditions (Controlled No Particular Approach; CNPA, Controlled After Classical knee flexion exercises; CAC, No Particular Approach; NPA, With tibial tilt manipulation
technique of MPT under taken; WM, After tibial tilt manipulation technique of MPT; AM). In the X-ray films, we measured the Femoro-tibial Angle and Femoro-tibial
Distance. With the deep knee flexion, each subject was asked the Numerical Rating Scale (NRS) of discomfort, as well.
Results: Femoro-tibial Angle in CNPA 56.60 3.38 , CAC 57.00 3.05 , NPA 56.00 3.21 , WM 56.70 3.79 , AM 57.20. 4.21 . Femoro-tibial Distance in CNPA
3.95 0.27 cm, CAC 3.86 0.23 cm, NPA 3.99 0.29 cm, WM 4.02 0.30 cm, AM 4.03 0.24 cm. NRS in CNPA 3.0 0.00, CAC 2.4 0.49, NPA 2.6 0.49, WM 3.4
1.62, AM 0.8 0.40.
Conclusion: With Manual Physical Therapy Technique, the inclination angle of the tibia was the largest, and the distance between the tibia and the femur was the
longest, during deep knee flexion. The NRS of the discomfort asked in the procedure was the smallest, as well.
Implications: These three results imply that MPT technique can improve the range of motion for the knee flexion with the inhibition of excessive posterior glide of
tibia and reduce the risk of the arthritis.
Funding Acknowledgements: Japanese Society for Manual Therapy
Ethics Approval: This study is approved in ethics committee of Osaka Kaisei Hospital.
Keywords: Knee Joint, Manual Physical Therapy, Tibial Angle

PO4-MT-055
EFFECT OF MYOFASCIAL TECHNIQUES IN ADDITION TO STANDARD PHYSICAL THERAPY FOR TREATMENT OF PAIN AND UPPER LIMB PROBLEMS IN BREAST CANCER
SURVIVORS: RANDOMIZED CONTROLLED TRIAL
A. De Groef 1,*, M. Van Kampen 2, N. Verlvoesem 2, E. Dieltjens 3, I. Geraerts 4, N. Devoogdt 4, M.-R. Christiaens 5 6, P. Neven 7 8
1
Dept of Rehabilitation, 2Department of Rehabilitation Sciences, KU Leuven - University of Leuven, 3Department of Rehabilitation Sciences, KU Leuven - Unversity of
Leuven, 4Department of Rehabilitation Sciences, KU Leuven - Unveristy of Leuven, 5Multidisciplinary Breast Centre, University Hosptials Leuven, 6Department of
Surgical Oncology, KU University - University of Leuven, 7Multidisciplinary Breast Center, Univesity Hosptials Leuven, 8Department of Obstetrics and Gynecology,
Univeristy Hospitals Leuven, Leuven, Belgium
Background: Background: After treatment for breast cancer, patients can suffer from pain and upper limb problems such as lymphedema, impaired shoulder range of
motion and subsequent difficulties in performing activities of daily life and decreased quality of life.
Purpose: Purpose: The aim of this study was to investigate the effect of myofascial therapy in addition to standard physical therapy on pain and upper limb problems
in breast cancer survivors.
Methods: Methods: A randomized placebo-controlled trial with concealed allocation, assessor and patient blinding and intention-to-treat analysis was performed.
Fifty women treated for unilateral primary breast cancer and with pain at the upper limb region were included.The intervention group received 12 sessions of
myofascial therapy consisting of release techniques on myofascial trigger points and adhesions in addition to a standard physical therapy program during 3 months.
The control group received 12 session of placebo therapy in addition to a standard physical therapy program during 3 months. The primary outcome was the change
in pain at the upper limb region measured with the Visual Analogue Scale (VAS). Secondary outcomes were the change in relative arm volume, active shoulder range
of motion, shoulder function and quality of life and prevalence rates of pain, arm lymphedema, impaired shoulder range of motion and shoulder dysfunctions.
Measures were taken before and after the intervention.
Results: Patients in the intervention group had a significantly greater decrease in pain compared to the control group (VAS -45/100 versus -24/100, p=0.036).
Myofascial therapy had a medium effect on treatment of pain in breast cancer survivors (partial eta squared = 0.092). No significant results were found for the
secondary outcomes.
Conclusion: Myofascial therapy is effective in decreasing pain at the upper limb region in breast cancer survivors.
Funding Acknowledgements: This study was funded by the agency for Innovation by Science and Technology (Applied Biomedical Research) (IWT 110703). The
authors have no further conflicts of interest.
Ethics Approval: This study was approved by the Ethical Committee of the University Hospitals Leuven (ref number: s54579). All participants gave written informed
consent before data collection began.
Keywords: Breast Neoplasms, Shoulder pain

PO4-PA-064
THE ESSENCE OF THE EXPERIENCE OF CHRONIC PAIN
T. Ojala*
Background: The purpose of this thesis was to search for a more profound understanding of the phenomenon of chronic pain from the perspective of persons with
chronic pain and who have been treated for their chronic pain. There are only few studies form this perspective.
Purpose: PhD thesis.
Methods: Thirty-four participants with different types chronic pain were interviewed. The transcribed interviews were analysed using Giorgis phenomenological
method consisting of four phases: (1) reading the transcriptions several times, (2) discriminating meaning units, (3) collecting meaning units into groups, into meaning
structures, (4) the synthesis, describing the phenomenon of chronic pain.
Results: The results indicate that chronic pain impaired the participants life by controlling thoughts and making life itself painful. The strongest arguments made by
the participants due to chronic pain were distress, loneliness, lost identity, and low quality of life. The participants stated that the key to managing their pain was to
reconsider their meanings of pain. In the analysis, four essential themes of chronic pain emerged, namely: Chronic pain affects the whole person, Invisibility of
chronic pain, Negative meaning of chronic pain, and Dominance of chronic pain.
Conclusion: Chronic pain is a multidimensional illness which requires a multidisciplinary approach to understand the phenomenon of it. Accordingly, a
multidisciplinary rehabilitation programme is required to manage it; unfortunately the opposite is true in clinical practice, adopting only a rhetoric approach. A
potential source of psychosocial symptoms may be the personal responses to the experience of chronic pain based on individual meaning.
Implications: The focus should be to identify and revise the meanings of pain in order to manage chronic pain and to restore positivity in personal life. The
phenomenological framework provides a relevant new insight into the present understanding of chronic pain.
Funding Acknowledgements: The Finnish Association for the Study of Pain.
Oulu University Hospital Clinic of Physical and Rehabilitation Medicine.
The Cancer Society of Northern Finland.
Suomen Ortopedisen Manuaalisen Terapian Yhdistys ry.
Keywords: CHRONIC PAIN, disease management, quality of life

PO4-SP-068
INCREASED SPINAL HEIGHT USING PROPPED SLOUCHED SITTING POSTURES: INNOVATIVE WAYS TO REHYDRATE INTERVERTEBRAL DISCS
J. Pape 1 2,*, J.-M. Brisme 2, P. Sizer 2, O. Matthijs 2 3, K. Browne 2, B. Dewan 2, S. Sobczak 2 4
1
Department of Physiotherapy, University Hospital of North Tees, Stockton on Tees, United Kingdom, 2Center for Rehabilitation Research, School of Health
Professions, Texas Tech University Health Sciences Center, Lubbock, United States, 3IAOM Fortbildung GmbH, Stuttgart, Germany, 4Dpartement d'anatomie,
Universit du Qubec Trois-Rivires, Qubec, Canada
Background: Physiotherapists are the primary healthcare providers involved in the prevention and management of lumbar intervertebral disc (IVD) disorders that
lead to spinal shrinkage and stenosis as a result from sustained compressive loading and aging. Sitting is a frequently adopted posture in home and work
environments that is associated with increased intradiscal pressure (IDP), spinal height loss and IVD pathology. Individuals utilize a variety of seated postures,
including those in upright and slouched positions. Although propped slouched sitting (PSS) produces low IDP compared to other postures and potentially offers a
position to restore spinal height, its effect on spinal height has not previously been investigated.
Purpose: To examine the effects of two sustained PSS postures on spinal height after a period of trunk loading.
Methods: This study used a pre-test, post-test, crossover design. A sample of convenience of 34 subjects (19 male; 15 female) without low back pain was recruited
(mean age 24.41.6 years). Subjects sat in (1) PSS without lumbar support and (2) PSS with lumbar support for 10 minutes, after a period of trunk loading. Spinal
height was measured using a commercially available stadiometer before and after the PSS postures. Spinal curvature in the PSS, upright, flexed and extended
postures were measured with an inclinometer.
Results: Mean increase in spinal height during PSS without lumbar support was 2.94 mm (3.63) and PSS with lumbar support 4.74 mm (3.07). A 2(loading status) x
2(support status) repeated measures ANOVA demonstrated a significant main effect (p<.001) for loading status (upright sitting postures and PSS postures). There was
a significant interaction between loading status and support status (p=.023). Post-hoc paired t-tests revealed significant spinal height differences between pre- and
post-PSS both with and without lumbar support (p=.001) but not between post-PSS with and without lumbar support (p>.099), suggesting a trivial contribution from
the lumbar support. Spinal height changes in PSS with lumbar support exhibited a fair correlation with both degrees lumbar flexion (r=0.31, p=.072) and dorsal sacral
inclination (r=0.30, p=.085).
Conclusion: Both PSS with and without lumbar support increased significantly the spinal height after a period of loading. Spinal heights post-PSS with or without
lumbar support were not significantly different.
Implications: The effects of different sitting postures on IVD hydration may have ramifications for working postures, practices and IVD pathology prevention. Such PSS
postures can provide a valuable alternative to upright sitting and may be recommended for recovering spinal height following periods of loading.
Ethics Approval: This study protocol was approved by the Institutional review Board at Texas Tech University Health Sciences Center. IRB Number. L15-048
Keywords: Intervertebral disc, Spinal height, Stadiometer

