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OBJECTIVES: Nonspecific chronic low back pain (NSCLBP) is associated with psychological and social factors such as social support. However, little research has focused on the latter. This article aimed to review the literature on the association between social support and clinical outcomes of patients with NSCLBP, particularly regarding differences in sex, gender, and types of social support. METHODS: MEDLINE, EMBASE, Web of Science, PsycINFO, and CENTRAL were searched until April 19, 2024, without restrictions of time or language. Eligible articles were observational studies reporting measures of association between social support and clinical outcomes among adults with NSCLBP. Risk of bias was assessed using the QUIPS tool, and findings were analyzed qualitatively. This systematic review was registered on PROSPERO (CRD42022363210). RESULTS: Of the 3528 identified studies, 11 were included in the review (1290 patients), showing a moderate to high risk of bias. Of the 5 studies showing a significant finding for pain, 4 reported a negative correlation (r=-0.18, -0.32, -0.35, -0.36) and 1 did not report any association index. Of the 6 studies showing a significant finding for disability, 2 reported a negative correlation (r=-0.29, -0.42), 2 reported a positive association (r=0.322; ß=0.29), and 2 did not report any association index. No data was available for the investigated subgroups or secondary clinical outcomes. DISCUSSION: Small associations were found between social support and clinical outcomes of individuals with NSCLBP. Further research is needed to establish its clinical relevance according to types of social support, sex, and gender.

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OBJECTIVE: Frozen Shoulder (FS) is a musculoskeletal pathology that leads to disability, functional decline, and a worsening in quality of life. Physiotherapists are the primary professionals involved in the treatment of FS, and it is essential to determine if their practice aligns with evidence-based suggestions. AIM: The aim is to assess the knowledge, skills, and operational strategies of Italian physiotherapists regarding FS and compare them with the existing literature. METHODS: A web-based, anonymous, and voluntary cross-sectional survey was developed and administered to Italian physiotherapists to evaluate their clinical practices. RESULTS: A total of 501 physiotherapists (38.5% female), completed the survey. More than half were under 35 years old (67.8%), declared working in private practice settings or being self-employed (57.1%), and were primarily engaged with musculoskeletal patients (81.8%). For subjects with FS at their first access, 21.4% identified X-rays as the most useful imaging technique to recognize pathologies beyond rehabilitation competence. In terms of general management, the majority reported working with an orthopaedic or physiatrist (47.5%) or in a multidisciplinary team (33.5%). Regarding manual therapy techniques, 63.3% of physiotherapists preferred intense degree mobilization, posterior direction, and moderate pain at the end of the range of motion for low irritable/high stiffness FS; however, there is a lack of consensus for managing very irritable/low stiffness FS. The majority of physiotherapists (57.7%) concurred that stretching improves the balance between metalloproteinase and its inhibitors. Additionally, 48.3% of physiotherapists selected mobile phone videos and messages to improve patients' compliance with exercises at home and for motivational/educational purposes. DISCUSSION AND CONCLUSION: The clinical practices of Italian physiotherapists in FS subjects sometimes deviate from evidence-based recommendations. While some discrepancies may be attributed to the existing uncertainties in the literature regarding knowledge and management strategies for FS patients, the authors recommend a stronger adherence to evidence-based practice.

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PURPOSE: This study aimed to investigate the correlation between mental and physical health-related quality of life and the outcomes of conservative treatment in patients with frozen shoulder (FS). METHODS: This was a two-center retrospective study. It included 84 consecutive patients who underwent a 3-month treatment comprising education, physical therapy, and corticosteroid-anesthetic injections. Changes in range of motion (ROM) and Shoulder Pain and Disability Index (SPADI) scores, measured at baseline and after 3 months, were selected as dependent variables. Data on age, sex, Body Mass Index, duration of symptoms, dominant affected limb, and Short Form-36 (SF-36) subscales were gathered at baseline and investigated as prognostic factors. Backward stepwise regression models were used to identify significant associations. RESULTS: At 3-month follow-up, all the patients showed significant improvement. Higher SF-36 General Health, Mental Health and Social Functioning scores at baseline were associated with a greater beneficial change in ROM and SPADI. In contrast, lower SF-36 Bodily Pain and Role Emotional scores were found to be associated with greater improvement. CONCLUSION: The study findings indicate that the self-perceived mental and physical health of patients have a significant impact on both subjective and objective clinical outcomes and healthcare professionals should take these aspects into account. LEVEL OF EVIDENCE: Prognostic Level II.

