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ABSTRACT BACKGROUND AND OBJECTIVES: The red flags screening purpose is to ensure that signs and symptoms that raise suspicion of serious diseases are being considered during the assessment, assisting physical therapists in their clinical decision process. Brazilian physical therapists are autonomous and can act as first contact professionals in the management of musculoskeletal disorders, therefore, they need to know how to recognize, screen and refer patients with red flags for better therapeutic management. The objectives of this study were to verify whether Brazilian physical therapists can recognize and manage patients who presented red flags, compare professionals' skills regarding different academic degree levels and clinical experience and identify which factors can influence the results. METHODS: A cross-sectional and quantitative research was conducted, collected from an online questionnaire. The target audience consisted of Brazilian physical therapists who have clinical experience in the management of patients with musculoskeletal disorders. Participants filled demographic data and made clinical decisions based on six clinical cases created by the authors, based on the literature, and reviewed by three experts. Data were analyzed using descriptive statistics, the Chi-square test of independence and logistic regression. RESULTS: The study analyzed 384 answers from Brazilian physical therapists with clinical experience in musculoskeletal conditions. Brazilian physical therapists, in general, have not shown to be able to properly recognize and manage the clinical cases involving red flags, with 23.2% of the sample performing appropriate management for medical conditions, 53.9% for emergency conditions and 61.8% for medical conditions with associated musculoskeletal dysfunction. More years of clinical experience and post-professional education did not positively influence the outcomes. Higher academic degrees (Doctorate) can influence positively on the management of non-emergency medical conditions. CONCLUSION: Brazilian physical therapists who work with patients with musculoskeletal disorders perform poorly in identifying red flags in hypothetical clinical cases.

RESUMO JUSTIFICATIVA E OBJETIVOS: O objetivo da triagem de bandeiras vermelhas é garantir que sinais e sintomas que levantam suspeitas de doenças graves sejam considerados durante a avaliação, auxiliando os fisioterapeutas no seu processo de decisão clínica. Os fisioterapeutas brasileiros são autônomos e podem atuar como profissionais de primeiro contato no manejo de distúrbios musculoesqueléticos, portanto, precisam saber reconhecer, rastrear e encaminhar pacientes com bandeiras vermelhas para melhor manejo terapêutico. Os objetivos deste estudo foram verificar se os fisioterapeutas brasileiros conseguem reconhecer e tratar pacientes que apresentavam bandeiras vermelhas, comparar as habilidades dos profissionais com diferentes níveis de formação acadêmica e experiência clínica e identificar quais fatores podem influenciar os resultados. METHODS: Uma pesquisa transversal e quantitativa foi realizada, coletada através de um questionário online. O público-alvo consistiu em fisioterapeutas brasileiros com experiência clínica no manejo de pacientes com disfunções musculoesqueléticas. Os participantes preencheram dados demográficos e tomaram decisões clínicas com base em seis casos clínicos criados pelos autores, com base na literatura, e revisados por três especialistas. Os dados foram analisados por estatísticas descritivas, pelo teste qui-quadrado de independência e por regressão logística. RESULTADOS: Foram analisadas 384 respostas de fisioterapeutas brasileiros com experiência clínica em disfunções musculoesqueléticas. Os fisioterapeutas brasileiros, em geral, não demonstraram ser capazes de reconhecer e manejar adequadamente os casos clínicos envolvendo bandeiras vermelhas, com 23,2% da amostra realizando manejo adequado para condições médicas, 53,9% para condições de emergência e 61,8% para condições médicas com disfunção musculoesquelética associada. Mais anos de experiência clínica e educação pós-profissional não influenciaram positivamente os resultados. Graus acadêmicos mais elevados (Doutorado) podem influenciar positivamente no manejo de condições médicas não emergenciais. RESULTADOS: Foram analisadas 384 respostas de fisioterapeutas brasileiros com experiência clínica em disfunções musculoesqueléticas. Os fisioterapeutas brasileiros, em geral, não demonstraram ser capazes de reconhecer e manejar adequadamente os casos clínicos envolvendo bandeiras vermelhas, com 23,2% da amostra realizando manejo adequado para condições médicas, 53,9% para condições de emergência e 61,8% para condições médicas com disfunção musculoesquelética associada. Mais anos de experiência clínica e educação pós-profissional não influenciaram positivamente os resultados. Graus acadêmicos mais elevados (Doutorado) podem influenciar positivamente no manejo de condições médicas não emergenciais. CONCLUSÃO: Fisioterapeutas brasileiros que atuam com pacientes com disfunções musculoesqueléticas apresentam um mau desempenho na identificação de bandeiras vermelhas em casos clínicos hipotéticos.