PO4-SP-069
THE EFFECT OF THORACIC SPINE MANIPULATION ON THORACIC SPINE PAIN AND MOBILITY PRELIMINARY RESULTS OF RCT
J. Takatalo 1,*, T. Leinonen 2, M. Rytknen 2, A. Hkkinen 3, J. Ylinen 4
1
Institute of Clinical Medicine, University of Oulu, 2Fysios Oulu, Fysioteekki, Oulu, 3Department of health sciences, University of Jyvskyl, 4Central Hospital of Central
Finland, Jyvskyl, Finland
Background: The effect of thoracic spine manipulation on thoracic spine symptoms and stiffness remains unknown.
Purpose: To evaluate the effect of thoracic spine manipulation on thoracic spine pain, disability and mobility in adult subjects.
Methods: Thirty-one subjects (21 females and 10 males) with mean age of 37 (range, 22-56) were recruited through local paper into the study. The subjects were
randomized into thoracic manipulation (n=17) and sham-transcutaneous nervous stimulation (n=14) groups and they received six treatments in three weeks. Thoracic
spine pain, disability and mobility were measured at baseline and post-treatments and the changes within three week were compared between groups with t-test
and Mann Whitney U test.
Results: Subjects had had thoracic spine pain for 28 weeks (range, 2-208) with mean visual analogue scale (VAS) of 44 mm (SD 17), maximum VAS of 58 mm (SD 16)
and mean night VAS of 40 (SD 24). Moreover, experienced state of health in VAS was 32 mm (SD 20), Roland-Morris Disability questionnaire (RMDQ) score was 5.6
(SD 3.5) and number of hypomobile thoracic spine segments in posterior to anterior (PA) pressure was 6.2 (SD 2.6). There were no differences between groups at
baseline. The mean change in experienced state of health (11; p=0.033), maximum VAS (34; p=0.012), mean night VAS (26; p=0.026) and segmental thoracic PA
pressure (3; p=0.001) were significantly higher in manipulation group. However, no differences between groups were found in mean VAS and RMDQ although the
trend was found to favour manipulation group. These are preliminary findings and require further analysing with adequate number of subjects.
Conclusion: Thoracic spine manipulation can decrease experienced pain in the thoracic spine area. Moreover, thoracic spine mobility and experienced state of health
improved as well.
Implications: Thoracic manipulation can be used in manual therapy practice to decrease the thoracic spine pain, immobility and, therefore, experienced state of
health.
Funding Acknowledgements: We would like to acknowledge Juho Vainio Foundation, Finnish Association of Physiotherapists and Finnish Association of Orthopaedic
Manual Therapy for providing funding.
Ethics Approval: Ethical committee of Northern Ostrobothnia Hospital District reviewed the study protocol.
Disclosure of Interest: J. Takatalo Conflict with: Juho Vainio Foundation, T. Leinonen: None Declared, M. Rytknen: None Declared, A. Hkkinen: None Declared, J.
Ylinen: None Declared
Keywords: manipulation, Pain, Thoracic spine mobility

PO4-SP-070
THE USE OF THE SLUMP TEST AS A DIAGNOSTIC AND TREATMENT TOOL AMONGST GRADUATE CLINICIANS IN THE UNITED KINGDOM
E. Fowler 1,*, L. Herrington 2
1
University of Nottingham, Nottingham, 2University of Salford , Salford, United Kingdom
Background: The slump test is used in the diagnostic process for patients with spinal and lower limb pain to evaluate the sensitivity of the central and peripheral
nervous systems to movement. As the slump test involves considerable dexterity by clinicians due to the combined gross movements necessary in this test, it may be
a daunting test to undertake in clinical practice and research, as the quality of the execution of the test may be compromised. This may be a contributing factor as to
why the slump test is relatively under-researched in comparison to upper limb neurodynamic tests, particularly in symptomatic patients.
Purpose: In the absence of high quality research into the slump test as a diagnostic and treatment aid for symptomatic individuals, it is important, as a starting point,
to evaluate the use of this test in clinical practice. The aim of this study is to evaluate the use of the slump test as a diagnostic and treatment tool amongst graduate
therapists in the United Kingdom
Methods: A cross-sectional (self-reported) on-line questionnaire survey of chartered physiotherapists, graduate sports rehabilitators and graduate sports therapists in
the United Kingdom was undertaken. The questionnaire was formulated based on the literature on neurodynamics and the slump test comprising of a mix of open
and closed questions (total n=16).The inclusion criteria for participants required that they were musculoskeletal physiotherapists, sports therapists or sports
rehabilitators with greater than one year experience.
Results: The questionnaire was undertaken by 67 clinicians from a variety of therapeutic backgrounds. Almost all participants (89%) reported using the slump test as
a diagnostic tool, however, the number of clinicians who use this test as a treatment modality was slightly lower (80%). Clinicians showed a preference for using the
slump test as a diagnostic and treatment tool in patients with symptoms in the posterior chain, inclusive of the spine. The majority of clinicians focussed on overt
(that is, replicating symptom) responses as an indicator of a positive slump test, rather than covert responses. Only 35% of clinicians responded to questions
regarding sliding and tensioning techniques, with the majority showing a preference for using sliding techniques as a treatment strategy.
Conclusion: Whilst research into neurodynamics has been expanding and developing rapidly in recent years, little is known about how practitioners use this
technique. It would appear from this survey that the limited research on the slump test as a treatment modality in symptomatic patients could possibly be reflected
in the relatively limited use of this test in practice amongst clinicians.
Implications: This study highlights that despite the growing research in neurodynamics and the slump test specifically, there is a need to ensure the translation of
new research is occurring into clinical practice
Funding Acknowledgements: No funding was obtained for this undertaking or completion of this study
Ethics Approval: Ethical approval was obtained by the University of Central Lancashire, Preston, UK
Keywords: Clinicians, Neurodynamics, Survey
Teaching, Learning and Professional Development