Self-perceived mental and physical health could impact the prognosis of subjects affected by frozen shoulder.Healthcare providers should adopt a multi-professional approach to frozen shoulder rehabilitation, integrating the psychological perspective into the management of this condition.For people affected by frozen shoulder, a comprehensive assessment that goes beyond just physical function is recommended.

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PURPOSE: To investigate if Extracorporeal Shock Wave therapy (ESWT) is effective in reducing pain and disability, in improving function, quality of life and complete resorption rate of calcification in patients with Rotator Cuff Calcific Tendinopathy. To investigate which modality of ESWT brings the greatest clinical improvements between High (HE)-SWT and Low Energy (LE)-SWT and between Focal (F)-SWT and Radial (R)-SWT. METHODS: MEDLINE, EMBASE, CENTRAL Database, and PEDro databases until February 2024 were searched. Study registers were further investigated. The Risk of Bias (RoB) was assessed with the Revised Cochrane RoB Tool (RoB 2). The certainty of evidence was rated with GRADE. RESULTS: Twenty-one randomized controlled trials were included. None was judged as overall low RoB. Comparing ESWT and Ultrasound Guided Needling Procedures (USGNP), the pooled results reported a significant difference favoring USGNP in pain at <24 and <48 weeks (MD = 1.17, p = 0.004, I2 = 59%; MD = 1.31, p = 0.004, I2 = 42%, respectively). Comparing ESWT and sham-ESWT, the pooled results reported a clinically significant difference favoring ESWT in pain and function at 24 weeks (MD = -5.72, p < 0.00001, I2 = 0%; Standardized Mean Difference = 2.94, p = 0.02 I2 = 98%, respectively). Comparing HE-SWT and LE-SWT, HE-SWT was statistically and clinically superior in pain and function at <24 weeks (MD = -1.83, p = 0.03, I2 = 87%; MD = 14.60, p = 0.002, I2 = 77%, respectively) and showed a significantly higher complete resorption rate of calcification at 12 weeks (Risk Ratio = 2.53, p = 0.001, I2 = 0%). F-SWT and R-SWT appear equally effective in reducing pain, improving disability and resorption rate. The certainty of evidence was rated as very low through GRADE approach. CONCLUSION: USGNP was statistically superior to ESWT in pain reduction at <24 and <48 weeks. ESWT was clinically better to sham-ESWT in pain reduction and function improvement at 24 weeks. HE-SWT was clinically more effective than LE-SWT in reducing pain, improving function at <24 weeks, and resolving calcific deposits at 12 weeks, while no differences between F-SWT and R-SWT were reported.

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PURPOSE: To cross-culturally adapt the Patient-Specific Functional Scale (PSFS) into Italian and study its classic psychometric properties in subjects with shoulder pain (SP). MATERIALS AND METHODS: The PSFS was translated into Italian and administered to 109 SP subjects. Acceptability (time to administer, floor and ceiling effects), reliability (internal consistency [Cronbach's alpha], test-retest reliability [Intraclass Correlation Coefficient (ICC)], and measurement error [Standard Error of Measurement (SEM), Minimal Detectable Change, (MDC)]), were assessed. Moreover, construct validity was investigated through a-priori hypothesis testing, comparing the PSFS with the Disability of the Shoulder, Arm and Hand (DASH) scale, 36-item Short Form Health Survey (SF-36) and Numeric Pain Rating scale (NPRS). RESULTS: The PSFS was successfully adapted into Italian, and its acceptability was satisfied. Internal consistency was high (Cronbach's alpha = 0.925), and test-retest reliability was good (ICC = 0.866, 95% CI = 0.749-0.931). A SEM of 0.7 points and an MDC of 1.9 points were obtained. We observed moderate evidence for construct validity, with 4/6 correlations between other measures being respected. CONCLUSION: This study provided reliability and validity of the PSFS in a sample of Italian SP subjects. Future studies should assess the responsiveness of using the PSFS as an outcome measure to capture clinical changes after treatment.