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BACKGROUND: Orofacial pain of myofascial origin is often associated with temporomandibular joint dysfunction, affects chewing muscles and may lead to functional limitations. Dry needling is an intervention commonly used for inactivating myofascial pain trigger points. OBJECTIVE: To systematically review the effects of dry needling on orofacial pain of myofascial origin in patients with temporomandibular joint dysfunction. METHODS: This systematic review has pain intensity as primary outcome. Searches were conducted on April 13th, 2018 in eight databases, without publication date restrictions. We selected randomized controlled trials published in English, Portuguese, or Spanish, with no restrictions regarding subject ethnicity, age or sex. RESULTS: Seven trials were considered eligible. There was discrepancy among dry needling treatment protocols. Meta-analysis showed that dry needling is better than other interventions for pain intensity as well as than sham therapy on pressure pain threshold, but there is very low-quality evidence and a small effect size. There were no statistically significant differences in other outcomes. CONCLUSION: Clinicians can use dry needling for the treatment of temporomandibular joint dysfunction, nevertheless, due the low quality of evidence and high risk of bias of some included studies, larger and low risk of bias trials are needed to assess the effects of dry needling on orofacial pain associated with temporomandibular joint dysfunction.

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BACKGROUND: Low back pain (LBP) has more than doubled in the last 20 years, probably influenced by biopsychosocial factors. Noninvasive treatments have been applied in individuals with chronic nonspecific LBP as spinal manipulation and pain education. However, the neurophysiological effects of these treatments are not clear. The aim of this research is to verify the pain control, functional and neurophysiological effects of spinal manipulation, and pain education in individuals with chronic nonspecific LBP. METHODS: This research is an assessor and subject blinded, 2-arm, randomized sham-controlled trial and will be conducted at Governador Celso Ramos Hospital, Florianópolis, Brazil. One hundred and twenty-eight individuals with chronic nonspecific LBP will be recruited for this study. Individuals will be randomly allocated into one of the two groups: (1) spinal manipulation plus pain education or (2) sham treatment plus pain education. Each group will be received two sessions per week over six weeks of treatment. The measures will be applied at baseline, six weeks, and three months after randomization. The primary outcome will be a pain intensity at six weeks postrandomization. Secondary outcomes will be pressure pain threshold, disability, fear and avoidance beliefs, kinesiophobia, risk of poor prognosis, quality of life, and inflammatory biomarkers. DISCUSSION: Evidence has shown that psychosocial factors are more involved in chronic pain than we thought a few years ago. Then, studies investigating both functional and neurophysiological effects of these interventions to evaluate the effectiveness of treatment and what else is happening at the cellular level in nervous system are needed.

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OBJECTIVES: Individuals with neck pain experience disrupted grip force control when performing manipulative tasks. Manipulative physical therapy might decrease pain and change the activity of surrounding muscles; however, its effect on upper limb motor control remains undetermined. This study aims to analyze the effects of cervical manipulation on pressure pain threshold (PPT), upper extremity muscle activity along with grip force control in individuals with neck pain. METHODS: Thirty subjects with neck pain were instructed to grasp and lift an object before and after cervical (n = 15) or sham (n = 15) manipulation. The patients' PPT, electromyographic (EMG) activity of the upper extremity/scapular muscles, and grip force control were analyzed before and after one session of manipulation. RESULTS: No significant differences were found in the grip force control, PPT and EMG activity variables between groups. DISCUSSION: These results suggest that a single session of cervical manipulation may not modify upper limb motor control, more specifically grip force control and EMG activity, in patients with cervical pain. Future studies should investigate potential changes in grip force control in patients with different features of neck pain and/or by applying long-term treatment. LEVEL OF EVIDENCE: 1b.

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PURPOSE: To investigate inter- and intra-observer agreement in the assessment of lumbar vertebral rotational (VR) asymmetry by a motion palpation test. METHODS: For this prospective and descriptive test-retest study, 51 asymptomatic participants (40 women, 11 men; mean age 23.3 [SD 5.6] years) were recruited from the community. Each participant was assessed in two sessions by the same three observers, who assessed VR by means of a palpatory test for movement asymmetry. This test is performed by applying posteroanterior pressure in an alternating manner to the left and right transverse processes of a vertebra to determine motion asymmetry in the transverse plane and thus the vertebral position. Observers classified the vertebral position as neutral, rotation to the right, and rotation to the left; they were blinded to which participant was being assessed and to any previous results. RESULTS: Intra- and inter-observer agreement was verified by the kappa coefficient (κ) and the weighted kappa coefficient (κ w ). Values of κ and κ w varied from 0.07 (95% CI, -0.10 to 0.245) to 0.37 (95% CI, 0.11-0.63) for intra-observer agreement and from 0.12 (95% CI, -0.06 to 0.29) to 0.30 (95% CI, 0.08-0.52) for inter-observer agreement. CONCLUSION: The motion palpation test used to assess VR asymmetry has low agreement levels; therefore, its clinical significance for measuring vertebral position is questionable.