PO1-ED-028
KINEMATIC REAL TIME FEEDBACK. A NEW METHODOLOGY FOR TEACHING MANUAL THERAPY: A RANDOMIZED CONTROLLED TRIAL
M. Gonzlez-Snchez, P. Vaes 1,*, M. Trinidad-Fernndez 2, C. Roldn-Jimnez 3, A. I. Cuesta-Vargas 4
1
KINE & Manuele Therapie, Vrije Universiteit Brussel, Brussels, Belgium, 2University of Mlaga, 3Univesity of Mlaga, 4Physiotherapy, University of Mlaga, Mlaga,
Spain
Background: The inertial sensors provide real-time kinematic information, making them an instrument with enormous educational potential. However, no study has
found any Inertial Sensor use as a tool to generate real-time feedback during the learning techniques of high velocity, low amplitude on thoracic spine.
Purpose: To compare inertial sensor real time-feedback (ISRTF) methods with traditional methodology to learn posterior-anterior thoracic manipulations.
Methods: Design: 24 students (G1: 12 ISRTF - G2: 12 Traditional Method) with no experience in manual therapy, participated in this randomized Controlled Trial With
Parallel intervention groups.
Protocol: Each participant performed a training posterior-anterior thoracic manipulation for 60 minutes using one of two methods compared in this study. G1 training
performed in front of a laptop where, in each manipulation received an ISRTF thanks to an inertial sensor positioned in T5 and compared it execution with a graph
provided by the teacher. G2 Performed their training supervised by the professor, with a student-teacher ratio 12-1. Each participant performed three times, before
and after intervention, a postero-anterior thoracic manipulation. Outcomes: measures before and after training were: maximum angular displacement, maximum
linear displacement, maintenance of pre-manipulative position (pre-manipulative displacement), release time after the execution of the technique and total time of
mobilization.
Statistical analysis consisted in an intra-group comparison (pre-post intervention), a comparison inter-group (post-intervention) and a measure of the stability of
execution.
Results: In the baseline analysis, no significant differences between the groups were found. In the intragroup analysis, significant differences were observed in all
variables analysed. In the inter-group analysis (post-intervention) significant differences in all the variables analysed were observed: maximum angular displacement
(6.11), maximum linear displacement (4.07 mm), maintenance-pre-manipulative position (pre-manipulative displacement) (1.26 mm), time of release after technical
completion (0.03 s) and total time mobilization (0.09 s). In addition, the stability ranges (ICC test - retest) of the variables in G1 range between 0.768 and 0.903, and
G2 range between 0.439 and 0.647.
Conclusion: The methodology of parameterized learning process through inertial sensor shows, to the students, further evolution in the execution of the posterioranterior thoracic manipulation, seeking higher range of motion, reduced execution time and higher stability in the execution of the technique.
Implications: The information provided by the ISRTF during the execution of each manipulation during the student learning favour to increase the consistency in the
execution of the technique and it reduce learning time thanks to increased student learning autonomy after to receive accurate and objective information after each
manipulation.
Funding Acknowledgements: NONE
Ethics Approval: University of Malaga Ethical Approval committee has approved the present study.
Keywords: feedback, Kinematic, Manual Therapy

PO1-ED-029
A DESCRIPTION OF THE DEVELOPMENT OF A POST-GRADUATE ORTHOPAEDIC MANUAL THERAPY RESIDENCY PROGRAM IN KENYA
S. Cunningham*, R. Jackson
Background: There are very few opportunities for long term, comprehensive postgraduate clinical education in developing countries due to fiscal and human
resource restraints. Therefore, physiotherapists have little opportunity following graduation to improve clinical reasoning and treatment skills. To assist with the
progression of clinical reasoning and skill development, an orthopaedic manual therapy residency program was introduced in Nairobi, Kenya.
Purpose: This structure of post-graduate residency education could provide a template for the development of additional programs in other developing countries to
promote the profession of physiotherapy and assist with evidence- based practice. Residency programs emphasizing clinical reasoning and manual therapy could
provide a means to optimize the effects of physiotherapy (minimize pain, normalize movement and maximize function) without the need for or access to expensive
equipment.
Methods: Multiple steps were taken to establish a long- term educational program, including comprehensive didactic education and clinical mentoring, to improve
clinical practice and healthcare delivery by physiotherapists in Kenya. Information will be provided regarding recruitment of residents, the discovery of financial
assistance for participants, cost of the program, and outcome results from quantitative and qualitative research.
Results: Fifty-one volunteers from the United States have participated in the provision of residency education in Kenya since 2012. Volunteers served as instructors
and provided clinical mentoring to the residents. The first cohort of the program graduated in December 2014 and the second cohort will graduate in December
2015. Currently, three additional cohorts are in progress of completing the 18-month residency program for a total of 80 residents. In addition, four graduates are
being trained to continue the residency program and are serving as teaching assistants for the on campus modules. The training of graduates to provide ongoing
education will result in a self sustaining program. Quantitative and qualitative research demonstrates a significant improvement in the ability to perform
examinations and match evidence- based treatment techniques to examination findings. Furthermore, residents have noted an improvement in patient outcomes
and resulting increase in patient referrals.
Conclusion: Through the residency program, approximately 10 percent of the physiotherapists in Kenya have received postgraduate training. All of the residents
have reported no previous access to continuing education, formal mentoring, or training. The residency has been successful in promoting access to evidence based
practice, clinical reasoning and professional development of the residents.
Implications: The manual therapy residency education model allowed for advancement of the participating physiotherapists treatment skills and clinical reasoning
without need to alter the current education system within the country or provide access to expensive equipment in order to provide evidence based practice. The
success of this program provides a template for the development of similar programs in other countries with limited resources.
Funding Acknowledgements: The residency is funded through the Jackson Clinics Foundation.
Ethics Approval: This research was approved by the University of Evansville Institutional Review Board.
Disclosure of Interest: S. Cunningham: None Declared, R. Jackson Conflict with: Founder of the Jackson Clinics Foundation providing funding for the residency
program
Keywords: Kenya, Residency Program

PO2-AP-003
STUDENT PHYSICAL THERAPIST CLINICAL PRACTICE, DECISION MAKING AND UTILIZATION OF THRUST JOINT MANIPULATION DURING CLINICAL EDUCATION
EXPERIENCES
M. Corkery 1,*, K. Hazel 1, C. Cesario 1
1
Department of Physical Therapy, Movement and Rehabilitation Sciences, Northeastern University, Boston, United States
Background: High velocity thrust joint manipulation (TJM) techniques are taught in physical therapy programs in the US, however their utilization rate during student
clinical education experiences is variable.
Purpose: The purpose of this study was to explore student physical therapist clinical practice; including frequency and type of TJM utilized and clinical decisionmaking regarding the use of TJM during clinical education experiences.
Methods: An electronic survey was sent to 107, final year Doctor of Physical Therapy students, regarding their final outpatient clinical experience. Survey data
queried students about clinic demographics, clinical instructor credentials, clinical practice patterns and techniques.
Results: The survey response rate was 67% (n=72). Clinics were located in 21 states. A majority of patients treated had a physicians referral however a majority of
respondents reported establishing a diagnosis or classification for patients. Students reported confidence in their differential diagnosis and clinical reasoning skills
and a majority reported recommending interdisciplinary referrals if medically necessary. Students reported a high utilization of therapeutic exercise and manual
therapy and a broad range of biophysical agents. Forty percent of respondents reported using TJM techniques, 96% non-thrust joint mobilization and 89% manual
traction. Students who utilized TJM were more likely to use clinical prediction rules to assist with clinical decision-making (x2=7.0028, p=0.0081) than students who
did not utilize TJM. Students who utilized TJM were more likely to have a clinical instructor who used TJM (x2=43.01, p<0.001).
Conclusion: Students reported a high utilization rate of manual therapy techniques in outpatient clinical experiences, and a lower utilization of TJM. Students who
worked with clinical instructors who used TJM were more likely to use TJM as a clinical intervention. Clinical prediction rules aided student clinical decision-making
regarding the use of TJM.
Implications: It is important that academic programs provide students with a strong foundation in TJM skills and that clinical education experiences provide students
with opportunities to be mentored by clinical instructors with advanced manual therapy training. Residencies and fellowships providing more intense mentoring,
instruction and opportunities to use TJM play an important role in the development of these skills for physical therapists.

Ethics Approval: This study was approved by the Institutional Review Board at Northeastern University.
Keywords: thrust joint manipulation, clinical prediction rule