The Patient-Specific Functional Scale is a reliable, and easy-to-use patient-reported outcome measure.The Patient-Specific Functional Scale was cross-cultural validated in the Italian language.The Patient-Specific Functional Scale has excellent internal consistency, high reliability, low measurement error, and moderate construct validity in subjects with shoulder pain.The Patient-Specific Functional Scale can be used in clinical practice by Italian physiotherapists to assess subjects with shoulder pain.

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BACKGROUND: Frozen Shoulder (FS) is a painful condition characterized by severe pain and progressive restriction of shoulder movement, leading to functional impairment and reduced quality of life. While different Patient Reported Outcome Measurements (PROMs) tools exist for assessing shoulder diseases, few specific PROMs are validated for FS patients. PURPOSE: This study aims to assess the psychometric properties of the Disability of Arm, Shoulder, and Hand (DASH) questionnaire in FS patients. METHODS: One hundred and twenty-four subjects (mean ± SD age = 55.4 ± 7.9 years; 55.6% female) diagnosed with FS were included and completed the DASH questionnaire, the Numerical Pain Rating Scale (NPRS), the Shoulder Pain and Disability Index (SPADI), and the Short-Form Health Survey 36 (SF-36). Floor or ceiling effects were investigated. Structural validity was analysed through a unidimensional Confirmatory Factor Analysis (CFA), internal consistency through Cronbach's alpha, test-retest reliability through the Intraclass Correlation coefficient (ICC), measurement error through the Standard Error of Measurement (SEM), and the Minimum Detectable Change (MDC), and construct validity through the hypothesis testing with the correlation with the other outcome measures used. RESULTS: No floor or ceiling effects were observed. CFA confirmed a one-factor structure after addressing local item dependency (Root Mean Square Error of Approximation = 0.055; Standardized Root Mean Square Residual = 0.077; Comparative Fit Index = 0.970; Tucker-Lewis Index = 0.968). Cronbach's alpha was high (= 0.951), and test-retest reliability was excellent (ICC = 0.999; 95% CI: 0.998-1.000). SEM was equal to 0.5 points, and MDC to 1.5 points. Construct validity was considered satisfactory as 80% of the a-priori hypotheses were met. CONCLUSION: The DASH questionnaire demonstrated good psychometric properties in FS patients, supporting its use as a valuable tool for assessing the impact of FS in clinical and research settings.

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BACKGROUND: The prevalence and cost of musculoskeletal diseases increased dramatically over the past few decades. Therefore, several institutions have begun to re-evaluate the quality of their musculoskeletal educational paths. However, current standardized questionnaires inadequately assess musculoskeletal knowledge, and other musculoskeletal-specific exams have limitations in implementation. The musculoskeletal 30-question multiple choice questionnaire (MSK-30) was proposed as a new tool for assessing basic musculoskeletal knowledge. AIM: To analyse basic musculoskeletal knowledge in a sample of Italian physiotherapists by administering the MSK-30 questionnaire. METHODS: After a transcultural adaptation process, the MSK-30 was developed and administered to Italian physiotherapists to assess their musculoskeletal knowledge. Participants were invited to participate in the survey via the SurveyMonkey link. Mann-Whitney test and the Kruskal-Wallis test with Bonferroni correction were used to observe the differences between groups in the MSK-30 scores. RESULTS: Four hundred-fourteen (n=414) physiotherapists participated in the survey. The median MSK-30 value was higher in physiotherapists who attended the International Federation of Orthopaedic Manipulative Physical Therapists postgraduate certification than in those who attended unstructured postgraduate training in musculoskeletal condition or in those who had not completed any postgraduate training in this field (p<0.001). CONCLUSIONS: This work demonstrates significant differences in the management of musculoskeletal disorders between those with specific postgraduate university education and those without. The findings can contribute to the advancement of the physiotherapy profession in Italy. Authors recommend further research with more robust methodologies to deeper understand this topic. Musculoskeletal conditions will continue to represent a significant portion of primary care visits, and future generations of physiotherapists must be prepared to address this challenge.

