How to provide an advice: some communication ideas

In this post, I will attempt to critically think about advices and how to deliver them.

I have recently been thinking about advices as I realized how detrimental / harmful they could be, how inefficient they may sometimes be, and how to tackle these unfortunates outcomes. This is applicable to social media, in personal encounters, or in health-care relationships (and probably other types of interactions but these are the ones I have been able to relate this topic to at the moment).

  1. Providing an advice is always an act of kindness, a benevolent manifestation of caring … but it may not be perceived as such by the person receiving it. After all, aren’t we all experiencing in the world subjectively according to our lives and context?
    Let me illustrate this with examples.
    • I) A patient tells me they tried to start physical activity and started running everyday. As a healthcare provider, I am concerned about their safety and want to advise them to be careful about overload as they were sedentary for years. I want to prevent potential injuries. My first reaction is to want to say: “Great, but you should be careful, if you run everyday you may get injured”.
    • II) I see a video of somebody on social media doing an exercise and realize they do not perform the movement with optimal pattern. I want to help them achieving the perfect form, to avoid them wasting their time and help them improve. Then, I am keen on commenting below the post: “Your form is not perfect, you should try to work on x or y, or try to change this parameter as it will help you”.
    • III) A friend tells me they have decided to go vegan, and I worry about their health which would led me to say: “Cool, but you should take B12 vitamin to avoid issues”.
    • In scenario I), it is easy to think it is my role to provide this advice for the person’s safety, and act preventively. Yet, the person’s may receive it in a different way. Maybe it will reduce their initial motivation to do physical activity. Maybe they will think it is unsafe for them to run because I (their health-care provider), am concerned about their running. Maybe they will get offended that I do not believe in their ability to self manage. Any situation could happen here.
    • In scenario II) I am on social media, so I comment my advice thinking I will help the person doing better. But maybe this person received several comments like mine. Maybe they will feel criticized. Maybe they will feel the hard-work does not pay and they are not good enough. Maybe they will feel they should stop trying.
    • In scenario III), even though I just wanted to take care of a friend, maybe their experience was different. Maybe they will think I consider myself more knowledgable than them on a topic they love. Maybe they know more then me about it. Maybe they will feel isolated and misunderstood in their project. Maybe they will feel angry at me doubting them. Maybe they will feel hopeless for the future of planet and animal well-being and depressed by society and humankind.

    • In conclusion, either my advice was detrimental (decreasing their confidence, hopes, or creating anger), or inefficient / useless (as the person will not listen).

2. To tackle these situations, here are some ideas I may want to consider prior to say or write my advice.

A) I shall make sure the advice is embedded in a chat. I could start a conversation first. When someone comes to tell me I should do something without saying hello, I may legitimately feel irritated. So, I can start talking first and engage with the person.
Example II) : before telling my friend the exercise they posted on social media is not perfect, I can get news about them. “I saw your video on social media, it made me realise I wanted to get new from you, how are you doing? :)”

B) Then, once the conversation is started, I can begin by congratulating the person for what they are doing. Compliments and encouragements are always welcome.
Example I): “Congratulation for starting running, it is a great effort you are doing here, this is inspiring!”.

C) I may want to genuinely ask for prior knowledge. Most of the time I do not know how much the person already knows about the advice I want to deliver. And if they already know about it, what is the point of my advice?
Example III): “I heard many things about vegan diet, are you aware of potential issues associated with it?”

D) If they they are aware and have the same understanding as me, then I can be reassured and no need to go further. But if we have a different view on the topic, I may want to ask if they would like to know my perception (ask for permission). This allows me to make sure: -They are willing to know more / -They are in the mental disposition to hear my perspective / advice = they are available for it (sometimes it is just not the right time) / -They will listen leading to better chances of my advice to be helpful.
Example II): “It seems that I have a different understanding about how to perform this exercise, would you like me to share what I know about it with you?”

E) Then I can provide my advice in a kind and appropriate manner, choosing my words carefully.
Example I): “In my experience as a physiotherapist, I have observed that overload may happen when people tend to go back to physical activity. Some even get injured when starting with high frequency and intensity due to their motivation. What can be helpful is to monitor symptoms this way, and if needed reduce the frequency to x times a week, and after a while gradually increase it”.

F) Bonus: I can even go further by asking for their thoughts about it. It allows me to see if my message was understood, how they felt about it and maybe identify other topics of discussion.
Example III): “What do you think about it? Does it resonate with your experience?”

Here were the key elements I identified that could help providing advices more effectively in professional practice and life. Some elements may be similar in motivational interviewing or other types of communication strategies.

I am open to hear about how you do provide advices and your thoughts about this topic so let me know them in the comment section.