PO2-AP-007
WHAT IS THE IDEAL TREATMENT TIME FOR MUSCULOSKELETAL PHYSIOTHERAPISTS? A SURVEY OF CASELOADS IN CANADA AND COUNTRIES WITH SIMILAR
HEALTH CARE SYSTEMS
S. Gibbons 1,*, J. Quirk 1
1
Background: Caseload sizes are not universally regulated in Canada and other countries. In Canada, physiotherapy are in both the public and private health care
systems. Although there are various guidelines and evidence based summaries for various conditions, physiotherapy lacks standard therapy protocols in which
clinicians should follow. There are numerous evidence based therapies which require one on one contact and more time spent with the patient such as various types
of hands on therapy, education, sensory discrimination training and teaching exercises with a highly cognitive component such as specific motor control
exercises. There are other therapies which can be allocated to an assistant such as remedial exercise, electrotherapy or in which the patient can be left on their own
such as acupuncture. Given the common fee for service and commission based pay, there is a potential for the therapist to be biased towards the type of care
provided and how many patients they see. Understanding caseload sizes is are important since several evidence based interventions take longer to administer and
the patient contact time may influence patient satisfaction, which is a recommended core outcome measure.
Purpose: The purpose of this project was to perform a health technology assessment of the caseload of physiotherapists. Stage 1: identify the stakeholders and
priority issues; Stage 2: perform a survey of hospitals and private clinics in Canada and identify common practice in other countries with similar health care systems;
Stage 3: identify the expectations of patients; Stage 4: understand physiotherapists perspective; Stage 5: identify treatment times used in high quality clinical trials of
common physiotherapy interventions; Stage 6: provide a summary, recommendations. This paper will report stage 2 of the project.
Methods: Clinics and hospitals from all Canadian provinces were searched from the Canadian Physiotherapy web site and through the yellow pages. All clinics and
hospitals from the smaller Atlantic provinces were contacted and asked how many clients were booked per hour and how much time was allotted for the initial
assessments. In the other provinces, the contact list was given a number and a random number generator was used to call the mean number of clinics in each
province. To identify common practice in other countries, participants from continuing education courses in 22 countries were contacted and asked how many
patients they saw per hour and how much time was allotted for an initial assessment.
Results: In private practice, the mean number of patients per hour for the clinics that responded in Canada was 3.8. 36 per cent of clinics refused to answer. Atlantic
Canada was the highest at 4.4 while Quebec was lowest at 2.3. The time for a new assessment ranged from "no extra time" to "one hour". In hospitals, it was
standard to see 2 patients per hour with new assessment times ranging from 30, 45 or 60 minutes. From the 483 course participants that were contacted, the per
hour treatment time ranged from 1.5 - 2.4. The initial assessment time ranged from 40 minutes to 1.5 hours. There were no reports of seeing more than 3 patients
per hour.
Conclusion: The caseload practice in Canadian private practice is diverse and Canada has a higher average patient per hour average than other countries. Future work
should aim to understand why the physiotherapy culture is so different in Canadian private practice and if this makes a difference to clinically relevant outcomes, skill
development, therapist burnout, and professional recruitment / interest in the profession
Implications: There may be a need for regulation or implementation of policies by professional associations. Third party payers may want preferred providers or
change fees.
Ethics Approval: Ethics approval was not required for this phase of the project
Keywords: Caseload, outcome measure, Survey

PO2-ED-029
GRADUATING RESIDENTS PERSPECTIVES OF THE INFLUENCE OF ORTHOPEDIC RESIDENCY TRAINING ON PROFESSIONAL DEVELOPMENT IN NAIROBI, KENYA
S. Cunningham 1,*, J. McFelea 2
1
Physical Therapy, Radford University, Roanoke, 2Physical Therapy, University of Evansville, Evansville, United States
Background: Access to advanced instruction, fundamental to promoting educational development, is limited throughout the country of Kenya. One restricting factor
has been the limited number of physiotherapists with advanced degrees and specialty training available to offer educational opportunities. To assist with the
progression of clinical reasoning and skill development, an orthopaedic manual therapy residency program was introduced in Nairobi, Kenya.
Purpose: The purposes of this study were to: (1) determine the demographic characteristics of physiotherapists participating in the first orthopaedic manual therapy
residency cohort in Nairobi, Kenya and; (2) characterize the influence of the residency program on professional development.
Methods: All 15 graduates of the first residency cohort agreed to participate in the study. After completing their final live- patient practical examination, the
graduates completed a survey to determine the influence of residency training on professional development. The survey utilized was adapted from previously
published outcomes of residency training in the United States. To determine internal consistency within the survey for the two themes, Cronbachs alpha was
performed. For professional development Cronbachs alpha was .864 and for career advancement it was .712. Descriptive statistics were utilized to analyze the data.
Results: Similar to the results of professional development surveys performed with residency graduates in the United States, the graduates reported a positive
influence of the residency training on their ability to: (1) perform a thorough clinical examination; (2) use a logical clinical reasoning process; (3) determine the nature
of a patients problem; (4) treat complex patients; (5) treat effectively to achieve projected outcomes; (6) perform overall patient management; (7) use scientific
literature to provide rational for interventions; (8) critically read and evaluate scientific literature; (9) communicate with patients, and; (9) communicate with other
health professionals. In addition, graduates reported an increase in the number of patient referrals and the number of professionals referring patients. Conversely,
dissimilar to residency graduates in the United States, only 46.7% of graduates reported a change in salary and 60% reported job promotion based on completion of
the residency program.
Conclusion: The residency graduates in Kenya reported similar outcomes to residency graduates in United States regarding professional development. Furthermore,
the graduates experienced an increase in number of referrals as their effectiveness in treatment of orthopedic pathology improved. This influence may be attributed
to the didactic coursework, skill development, and clinical mentoring offered through the residency program.
Implications: Results from this pilot study suggests that the residency program in Kenya was successful in promoting professional development similar to the
programs in the United States. This successful program may provide the framework for the development of additional residency programs in countries with limited
educational resources.
Funding Acknowledgements: This study was funded by the Institute for Global Enterprise Global Scholars Program.

PO2-ED-030
"WATCH AND LEARN"...THE USE OF VIDEO PODCASTS IN THE DEVELOPMENT OF MANUAL THERAPY SKILLS IN PRE-REGISTRATION PHYSIOTHERAPY STUDENTS
J. Hindle*, K. Hurst 1
1
health professions, mmu, manchester, United Kingdom
Background: Learning a skill such as manual therapy requires knowledge, technical ability and clinical reasoning. Emerging technologies and a net generation pose
new challenges to physiotherapy educators when developing manual therapy curricula. Video podcasts have great potential when used as a pedogogical tool. This
has relevance to the effective teaching of manual therapy skills in students.
Purpose: Video podcasts covering the upper and lower quadrants, demonstrating Maitland passive accessory and physiological graded joint mobilisations were
created by the authors. These were embedded within a musculoskeletal module with careful consideration given to maximising students' learning.The aim of the
study was to assess students' perceptions of the use of video podcasts when developing manual therapy skills.
Methods: A questionnaire containing open and closed questions was undertaken at Manchester Metropolitan University (MMU) with 41 pre-registration
physiotherapy students. Following piloting, the final questionnaire yielded quantitative and qualitative data in three sections, designed to explore students'
engageent, perceived educational value and skill acquisition.
Results: The questionnaire achieved a response rate of 100%. All respondents accessed and engaged with the podcasts as part of their learning of manual therapy
skills. Students valued watching whilst simultaneously practising manual therapy skills. The podcasts supported students' skill acquisition in terms of improving their
therapist and patient positioning (95%, 39/41) and specificity and localisation of manual therapy techniques (93%, 38/41). Students however were less decisive as to
how the podcasts supported clinical reasoning in determining choice of technique (44%, 18/41) and grade (41%,17/41). The majority of students (88%, 36/41) agreed
that the podcasts helped them to practise in their own time, promoting independent learning.
Conclusion: The manual therapy video podcasts provided a valued learning resource, serving as a visual, auditory and kinaesthetic aid. The podcasts were most useful
from a technical perspective in terms of skill acquisition. The mobile nature of the technology served to promote self-efficacy and independent learning. The podcasts
however did not promote clinical reasoning and therefore a blended learning approach using a combination of e-learning and face to face contact is essential in
teaching effective manual therapy skills. Future research should consider the impact of such an approach on student performance.
Implications: Educators teaching manual therapy should consider a blended learning approach, combining video podcasts with traditional learning and teaching
strategies. Careful consideration should be given to how video podcasts can best support all aspects of skill acquisition, extending beyond technical ability.
Ethics Approval: MMU Faculty Ethics Committee no.1009
Keywords: Manual Therapy, Skill Acquisition, Video Podcasts