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PURPOSE: To investigate the benefit of spinal high-velocity low-amplitude thrust (HVLAT) in improving pain and disability in persons with painful shoulder as primary outcomes. Function, quality of life, persons (and clinicians) satisfaction, adverse events rate, and time for recovery were secondary outcomes. METHODS: A systematic review with meta-analysis was conducted and MEDLINE, CENTRAL, Embase, and PEDro until 20 September 2023 were investigated. Two thousand eight hundred and ninety-nine records were retrieved and nine studies were included. Risk of bias of included studies was assessed through the Revised Cochrane risk-of-bias tool. The certainty of evidence of the pooled results was graded with GRADE approach. RESULTS: The analysis included nine studies (441 persons). The pooled results showed non-significant differences between HVLAT versus sham in pain at pre-post follow-up (MD -0.13, 95% confidence interval (CI) -0.60; 0.35; p = 0.61, I2 = 0%), and at <4 days follow-up (SMD 0.16, 95%CI -0.16; 0.48; p = 0.34, I2 = 23%); in function at <4 days follow-up (SMD -0.29, 95%CI -0.69; 0.11; p = 0.16, I2 = 50%). The certainty of evidence ranged from low to very low. CONCLUSIONS: HVLAT was not more effective than sham in improving pain and function at pre-post and at <4 days follow-up. When used as an "add-on technique", HVLAT did not improve pain nor disability.

High-velocity low-amplitude thrust (HVLAT) manipulation is no more effective than sham in improving shoulder pain at pre-post follow-up.Clinician should not be recommended to deliver HVLAT manipulation in subjects with painful shoulder with the purpose of reducing pain intensity.However, HVLAT manipulation should be considered within a multimodal approach to address function in painful shoulder subjects.

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PURPOSE: Shoulder stiffness (SS) is a condition characterised by active and passive restricted glenohumeral range of motion, which can occur spontaneously in an idiopathic manner or be associated with a known underlying aetiology. Several treatment options are available and currently no consensus has been obtained on which treatment algorithm represents the best choice for the patient. Herein we present the results of a national consensus on the treatment of primary SS. METHODS: The project followed the modified Delphi consensus process, involving a steering, a rating and a peer-review group. Sixteen questions were generated and subsequently answered by the steering group after a thorough literature search. A rating group composed by professionals specialised in the diagnosis and treatment of shoulder pathologies rated the question-answer sets according to the scientific evidence and their clinical experience. RESULTS: Recommendations were rated with an average of 8.4 points out of maximum 9 points. None of the 16 answers received a rating of less than 8 and all the answers were considered as appropriate. The majority of responses were assessed as Grade A, signifying a substantial availability of scientific evidence to guide treatment and support recommendations encompassing diagnostics, physiotherapy, electrophysical agents, oral and injective medical therapies, as well as surgical interventions for primary SS. CONCLUSIONS: A consensus regarding the conservative and surgical treatment of primary SS could be achieved at a national level. This consensus sets basis for evidence-based clinical practice in the management of primary SS and can serve as a model for similar initiatives and adaptable guidelines in other European countries and potentially on a global scale. LEVEL OF EVIDENCE: Level I.