Objet: Analyser la convergence interobservateurs et intra-observateur dans l'évaluation de l'asymétrie de la rotation des vertèbres (RV) lombaires par palpation du mouvement. Méthodes: Pour cette étude test-retest prospective et descriptive, on a recruté dans la communauté 51 participants asymptomatiques (40 femmes, 11 hommes; âge moyen de 23,3 [ET de 5,6] ans). Les trois mêmes observateurs ont évalué chaque participant au cours de deux séances et déterminé la RV par palpation afin de déterminer l'asymétrie du mouvement. On pratique ce test en appliquant une pression antérieure en alternance sur les apophyses transverses gauche et droite d'une vertèbre afin de déterminer l'asymétrie du mouvement dans le plan transversal et, par conséquent, la position de la vertèbre. Les observateurs ont classé la position de la vertèbre comme neutre, en rotation vers la droite et en rotation vers la gauche. Ils ne savaient pas quel participant était évalué et ne connaissaient pas les résultats antérieurs. Résultats: On a vérifié la convergence interobservateurs et intra-observateur au moyen du coefficient kappa (κ) et du coefficient kappa pondéré (κ p ). Les valeurs de κ et κ p ont varié de 0,07 (IC à 95% de 0,10 à 0,245) à 0,37 (IC à 95% de 0,11 à 0,63) dans le cas de la convergence intra-observateur et de 0,12 (IC à 95% de −0,06 à 0,29) à 0,30 (IC à 95% de 0,08 à 0,52) dans celui de la convergence interobservateurs. Conclusion: La palpation du mouvement utilisée pour évaluer l'asymétrie de la RV produit de faibles niveaux de convergence, et son importance clinique pour la mesure de la position des vertèbres est donc douteuse.

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STUDY DESIGN: Repeated measures experiment. INTRODUCTION: Traumatic injuries and certain other diseases of the hand typically affect mobility of the finger joints. Decreased mobility may alter grip force control while one is grasping and lifting objects. However, the effect of finger joint hypomobility on grip force control has not yet been systematically investigated. PURPOSE OF THE STUDY: The aim of this study was to investigate the effects of limited finger joint mobility, without other associated symptoms like pain, or sensory/proprioceptive deficits, on precision grip force control. METHODS: Fifteen healthy subjects performed a pinching and lifting task of an object equipped with a force sensor and an accelerometer, via opposition of the thumb and index finger, in the following experimental conditions: unrestricted finger joint movement (UJM), restricted finger flexion (RFF), restricted finger extension (RFE), mock restricted flexion (MRF), mock restricted extension (MRE). The following pinch force variables were measured and analyzed: grip force at lift off, grip force peak, load force peak, latency, and static force. RESULTS: A significant increase in latency (F = 4.41, p < 0.01) was noted during RFE relative to UJM and MRF conditions. There were no statistically-significant differences between the conditions among the other variables of precision grip force control. CONCLUSIONS: Limited joint mobility of the thumb and index finger may cause temporal changes in precision grip force control, which can lead to reduced manual dexterity. Restoring range of motion might be an important priority to improve thumb-index pinch force control during manipulative tasks.

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O objetivo desta pesquisa foi analisar a efetividade do teste Slump e Lasegue no diagnóstico fisioterapêutico das síndromes dolorosas que acometem a coluna lombar. Este estudo caracteriza-se como teórico-prático, classificado como quase-experimental, de campo, de caráter quantitativo e qualitativo. A amostra abrangeu 47 indivíduos compreendidos na faixa etária de 16 a 68 anos, composta de forma aleatória, foram incluídos os portadores de síndromes dolorosas na coluna lombar, com ou sem irradiação dos sintomas para os membros inferiores. Posteriormente foram submetidos aos testes Lasegue e Slump. Utilizou-se o protocolo do teste Slump descrito por Maitland [1] e do teste de Lasegue descrito por Hoppenfeld [2]. Após a coleta de dados, realizou-se a interpretação e confrontação dos mesmos, através de análise estatística descritiva. Com base nos resultados obtidos constatou-se que o teste Slump é mais efetivo do que o teste de Lasegue na avaliação fisioterapêutica das síndromes dolorosas da coluna lombar sendo que a utilização do teste de Lasegue isoladamente não possui valor diagnóstico significativo. Portanto, a contribuição destes testes funcionais na elaboração do diagnóstico cinético-funcional e possibilitou uma reeducação funcional coerente com as necessidadesdos pacientes.

The general objective of this research was to analyze the effectiveness of the test Slump and Lasegue in thephysical therapy diagnosis of the painful syndromes that they attack the lumbar column. This study is characterized as theoretical-practical, classified as almost-experimental, of field, of quantitative and qualitative character.The sample of the referring research was composed by 47 individuais understood in the age group from 16 to 68 years, bearers of painful syndromes in the lumbar column, with or without irradiation of the symptoms forthe inferior members. The individuals were chosen in a random way and later they were submitted to the tests Lasegue and Slump during the physical therapy consultation. The protocol of the test was used Slump describedby Maitland [1] and of the test of Lasegue described by Hoppenfeld [2]. After the collection of data regarding the results of the tests, he took place the interpretation and confrontation of the same ones, through descriptive statistical analysis. With base in the obtained results was verified that the test Slump is more effective than the test of Lasegue in the physical therapy evaluation of the painful syndromes of the lumbar column and the use of the test of Lasegue separately doesn't possess value significant diagnosis. It is demonstrated this way the contribution of the functional tests in the elaboration of the kinetic-functional diagnosis allowing a coherent functional re-educate with the patients' needs.

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