PO2-MT-061
A MODEL FOR ADAPTATION OF MANUAL TECHNIQUES FOR PRACTITIONERS OUTSIZED BY THEIR PATIENTS
M. Lee 1,*, C. Hazle 2
1
Kentucky Orthopedic Rehab Team, Nicholasville, KY, 2College of Health Sciences, University of Kentucky, Lexington, KY, United States
Background: Evidence supports the effectiveness of manual therapy in the multi-modal management of patients with musculoskeletal disorders. Many traditionally
taught manual therapy techniques are difficult to perform when practitioners are out-sized by their patients, rendering treatment inconsistent with the best
evidence. The growing obesity rates worldwide (Ogden et al., 2014; WHO, 2015) potentially foreshadow this problem for future physiotherapy practice. Additionally,
the rate of work-related musculoskeletal disorders among physiotherapists is significant, causing practitioners to change their work setting or alter career paths
(Cromie et al., 2008; Campo et al., 2009 & 2010; Darragh et al., 2012; Nordin et al., 2011). Manual therapy has been cited as a causative factor in many cases of workrelated musculoskeletal disorders among physiotherapists, possibly related to the exertion or strain required to perform these techniques (Holder et al., 1999;
Adegoke et al., 2008; Bork et al., 1996; Grooten et al., 2011; Darragh et al., 2012; Nordin et al., 2011).
Purpose: The purpose was to create a decision making model to guide practitioners, students, and educators on modifications for manual techniques when physical
circumstances are difficult for standard performance, such as when practitioners are small and/or patient are large. By serving this purpose, an additional goal was to
facilitate practice consistent with standards of care with use of manual techniques despite challenging human factors.
Methods: A cognitive and practical model was created to guide practitioners, students, and educators in modifying manual treatment techniques when encountering
physical difficulty when using traditional techniques, brought about by a size differential between practitioner and patient.
The model is a clinically applicable and pragmatic visual guide to facilitate strategies for altering manual techniques with considerations to the following: patient
position, practitioner position, maximizing the use of gravity, employing table adjustments and use of tools or aids to facilitated delivery of various techniques.
Results: Manual therapy techniques difficult for the smaller practitioners can be modified using basic principles, using the decision making model. The authors will
demonstrate the application of the decision making model for commonly used manual techniques of the general lumbopelvic manipulation, thoracic spine posterior
to anterior thrust and posterior to anterior hip mobilization.
Conclusion: Many commonly used manual therapy techniques can be adapted for use with large patients or when a significant negative size differential exists with
practitioner and patient. Thus, the inclusion of manual therapy and practice consistent with professional standards remains possible when patient or practitioner size
creates difficult circumstances.
Implications: Physiotherapy educational curricula and post-graduate training programs should adopt strategies for managing large patients and/or training small
clinicians, including a decision making model for technique modification.
Funding Acknowledgements: No external funding.
Ethics Approval: Ethics approval not required.
Keywords: Manual Therapy, obesity, professional issues

PO2-MT-062
SUPPORT SYSTEM TO MAKING DECISION ON ORTHOPEDIC MANUAL THERAPY
A. Carrasco 1,*, S. Cabanillas 1, M. Fortn 1, C. Hidalgo 1, J. M. Trics 1, S. Prez 1, M. Malo 1, J. Estban 1, S. Rodriguez 1, S. Jimnez 1
1
OMT Espaa, Zaragoza, Spain
Background: The Orthopaedic Manual Physical Therapy is an area of specialization within physiotherapy for evaluation and treatment of artro -neuro musculoskeletal dysfunction. It is based on clinical reasoning, scientific and clinical evidence and the biopsychosocial approach to each individual patient. OMPT uses
evaluation and treatment approaches including highly specific manual techniques and therapeutic exercises.
There are different models of support system that collect data for several health professions. However, few are tailored to the current needs of the OMT therapists.
Purpose: To design a digital tool for OMPT students to guide assessment, diagnosis and treatment of patients.
Methods: An online application will be developed from the previous version used by Clinical Center of Orthopedic Manual Therapy (OMPT Application of
physiotherapy Anamnesis-UZ) which is the result of an Educational Innovation Project at the University of Zaragoza and provides the Know-How transferred from the
University of Zaragoza to the Spin-off, Orthopaedic Manual Therapy Spain Clinic.
To develop the online application we will work in collaboration with a research group in the field of Computer Engineering at the Zaragoza University. The program
will be performed within the guidelines of a software development project in accordance with the procedures normally followed by this research group and which are
comparable to those certified by ISO / IEC 15504 (SPICE) level 2. The research work carried out in this project will always be directed by a PhD with experience in this
field.
The different sections that integrate the application are: History, Inspection, Test of function, Neurologic examination and different validated questionnaires.
Results: The application for decision-making in Orthopaedic Manual Physical Therapy will allow a more efficient data management, helping the therapist to collect
information more dynamically at the clinic. The data recorded during the examination of the different body areas are broken down into a functional diagnosis to
perform a treatment according to the findings.
Conclusion: A new digital tool for manual therapist has been developed to improve the clinical and educational tasks.
Implications: The web application will help professionals and students OMT to the collection and management of data in the clinical setting to avoid loss of
information and optimizing time for examination.
Funding Acknowledgements: Innova Project. Departamento de Industria e Innoviacin. Gobierno de Aragn
Ethics Approval: Ethics approval was not required or if you do not have an ethics system in your coutnry, please state this
Keywords: evaluation, making decision, Support system

PO3-ED-028
SHAPING: THE CORE CONCEPT IN HOW MUSCULOSKELETAL PHYSIOTHERAPISTS USE KNOWLEDGE IN PRACTICE - A CONSTRUCTIVIST GROUNDED THEORY STUDY
R. Game*, N. Petty 1, C. Ramage 2
1
Clinical Study Centre for Health and Social Care, University of Brighton, Eastbourne, 2School of Nursing and Midwifery, University of Brighton, Brighton, United
Kingdom
Background: This research study has been completed in partial fulfilment of a professional doctorate in Physiotherapy.
Purpose: The aim of this research study was to construct an explanatory theory of how knowledge is used in practice by musculoskeletal physiotherapists. There is a
gap in the literature relating to how knowledge is used in practice. Furthermore, there is very little addressing the establishment of an epistemology of practice for
musculoskeletal physiotherapy.
Methods: A constructivist grounded theory methodology was used. Methods incorporated nineteen semi-structured interviews. All participants had been qualified at
least five years and worked in musculoskeletal physiotherapy a minimum of three years. All participants were musculoskeletal physiotherapists currently working in
outpatient settings in the National Health Service. There were fifteen participants in the study, eleven of whom were interviewed once. Four of the participants were
interviewed a second time to further explore and develop the explanatory theory created from the first fifteen interviews
Results: A theory was constructed to explain the use of knowledge in practice which has three categories and one core concept of Shaping. The three categories
encompass three dynamic ways in which knowledge is used. Each of the knowledge categories were identified as having a differing effect on the core concept. Four
sub-categories of practitioner were identified on a continuum of practice. The participants varied in their experience, nationality, gender and self-described practice
bias. But the coding of data and analytical processes of constructivist grounded theory, created categories and a core concept that resonated with the conceptions of
knowledge use that were consistent across all participants.
Conclusion: Knowledge use in practice is complex, dynamic and flexible. Multiple knowledge types are used in many different ways to deliver relationship centred
care. There is no suggestion from this theory that any single modality of knowledge use is superior to the others. It is the plurality of practice that is essential for
relationship centred care in musculoskeletal physiotherapy.
Implications: This explanatory theory has implications for all musculoskeletal physiotherapists and potentially other professions who work within this field of practice.
The theories usefulness extends to clinical practice, education and the profession as a whole.
Funding Acknowledgements: Partially funded by Hounslow & Richmond Community Healthcare NHS Trust
Ethics Approval: Ethical approval for this study was granted by the Faculty of Health and Social Science Research Ethics and Governance Committee University of
Brighton (reference: FREGC-12-028.R1) and also, National Study Ethics Service Committee (NRES & NREC reference: 13/LO/0369 & IRAS project identification: 67544).
Keywords: Epistemology, Grounded theory, professional Knowledge