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BACKGROUND AND PURPOSE: Frozen shoulder (FS) is defined as a condition characterised by functional restriction and daily and nightly pain. As in other shoulder pathologies, the manifestation of psychological factors is recognised in FS; however, from a psychological point of view, only few studies have reported its prognostic value. The aim of this systematic review is to investigate, in patients with FS, the prognostic value of psychological factors on pain, function, disability, health-related quality of life, return to work and time to recovery. MATERIALS AND METHODS: This systematic review was reported following the Preferred Reporting Items for Systematic reviews and Meta-Analysis-PRISMA 2020 guideline. The authors followed the Cochrane Handbook for Systematic review of Intervention as methodological guidance. The Quality in Prognostic Studies-QUIPS tool was used to assess the risk of bias. RESULTS: Pain-related fear and depression could be prognostic regarding patient-reported outcome measures assessing shoulder function, disability, and pain; instead, pain catastrophizing could have a prognostic value assessed by the disability of the arm shoulder and hand -DASH scale. Anxiety would appear to impact on disability and pain. DISCUSSION AND CONCLUSIONS: As widely reported in numerous musculoskeletal conditions, also in FS psychological factors influence the physical dimension such as pain, disability and function. Therefore, clinicians should be encouraged to identify these factors through a comprehensive assessment of the bio-psychological profile of each individual with FS. Perhaps, patients with FS that show such psychological prognostic factors could benefit from a comprehensive and shared approach with other dedicated professionals.

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PURPOSE: This systematic review with meta-analysis aimed to assess the effectiveness of electrophysical agents in improving pain, function, disability, range of motion, quality of life, perceived stiffness, and time to recovery in subjects with frozen shoulder (FS). METHODS: A thorough search of MEDLINE, Cochrane Library, PEDro, and EMBASE yielded 1143 articles, of which 23 randomized controlled trials were included. Risk of bias (RoB) was assessed through Cochrane Risk of Bias 2 tool. The certainty of evidence was evaluated through the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). RESULTS: The analysis included a total of 1073 subjects. None of the studies were judged as low RoB. Potentially clinically significant differences were observed in pain at 6 weeks and 5 months after extracorporeal shockwave therapy (ESWT), and in disability up to 3 months with laser therapy, albeit with uncertain results due to the high RoB and to the study heterogeneity. Ultrasound (US) therapy did not yield significant differences in any outcomes. The certainty of evidence was very low. CONCLUSIONS: Based on the high heterogeneity and low quality and certainty of evidence, ESWT, laser, and US cannot be recommended for FS treatment. Caution should be exercised in interpreting the findings.

Although a clinical difference in pain and disability was observed, the certainty of the evidence was low.Ultrasound therapy is not recommended in patients with frozen shoulder.Electrophysical agents may not ensure adequate therapeutic efficacy.

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OBJECTIVES: To explore the relationships between the risk of bias and treatment effect estimates for exercise therapy interventions on pain intensity and physical functioning outcomes in randomized controlled trials (RCTs) involving patients with chronic low back pain. STUDY DESIGN AND SETTING: A cross-sectional meta-epidemiological study of the 230 RCTs (31,674 participants) in the 2021 'Exercise therapy for chronic low back pain' Cochrane Review were included. Study design characteristics, sample size, prospective trial registration, flowchart information, interventions, and comparisons were extracted. Independent pairs of reviewers assessed the risk of bias using the Cochrane Risk of Bias 2 tool. RESULTS: The metaregression included 220 (pain intensity) and 203 (physical functioning) effect sizes. Unadjusted and adjusted metaregression models showed no significant associations between the bias domains and pain intensity effect sizes. Only domain 'bias in the measurement of the outcome' was significantly associated with physical functioning (standardized mean difference: -0.40, 95% confidence interval: -0.77 to -0.02) when adjusted for flowchart reported (yes/no), prospective trial registration, sample size, and comparator type. CONCLUSION: The risk of bias in the measurement of the outcome could lead to slight overestimates of the effect size for physical functioning. Clinicians should consider this when they read and assess RCT results in this field. We encourage metaresearchers to replicate our findings using a consistent approach for evaluating the risk of bias (i.e., the RoB 2 tool) in other musculoskeletal conditions and interventions to investigate their generalizability.