PO3-ED-029
DOES A TWO-DAY POSTGRADUATE COURSE ON THE MANAGEMENT OF CHRONIC MUSCULO-SKELETAL PAIN INCREASES THE PHYSIOTHERAPISTS PAIN
NEUROPHYSIOLOGY KNOWLEDGE?
L. Pitance 1 2,*, P. Brasseur 3, C. Rondeaux 4, N. Roussel 5, M. Meeus 5, O. Bruyre 6, C. Demoulin 3
1
Clinical research institute, Universit Catholique de Louvain, 2Oral and maxillo-facial surgery, Cliniques Universitaires Saint-Luc, Brussels, 3Faculty of sport and
rehabilitation science, Universit de Lige, Lige, 4Facult des sciences de la motricit, Universit Catholique de Louvain, Louvain La Neuve, 5University of Antwerpen,
Antwerpen, 6Department of Public Health, Epidemiology and Health Economics, Universit de Lige, Lige, Belgium
Background: Pain neurophysiology education is an important component in the physiotherapy management of patients with chronic musculoskeletal pain. However
the amount pain education in physiotherapy curricula is only recently growing and the awareness and skills of working physiotherapists is thus often still limited. The
effectiveness of a specific education course to increase the physiotherapists knowledge on pain neurophysiology and pain management is unknown.
Purpose: The purpose of the present study was to evaluate the effectiveness of a post graduate course on management of patients with chronic musculo-skeletal
pain to improve the physiotherapists knowledge on pain neurophysiology.
Methods: Thirty five physiotherapists (years of experience 6 6 years) participating in a two-day post graduate course on the management of chronic
musculoskeletal pain (neurophysiology of pain and central sensitization, retrain the brain therapy modalities etc.) filled in the 19 true-false items of the French
version of the Neurophysiology of Pain Questionnaire (NPQ) before (pre-test) and after the course (post-test). Participants obtained one point for every correct
answer on 19 questions (maximal score = 19). The total NPQ score was calculated and expressed in percentage (%). A paired-t-test was used to compare the pre- and
post-test on each item. Correlation analyses were conducted to investigate the relationship between the initial score and the clinical experience.
Results: After the course, the mean total NPQ score increased significantly (67.4 13.0% vs. 81.05 6.7%; p<0.001) whereas the percentage of I do not know
answers for the 19 questions significantly decreased (13.7 14.3% vs 0.9 2.4%; p<0.001). However, three questions concerning (Q2, Q11,Q17) were still not
correctly answered following the course by at least 70 % of the participants.
In contrast, questions 9 and 15 were correctly answered by at least 80% of the participants respectively for the pre-test and post-test. Interestingly, the initial NPQ
Scores were negatively correlated to the number of years of physiotherapy practice (-0.358; p = 0.038).
Conclusion: A two-day course designed for physiotherapists can significantly increase their knowledge on pain neurophysiology.
Implications: A specific postgraduate course is relevant for physiotherapists in order to improve their knowledge in pain neurophysiology. Our results suggest the
opportunity to slightly adapt the course content to improve the scores even more.
Ethics Approval: The study was accepted by our local Ethic Committee
Keywords: pain education, pain neurophysiology questionnaire

PO3-ED-030
CAN A NEW INTERACTIVE, SIMULATED PATIENT SCENARIO TOOL BE CREATED TO ASSESS THE PERFORMANCE IN MUSCULOSKELETAL CLINICAL REASONING OF
PHYSIOTHERAPISTS IN A HOSPITAL SETTING IN SINGAPORE? A PRELIMINARY REPORT.
F. L. Loy 1,*, C. Krishnasamy 2, R. Gadru 1, P. H. Ong 1, S. Udipi 1, T. S. R. Soh 1
1
Physiotherapy, Tan Tock Seng Hospital, 2HOMER, National Healthcare Group, Singapore, Singapore
Background: Clinical reasoning is an important aspect of good management of patients presenting with musculoskeletal pain conditions. Currently, there is no
structured assessment of reasoning within actual clinical setting. Physiotherapists are assessed through direct observation of their management with individual
patients, followed by the nature of the subsequent discussions. Without the structured assessment format and a common case for assessment, physiotherapy
educators are unable to efficiently determine the specific physiotherapists clinical reasoning ability. This can hinder efficient supervision and education within the
workplace setting.
Purpose: The purpose of the study was to create two simulated musculoskeletal patient scenarios and assess how they relate to the musculoskeletal physiotherapy
experience and training.
Methods: Three physiotherapists with postgraduate in musculoskeletal physiotherapy and pain management, and more than 7 years of musculoskeletal specific
experience created 2 simulated patient scenarios, with in-built quizzes that examine different aspects of clinical reasoning. Scenario 1 was a case about an upper
quadrant pain problem and Scenario 2 was about a lower quadrant problem. The scenarios were set up on a Learning Management System platform, with a separate
survey examining qualification and work experiences of the participants. 120 physiotherapists working at the hospital were invited to participate in this study, by
accessing the online survey and scenarios within a 2-month period. The results are presented using descriptive statistics, and spearman correlation tests are used to
compare the results. The significant level is set at p< 0.05.
Results: 14 participants (aged 24-34 years) completed Scenario 1 and returned scores of 28-60%. The duration of musculoskeletal-specific experience (0-93 months)
were significantly related to the Scenario 1 scores (rho=0.54, p=0.049). 5 (35.7%) of the participants had a postgraduate physiotherapy qualifications. 9 participants
(aged 24-31 years) completed scenario 2 and returned scores of 45.8-62.5%. The scores were not related to musculoskeletal-specific experience (4-84 months) and 1
(11.1%) of the participant had postgraduate qualification.
Conclusion: The scores of Scenario 1 showed moderate correlation to musculoskeletal-specific experience. Formal postgraduate physiotherapy qualification
appeared to contribute to this relationship. A bigger sample size can further verify the presence of this relation.
Implications: The scores of participants with varying levels of experience and qualifications can serve to create a set of baseline data for this online scenario tool. This
tool can be implemented on other physiotherapists commencing on a musculoskeletal posting. The resultant score can complement other existing work-based
assessment, and can be used to better inform supervision and education.
Funding Acknowledgements: Work is unfunded.
Ethics Approval: f) Ethics approval was granted by the National Healthcare Group (NHG) Domain Specific Review Board, Singapore.
Keywords: assessment, Clinical Reasoning, simulation

PO3-LL-056
RELIABILITY OF THE ASSESSMENT OF MOMENTARY HIP RESTING POSITION IN PEOPLE WITH OSTEOARTHRITIS
M. Fortn Agud 1,*, S. Prez Guilln 1, C. Hidalgo Garca 1, J. M. Trics Moreno 1, E. Estbanez de Miguel, S. Jimnez del Barrio, P. Pardos Aguilella, S. Rodrguez Marco,
A. Carrasco Uribarren
1
OMT-Spain, Zaragoza, Spain
Background: The joint resting position is defined as the position, where periarticular structures are more relaxed and there is the most joint play. This position is used
very often to assess and to treat joints. The resting position of the joints is defined for healthy subjects, but when there is any joint pathology this resting position
changes.
Purpose: The objective of this study is to assess intra- and intersession reliability of the assessment of hip resting position in OA patients.
Methods: Reliability test retest study. 40 subjects with hip osteoarthritis participate. Two physical therapists one with three years experience in Orthopaedic Manual
Therapy and one with one year experience in OMT assessed the hip resting position and the passive hip range of motion of the 40 subjects in two different sessions.
There was a time interval of 5 days between assessment sessions. The ICC was analysed to determine the reliability of the goniometric assessment.
Results: Hip resting position was measured in two planes: sagittal and frontal. We obtained a good intersession reliability for flexion (ICC:0,710, SEM:0,36) and
moderate reliability for the abduction (ICC:0,536, SEM:0,14) of the hip joint. Inter-examiner reliability was moderate for flexion (ICC:0,692, SEM:1,41) and for
abduction (ICC:0,650, SEM: 0,53).
Conclusion: This study shows that the reliability of the assessment of hip resting position in OA subjects is moderate; for the intrasession interrater measures and
good to moderate for measures taken by the same examiner with a time interval of five days between measures.
Implications: Good interrater reliability allows physiotherapist to ensure professional understanding of the momentary resting position
The good intersession reliability we obtained might be the previous step for doing in the future studies that look for changes in resting position after an OMT
treatment.
Funding Acknowledgements: Unfunded work
Ethics Approval: Ethics Committee for Clinical Research of Aragon (CEICA)
Keywords: Hip osteoarthritis, Physical therapy, Reliability

PO4-AP-004
RESEARCH IN THE FIELD OF PHYSICAL THERAPY
G. Bungartz 1,*, L. Jaeger 1, B. Schulte-Frei 1
1
Hochschule Fresenius, Cologne, Germany
Background: Universities in many western countries offer professional degrees in the health care sector, such as physical therapy, nursing, and others. With
education organized differently, some countries appear not to favor an academic education for the health care professions besides medicine. However, modifications
of these, often-times, traditional systems is currently debated intensively.
Purpose: This study aims to evaluate the development of research in the area of physical therapy (PT) to gain new perceptions about the effects of an academic
versus non-academic education in this field.
Methods: To achieve this we analyzed data on amount and quality of scientific publications from 1999 to 2014 using the SCImago database.
Results: Our data show that globally the number of articles published in the 50 top PT-journals doubled from approximately 3000 papers in 1999 to 6000 in 2014.
Comparable data from other medical fields demonstrate that the field of PT produces more articles and most importantly, that the velocity with which the rate of
publications has been increasing is twice as high. As in other areas the rate of citations generated by a given article is used as a measure of impact (IF). In the field of
PT this number increased fourfold within the last 15 years and bypassed other medical fields, such as anatomy. In addition to global developments we compared the
contribution of selected western countries. Normalized to population the UK had the leading position before 1999 but lost its lead to Australia and Scandinavian
countries and fell back to the midfield in 2014. Germany and France contributed the fewest research papers in the field of PT. Those countries ranked highest
outperformed those on the bottom by approximately sevenfold. Interestingly, this performance in quantity is in line with the average rate of citations per article.
To address the question whether this is a general or a PT-specific finding, i.e. whether there are systematic issues, such as language, etc. in Germany, we analyzed
respective bibliographical data for different medical fields. These data located Germany within the range of other well performing countries in terms of quantity and
quality.
Conclusion: These data demonstrate an enormous dynamic and innovative potential of PT-related research. With the described developments being stable in last 15
years our data suggest a further increase in number and quality in the future.
The low contribution of Germany to PT research appears to be specific for this field.
Implications: At this time it can only be speculated about the reasons for the latter findings. However, the very recent onset of academic education of physical
therapists in Germany might well play an important role, particularly as the most productive countries, such as Australia, have a long legacy of academically educated
physical therapists. These results imply that it might be essential to reform the educaton system to ensure the best possible, evidence based therapeutic care for
patients.
Funding Acknowledgements: This work was not funded.
Ethics Approval: No ethics approval required
Keywords: country ranking, Impact Factor, Research

PO4-ED-029
THE RELATIONSHIP BETWEEN CLINICAL REASONING ASSESSMENT IN MUSCULOSKELETAL PHYSIOTHERAPY AND CLINICAL PLACEMENT
J.-P. Dumas 1,*, J.-G. Blais 2, B. Charlin 2
1
Universit de Sherbrooke, Sherbrooke, 2Universit de Montreal, Montreal, Canada
Background: Clinical reasoning problem (CRP) is a relatively new test format that compares data interpretation (an important aspect of clinical reasoning) of clinical
vignette by students with data interpretation of a reference panel. Even if similar format of the test has been used in medical and physiotherapy education, there is
very little information about its validity. One possible aspect of the validation process of the test is to compare its results to the evaluation of clinical reasoning in
authentic situations.
Purpose: To compare the CRP results of three cohorts of entry-level physiotherapy students with the assessment of clinical reasoning during their clinical placements
in musculoskeletal physiotherapy.
Methods: The development of the physiotherapy CRP has been based on a table of specification from the content of a second year musculoskeletal course of a four
year (bachelor/master) program at the Universit de Sherbrooke. Eight clinical vignettes that included 218 items has been developed. Each vignette involved different
clinical decisions (diagnostic or intervention) and the interpretation of clinical data to reach those decisions. The scoring grid of the CRP test was constructed using an
aggregated score based on the answers from a panel of 18 physiotherapists with expertise in musculoskeletal physiotherapy. Ninety-one physiotherapy students (2nd
year = 33, 3rd year = 32, 4th year = 26) voluntarily participated in this study. Internal consistency of the test was calculated with Cronbachs alpha. Based on the results
of the qualitative and quantitative information found in the clinical placements assessment tools for these students, their clinical reasoning performance has been
classified in four categories (1 : major difficulty in clinical reasoning; 2 : minor difficulty in clinical reasoning; 3 : according to the expected level of clinical reasoning; 4
: above the expected level of clinical reasoning). One hundred and eighty three clinical placements assessment tools in musculoskeletal physiotherapy has been
analysed.
Results: The level of internal consistency (Cronbach alpha) was 0.88 for the CRP test. Mean score (CRP) for students (n = 4) in category 1 was: 52.6 (SD 6.3); for
students (n = 10) in category 2: 56.1 (SD 6.1); for students (n = 46) in category 3: 58.1 (SD 8.27) and 61.4 (SD 7.6) for students (n = 24) in category 4 of clinical
reasoning.
Conclusion: Based on the result of this study, the CRP test results seem to be related the level of clinical reasoning seen during the clinical placement of
physiotherapy students.
Implications: The CRP test format could be a useful tool in physiotherapy education to help in the assessment of clinical data interpretation and potentially for the
early screening of clinical reasoning difficulties of physiotherapy students.
Funding Acknowledgements: This work was supported by the Universit de Sherbrooke start up research fund.
Ethics Approval: Ethic approval was received form the Comit plurifacultaire d'thique de la recherche de lUniversit de Montral.
Keywords: 1.Clinical reasoning 2. Assessment. 3. Clinical placement

PO4-LB-045
IMPACT OF AN E-LEARNING PROGRAMME ON THE BIOPSYCHOSOCIAL MODEL FOR NON-SPECIFIC LOW-BACK PAIN ON EXPERIENCED OSTEOPATHS ATTITUDES TO
BACK PAIN: A MIXED-METHODS STUDY.
J. Draper-Rodi, S. Vogel 1,*, A. Bishop 2
1
The British School of Osteopathy, London, 2Research Institute for Primary Care and Health, Sciences, Keele University, Keele, United Kingdom
Background: Guidelines recommend the biopsychosocial (BPS) model for managing non-specific low back pain (NSLBP) but the best method for teaching the BPS
model is unclear. Printed material and face-to-face learning have limited effects on practitioners attitudes to back pain. An alternative way is needed and e-learning
is a promising option. E-learning is becoming an important part of teaching but little guidance is available to the osteopathic profession.
Purpose: This study had four aims. First to test the impact of an e-learning programme on the BPS model for non-specific LBP on experienced practitioners attitudes
to back pain; secondly, to provide data for a subsequent study on sample size calculation; thirdly to test the feasibility of the study concerning data collection
questionnaires, the randomization procedure, the acceptability of intervention, the recruitment process, the adherence and the consent process; and finally to
explore the participants views on the e-learning programme and possible impact it has on their reported behaviour.
Methods: An e-learning programme was designed and developed. It was informed by a scoping review of the BPS factors for NSLBP, a behaviour change model and it
followed the ADDIE 5 stage model: Analysis, Design, Development, Implementation and Evaluation.
A mixed-methods study is being conducted to evaluate the impact of the e-learning programme on the participants attitudes to back pain. The e-learning programme
is being tested in a pilot Randomised controlled trial (RCT) to assess experienced osteopaths attitudes before and after the intervention, using the Pain Attitudes and
Beliefs Scale for Physical Therapists (PABS) and the Attitudes to Back Pain Scale (ABS). The qualitative study will be undertaken in February 2016 to assess
participants views on the e-learning programme and explore possible impact on their reported practice behaviours.
Results: The RCT is being completed. 45 osteopaths with 15 years of experience and who have not been teaching in Osteopathic Education Institutions in the last 10
years consented and are taking part. The two trial arms are: the 6-week e-learning programme (intervention group) and a waiting list group (control group).
Participants completed the ABS and PABS pre and post intervention. Results from the mixed-methods study on the impact of this programme on osteopaths
attitudes to back pain and their views on the e-learning programme and possible impact on their behaviour will be ready for presentation at the IFOMPT conference
2016 along with a description of the nature of the programme.
Conclusion: This study is in progress but preliminary results show good feasibility and data on sample size calculation for a subsequent study will be available.
Participants informal feedback is positive and adherence is good.
Implications: Preliminary results suggest that e-learning is an appropriate tool to deliver CPD on the biopsychosocial approach to non-specific low back pain. To date
engagement of participants in the e-learning is good and satisfaction with the content and implementation method used.
Funding Acknowledgements: This research is part of Jerry Draper-Rodis Professional Doctorate in Osteopathy, partly funded by the British School of Osteopathy.
Ethics Approval: This research was approved by the Research Degrees Committee from the University of Bedfordshire and ethics approval was received from the
British School of Osteopathy Research Ethics Committee.
Keywords: biopsychosocial, e-learning, low back pain