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This study aimed to investigate the knowledge and use of effective communication strategies among Italian physiotherapists. We utilized a questionnaire consisting of 19 questions to collect data on the knowledge and use of effective communication strategies among Italian physiotherapists. The results revealed that only 35.8% of the respondents reported being aware of communication strategies related to physiotherapy, with their first exposure occurring during their three-year degree. Despite the majority of respondents agreeing that communication is an effective strategy for improving patient adherence, only about half reported making moderate use of open-ended questions and metaphors during treatment sessions. Furthermore, more than half of the respondents reported being unaware of Motivational Interviewing. The results of this study found that there is a consensus among Italian physiotherapists about the importance of effective communication in clinical practice, though the knowledge and application of some communication strategies remain limited. These findings suggest that there is room for improvement in the training and education of physiotherapists in Italy, with a need for greater emphasis on communication strategies in the university educational curriculum, starting from the bachelor's degree.

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OBJECTIVE: We aimed to estimate the benefits and harms of cervical spinal manipulative therapy (SMT) for treating neck pain. DESIGN: Intervention systematic review with meta-analysis of randomized controlled trials (RCTs). LITERATURE SEARCH: We searched the MEDLINE, Cochrane CENTRAL, Embase, CINAHL, PEDro, Chiropractic Literature Index bibliographic databases, and grey literature sources, up to June 6, 2022. STUDY SELECTION CRITERIA: RCTs evaluating SMT compared to guideline-recommended and nonrecommended interventions, sham SMT, and no intervention for adults with neck pain were eligible for our systematic review. Prespecified outcomes included pain, range of motion, disability, health-related quality of life. DATA SYNTHESIS: Random-effects meta-analysis for clinically homogenous RCTs at short-term and long-term outcomes. Risk of bias was assessed using the Cochrane Risk of Bias 2.0 Tool. We used the Grading of Recommendations, Assessment, Development, and Evaluations approach to judge the certainty of evidence. RESULTS: We included 28 RCTs. There was very low to low certainty evidence that SMT was more effective than recommended interventions for improving pain at short term (standardized mean difference [SMD], 0.66; 95% confidence interval [CI]: 0.35, 0.97) and long term (SMD, 0.73; 95% CI: 0.31, 1.16), and for reducing disability at short-term (SMD, 0.95; 95% CI: 0.48, 1.42) and long term (SMD, 0.65; 95% CI: 0.23, 1.06). Transient side effects only were found (eg, muscle soreness). CONCLUSION: There was very low certainty evidence supporting cervical SMT as an intervention to reduce pain and improve disability in people with neck pain. J Orthop Sports Phys Ther 2023;53(9):510-528. Epub: 10 August 2023. doi:10.2519/jospt.2023.11708.