PO4-MT-056
HOW SHOULD WE TEACH SIDE-LYING LUMBAR MANIPULATION? A CONSENSUS STUDY
M. O'Donnell 1,*, J. Armour Smith 2, K. Kulig 1, A. Abzug 1
1
Division of Biokinesiology & Physical Therapy, University of Southern California, Los Angeles, Ca. , 2Department of Physical Therapy, Chapman University, Orange, Ca.,
United States
Background: Side-lying lumbar manipulation (SLM) is a motor skill performed and taught by manual therapists. A systematically developed consensus-based
procedure describing the key elements and their temporal characteristics of the SLM is lacking.
Purpose: The purpose of this study was to develop consensus on aspects of patients and operators position, and motion that are considered by manual therapy
educators to be most important when teaching a SLM
Methods: Three sequential questionnaires were used to establish consensus using a correspondence based Delphi survey. Research software (Qualtrics, Provo, UT)
was used for all rounds. Round 1 consisted of open responses and the other two rounds used Likert scales. For each item, the number of responses for Not at all
important and Very unimportant were collated and categorized as Unimportant, and the number of responses for Very important and Extremely important
were collated and categorized as Important. Consensus was considered to be established if 75% of respondents identified an item as Important or Unimportant
Results: 612 individuals completed Round 1 of the survey (25% response rate). Respondents were highly experienced manual therapists, with 56% reporting at least
fifteen years of practice. 365 respondents completed Round 2 of the survey, representing a 60% retention rate from Round 1. Round 3 survey was completed by 258
respondents (71% retention rate from Round 2; 11% overall response rate). The responses were separated into two categories: patient positioning and operator
positioning. We determined that manual therapy educators feel that patient comfort, table height and the need to use rotation and side bending to localize the target
segment were important. Operator position was divided into preparatory and thrust phases. In the preparatory phase, the operators body should be up and over
the patient, and operators forearms are used to maintain patients trunk position. During the thrust phase, it was deemed important to generate force through the
operators body and legs and to create the force by dropping downwards. It was also considered to be important to generate the force with a high velocity and low
amplitude.
Conclusion: Using a Delphi Survey we were able to establish a consensus of what manual therapy educators believe are the important elements of patient and
therapist position and therapist motion during a sideling lumbar manipulation
Implications: Development of a consensus on the essential components of this specific technique provides educational guidelines for consistency in teaching this
effective intervention.
Funding Acknowledgements: This study was funded by a grant from the California Manual Physical Therapy Special Interest Group and By Cardon Rehabilitation
Ethics Approval: This study was approved by the Institutional Review Board of the University of Southern California.
Keywords: Manipulation, Teaching, Delphi

PO4-MT-058
EXPERT AND NOVICE CLINICIANS PERFORMING SIDE-LYING LUMBAR MANIPULATION: WHAT ARE THE DIFFERENCES IN MOVEMENT DYNAMICS?
J. Derian 1,*, J. Armour Smith 1, M. O'Donnell 1, A. Abzug 1, K. Kulig 1
1
Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, United States
Background: Side-lying lumbar manipulation (SLM) is widely used by manual therapists of varying backgrounds. Teaching this motor skill requires a thorough
understanding of its dynamics. However, the current anecdotal and research evidence primarily focuses on the preparatory phase and the direction of force applied
to the pelvis rather than the therapists dynamics. We believe that momentum, the product of trunks mass and velocity, and the ground reaction forces (GRF) under
each foot of a therapist are the defining characteristics of SLM dynamics.
Purpose: To determine the peak momentum developed during SLM in expert and novice clinicians and to characterize the vertical ground reaction forces under each
leg of the clinician.
Methods: Ten male clinicians, 5 novice (therapists enrolled in an orthopaedic residency) and 5 expert (at least 30 years of orthopaedic experience) performed the
SLM twice on two male models for a total of 4 trials per clinician. Motion capture data were collected at 200Hz, with a sacral marker used to approximate center of
mass (COM) kinematics. GRF were recoded using two adjacent force plates (1600Hz), one under each clinicians foot. The vertical GRF (vGRF) profile served as a guide
to extract the manipulation (drop) event, distinguishing it from the preparatory and recovery phases. The drop phase of the manipulation was defined as:
beginning at the highest vGRF, and ending at the lowest vGRF. Recovery phase was defined as: beginning at the end of drop, and ending when the vGRF returned to
the pre-manipulative value or 300 msec after the end of manipulation (whichever came first). Peak linear vertical COM momentum and vGRF magnitude at start of
manipulation were compared between groups using ANCOVA and independent t-tests respectively (p<0.05). As a secondary analysis, vGRF profiles were compared
between one representative expert (E1) and 5 novices. The best-fit lines were determined along the slope of vGRF vs. time for each phase of the manipulation, with
both slope and R2 values recorded.
Results: Mean peak vertical COM momentum was 221.2 (48.6) N in experts and 96.7 (17.6) N in novices. The difference, co-varied for mass, was statistically
significant (p= 0.022). The vGRF of the back foot at the start of the manipulation was 41.0 (4.8) % body weight in the experts and 32.0 (5.4) % in the novices (p=
0.049). The mean coefficient of determination (R2) of the vGRF for E1 was 0.942 (0.055) and ranged between 0.018-0.9953 in the 5 novices.
Conclusion: Experienced clinicians execute SLM with greater peak linear momentum compared with the novices. The experts also begin their manipulation with
greater force through the back foot. This suggests that the experts perform the SLM quicker, and that the maneuver may rely on a feed-forward mechanism. Further
support for this mechanism may be seen in the vGRF profile of E1 closely resembling a linear relationship. This mechanism was likely less efficiently explored in
novices. Future research investigating the performance of a larger group of clinicians and relating the performance to the therapeutic outcomes is warranted.
Implications: GRF profiles and COM kinematics may be used to improve a particular clinicians performance and improve the skill acquisition of new learners.
Funding Acknowledgements: This study was funded by a grant from the California Manual Physical Therapy Special Interest Group and by Cardon Rehabilitation.
Ethics Approval: This study was approved by the Institutional Review Board of the University of Southern California.
Keywords: biomechanics, education, manipulative therapy

PO4-MT-059
GRADUATES PERSPECTIVES OF FACILITATORS AND BARRIERS ASSOCIATED WITH PARTICIPATION IN AN ORTHOPEDIC MANUAL THERAPY RESIDENCY PROGRAM IN
NAIROBI, KENYA
S. Cunningham 1,*, J. Taylor McFelea 2
1
Physical Therapy, Radford University, Roanoke, 2Physical Therapy, University of Evansville, Evansville, United States
Background: There are very few opportunities for long term, comprehensive post-graduate clinical education in developing countries due to fiscal and human
resource constraints. Therefore, physiotherapists have minimal opportunity following graduation to improve clinical reasoning and treatment skills. To address this
educational shortcoming, an orthopaedic manual therapy residency program has been introduced in Nairobi, Kenya. The utilization of a residency model of education
in developing countries is an innovative approach used to provide access to advanced instruction, which is fundamental to promoting continued development of
clinical reasoning and manual therapy skills. By understanding the perceptions of physiotherapists who have participated in the residency program, the barriers and
facilitators for access to the program and incorporation of newly aquired knowledge and manual therapy skills in the clinic can be identified and addressed.
Purpose: The purpose of this qualitative study was to identify facilitators and barriers for participation in the residency program and for the integration of the new
knowledge and manual therapy skills into clinical practice.
Methods: Individual, face-to-face, audio-recorded interviews (n=15) were conducted over a three-day period after residents had completed their final practical
examination and given consent. The interviews were transcribed by an independent transcriptionist. The data was coded and general themes were identified specific
to facilitators and barriers to access the program and incorporate the manual therapy skills learned into clinical practice.
Results: Themes identified with regard to access to the program were as follows:(1) An initial social stigma experienced by physiotherapists that participated in the
program from colleagues that remainned in the clinic;(2) Later, encouragement from management to continue participating in the program as patient outcomes
improved.
Themes identified with regard to implementing the newly aquired knowledge and skills in the clinic were as follows: (1) Patients required education regarding
manual therapy treatment techniques in order to become comfortable with the new approach to care; (2) Residents experienced a decrease in productivity as they
were practicing their newly acquired skills and assessment techniques in the clinic; (3) There was a positive impact on the ability to utilize clinical reasoning to
establish multiple hypotheses for a patients diagnosis and then effectively determine a diagnosis from which to choose evidence-based treatment techniques; and
(4) Mentoring in the clinic was the most effective method for integrating newly acquired knowledge into practice.
Conclusion: Graduates of the first cohort of physioptherapists to complete a manual therapy residency program in Nairobi, Kenya identified several barriers and
facilitators to access to the program and the incorporation newly acquired knowledge and manual therapy skills in the clinic. The novelty of the program was
apparent as education of patients, colleagues, and employers was identified as an initial barrier. All graduates reported a positive influence of the residency program
on the advancement of their clinical reasoning skills and improved patient outcomes.
Implications: Instructors can assist residents in understanding and overcoming identified barriers. The positive impact on patient outcomes may become a facilitator
for continued growth of the post-graduate orthopaedic manual therapy residency program.
Funding Acknowledgements: The residency is funded through the Jackson Clinics Foundation and supported by the Kenya Ministry of Health.

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Advanced assessment/practice and managing complex patients

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Advanced assessment/practice and managing complex patients

Advanced assessment/practice and managing complex patients

Advanced assessment/practice and managing complex patients

Advanced assessment/practice and managing complex patients

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