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BACKGROUND: The incidence of Total Shoulder Arthroplasty (TSA) and Reverse Total Shoulder Arthroplasty (RTSA) is constantly increasing. As a result, the interest in post-surgical rehabilitation has grown, since it is crucial in order to achieve full recovery and successful outcomes. The first aim of this study is to investigate the Italian physiotherapists (PTs) clinical practice in the management of patients with TSA and RTSA and to compare it with the best evidence available in the literature. The second purpose of this study is to assess any existing difference between the survey answers and the different sample subgroups. MATERIALS AND METHODS: This cross-sectional observation study was designed following the CHERRIES checklist and the STROBE guidelines. A 4-sections survey with a total of 30 questions was developed for investigating post-surgery rehabilitation management in patient with TSA and RTSA. The survey was sent to Italian PTs from December 2020 until February 2021. RESULTS: Six-hundred and seven PTs completed the survey regarding both TSA and RTSA; 43.5% of participants (n = 264/607) stated that TSA is more likely to dislocate during abduction and external rotation. Regarding reverse prosthesis, 53.5% (n = 325/607) affirmed RTSA is more likely to dislocate during internal rotation, adduction and extension. In order to recover passive Range of Motion (pROM), 62.1% (n = 377/607) of participants reported that they gain anterior flexion, abduction, internal rotation, external rotation up to 30°, with full pROM in all directions granted at 6-12 weeks. Regarding the active ROM (aROM), 44.2% (n = 268/607) of participants stated that they use active-assisted procedures within a range under 90° of elevation and abduction at 3-4 weeks and higher than 90° at 6-12 weeks, with full recovery at a 3-month mark. Sixty-five point seven percent of the sample (n = 399/607) declared that, during the rehabilitation of patients with TSA, they tend to focus on strengthening the scapular and rotator cuff muscles, deltoid, biceps and triceps. Conversely, 68.0% (n = 413/607) of participants stated that, for the rehabilitation of patients with RTSA, they preferably focus on strengthening the periscapular and deltoid muscles. Finally, 33.1% (n = 201/607) of participants indicated the instability of the glenoid prosthetic component as the most frequent complication in patients with TSA, while 42.5% (n = 258/607) of PTs identified scapular neck erosion as the most frequent post-RTSA surgery complication. CONCLUSIONS: The clinical practice of Italian PTs effectively reflects the indications of the literature as far as the strengthening of the main muscle groups and the prevention of movements, which may result in a dislocation, are concerned. Some differences emerged in the clinical practice of Italian PTs, regarding the restoration of active and passive movement, the starting and progression of muscle strengthening and the return to sport (RTS). These differences are actually quite representative of the current knowledge in post-surgical rehabilitation for shoulder prosthesis in the rehabilitation field. LEVEL OF EVIDENCE: V.

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Parsonage-Turner Syndrome or neuralgic amyotrophy is a peripheral neuropathy typically characterized by an abrupt onset of pain, followed by progressive neurological deficits (e.g. weakness, atrophy, occasionally sensory abnormalities) that involve the upper limb, mainly the shoulder, encompassing an extensive spectrum of clinical manifestations, somehow difficult to recognize. This case report describes the proper management of a 35-year-old, bank employee and sports amateur who reported subtle and progressive upper limb disorder with previous history of neck pain. SARS-CoV-2 pandemic era made patient's access to the healthcare system more complicated. Nevertheless, proper management of knowledge, relevant aspects of telerehabilitation-based consultation for musculoskeletal pain, advanced skills, tools and technologies led the physiotherapist to suspect an atypical presentation of Parsonage-Turner Syndrome. Further, neurologist consultation and electromyography suggested signs of denervation in the serratus anterior and supraspinatus muscle. Therefore, an appropriate physiotherapist's screening for referral is conducted to correct diagnosis and thorough treatment.

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BACKGROUND: The point prevalence of Cauda Equina Syndrome (CES) as a cause of Low Back Pain (LBP) is estimated at 0.04% in primary care, and it is reported as a complication in about 2% of patients with disc herniation. Compression of the cauda equina usually occurs as a result of disc prolapse. However, CES may be caused by any space-occupying lesion, including spinal stenosis, neoplasms, cysts, infection, and osteophytes. First contact physiotherapists may encounter patients with early CES, as the clinical presentation of CES can mimic non-specific LBP. CASE PRESENTATION: This case report presents the medical history, diagnostic tests and relevant clinical data of a 52-year-old man complaining of LBP. The patient's medical history, his symptoms and the clinical findings led to the identification of a number of red flags (i.e. risk factors) suggestive of a non-musculoskeletal condition. The patient was referred to the emergency department for further investigation. Having undergone several diagnostic tests, the patient was diagnosed with CES due to malignancy. CONCLUSIONS: This case report highlights the importance of differential screening throughout the treatment period, in order to identify red flags that warrant further investigation and a referral to an appropriate specialist. Physiotherapy screening should include clinical reasoning, careful analysis of clinical presentation and symptom progression, in addition to appropriate referral for medical assessment and diagnostic imaging, if necessary.

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INTRODUCTION: Maladaptive psychological responses may hinder participation and return to pre-injury level in sport. The aim of this study was to investigate the psychological factors influence on pain, function, quality of life and time to return to sport in subjects with shoulder instability. EVIDENCE ACQUISITION: The research was conducted until the 15th of May 2022 in MEDLINE, CENTRAL, PEDro, and PubPSYCH regardless language, publication status or date. We included adults (≥16 years old) with shoulder instability. Quality assessment was performed using Joanna Briggs Institute Critical Appraisal tools. EVIDENCE SYNTHESIS: Three papers, 270 participants, met the inclusion criteria. Subjects with preoperative depression demonstrated worse 1-year postoperative shoulder-related quality of life score than the cohort without depression. Shoulder function had a weak negative correlation with depression. Pain intensity and depression showed a positive correlation of moderate strength. Fear of re-injury correlated with SPADI total, pain and function; moreover, it increased the likelihood of recurrent dislocation in multivariate analysis. Kinesiophobia at baseline correlated with WOSI. CONCLUSIONS: Depression, fear of re-injury and kinesiophobia correlate with pain, function, quality of life and return to sport in people with shoulder instability. We recommend a multi-professional approach to integrate the psychological standpoint in rehabilitation treatment to maximize quality of life and function in subjects with instability.

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BACKGROUND: The prevalence of Thoracic Pain (TP) is estimated to be low compared to other common musculoskeletal disorders such as nonspecific low back pain (LBP). Notably, compared to LBP, TP or referral pain to the thoracic area potentially may involve serious pathologies. Visceral referral of pain may present to the thoracic spine or anteriorly in the abdomen or chest. Rupture of the spleen in the absence of trauma or previously diagnosed disease is rare and rarely documented in emergency medicine literature. The incidence of red flags are higher in the thoracic area in comparison to the lumbar or cervical regions, but TP can also be of musculoskeletal origin and for this reason it is important to assess the origin of pain. CASE DESCRIPTION: This case report describes the clinical history, evaluation and management of a 60-year-old complaining of upper thoracic, bilateral shoulder, and right upper quadrant abdominal pain. The patient's clinical findings from a physiotherapist's assessment led to a referral to a physician to explore a potential non-musculoskeletal origin. A splenectomy was required due to a non-traumatic rupture of the spleen. After 20 days of hospitalization from the surgery, the patient returned to all normal activities of daily living. DISCUSSION AND CONCLUSION: The purpose of this current case report is to describe the clinical reasoning of a physiotherapist screening a patient who presented with thoracic pain due to a spontaneous rupture of the spleen, that resulted in a referral to another health practitioner.

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Hemangiomas are the most common benign tumours affecting the spine, with an incidence of 10-12% of the general population. Although most hemangiomas are asymptomatic, there are aggressive forms which can develop symptoms, leading patients to show signs of disability. This case report aims to highlight the importance of red flags screening, and to report the physiotherapist's clinical reasoning that led him to refer his patient to other healthcare professionals. This case also illustrated the pre- and post-surgical treatment of a specific low back pain case in a patient affected by aggressive vertebral hemangioma and spinal cord compression. The patient is a 52-year-old man, who reported intense pain in his sacral region about three months prior, which worsened while in sitting position. The physiotherapist proceeded with a complete medical history investigation and clinical examination. After an impaired neurological examination, the patient was referred to another health professional, who diagnosed multiple vertebral hemangiomas in the patient's lumbosacral tract. The therapeutic intervention included the patient's post-surgical rehabilitation following a vascular embolization. This case report shows the importance of proper patient screening. Indeed, during patients' assessment, it is paramount to recognize red flags and to investigate them appropriately. An early referral of patients with conditions that require the support and expertise of other professionals can lead to a timely diagnosis and avoid costly and unnecessary rehabilitation procedures. In this case, the interdisciplinary collaboration between physiotherapist and neurosurgeon was crucial in guiding the patient towards recovery.

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