Take care


Safety netting; best practice in face of uncertainty

(Greenhalgh, Finucane, Mercer, & Selfe, 2020)

Aim: Promote safety-netting as best practice

Methods: Editorial + clinical examples

Limitations: Author’s views

In practice:

– Working collaboratively with the person to monitor symptoms: Therapeutic alliance, Shared Decision Making
– Use time as a reasoning tool: resolving symptoms or red flag developing
– Clear communication required
– Anticipating patient’s at risk

Important features:

  • Provide information (specific red flags)
  • Empower patients to recognise Red-Flags and seek timely appropriate care (when)
  • Advice on how & where to seek help
  • Explain natural history
  • Provide written instructions
  • Document safety-netting


  1. Correct information not given
  2. Language not heard / understood
  3. Content unclear

Greenhalgh, S., Finucane, L. M., Mercer, C., & Selfe, J. (2020). Safety netting; best practice in the face of uncertainty. Musculoskeletal Science and Practice, 48(May), 102179.

The first physiotherapy consultation: the assessment

When consulting for a physiotherapist for the first time it is difficult to know what to expect and understand what will happen and why. This post has been written to provide insights about the first appointment and explanations about the assessment part.

Why will your physio will perform an assessment?

Safety first.

“Primum non Nocere”.

  1. These quotes illustrate well the most important aspect of medical care. The first role of a health care provider is to make sure they will not cause more harm than good. This is why they will continuously screen for serious pathologies that may look like a “usual” musculoskeletal condition (back / neck pain, tendinopathy, sprain, etc …) but that could in reality be a more serious / urgent pathology that may require medical treatment to avoid life threatening outcomes or irreversible sequelae. Some examples could be cancer, fractures, infections of inflammatory pathologies … This is why the physiotherapist will ask for a wide range of questions about your medical history, your problem, and even some more personal / intimate questions to get all the information they need to make sure they can help you safely and that you do not require to be referred to another health care provider (doctor, specialist, emergency department etc.). This will happen throughout you medical journey, as some conditions evolve and might not be noticed in the first place. This is why this screening is a continuous process.
  2. They will ask questions about your life in general to get to know you better. This is also important as the best outcomes will be achieved through personalized care. Hence the fact that your physiotherapist will be able to help you more efficiently if they know more about you. Moreover, for some conditions people should be offered different management according to some lifestyle or psycho-social factors. For example, anxiety plays a huge part in persistent pain. In consequence, your physio may ask questions about your perception of the problem, your stress levels etc, to know more about what would be more more beneficial for you and what they may offer you.
  3. They will also carefully select the physical examination tests they will perform to get an understanding of your problem, how you cope with it, evaluate where you are at the moment regarding your symptoms, your abilities. This, to design the perfect rehabilitation suited for you at this time and be able to monitor your progresses over time. They will use a complex reasoning using all information they obtained to help you with the most appropriate plan according to your needs, preferences, current scientific recommendations, and their expertise and readjust it with time.
  4. This is a shared process. You are an equal part of it and play a great role in it. As a human being, your feelings, emotions, thoughts, behaviours and participation will influence the process largely. This is why they will try to establish a good communication and relation with you. Thanks to a collaborative work from you and your health-care provider(s), you will benefit from the best possible experience. Medical team will then be able to help you to cope with your problem and how it affects you and your life optimally.
  5. Your physiotherapist and your health care providers in general are working with you and for you. They will be curious about if you have questions, worries or other element that they can answer, reassure or help you with. However, medical science is not straightforward and is full of uncertainties. For that reason, sometimes, they will not be able to answer all questions in a definitive way. They may instead explain you their hypothesis, the current state of science regarding your question, what can be done, and how.

    This first session is really about getting to know you, agreeing on what can be offered to help you and guide / help you in the journey so that you feel as supported and cared for as possible.

I hope this information helps and provided you with insights about your first MSK physiotherapy appointment.

Take care


Alice’s sciatica

Here is the testimonial of Alice who accepted to share with you her story and her experience of her sciatica. She wrote this post and allowed me to translate it in English and publish it here.

Part 1: The vicious circle

It all started in October 2018; I was 26 years old. After a hectic cycling session, I wake up overnight physically unable to stand up. A radiating pain catches me and prevents me from using my back. It was a sciatica of the left leg. I was then prescribed a treatment made of anti-inflammatory medication and a large amount of bed-rest until pain goes away (which I greatly regret). This vicious circle lasted almost 3 years with episodes: I was having medication and bed-rest every 2-3 months. Besides physical pain, invisible for others, I started feeling a real malaise. I was always wondering: “How explaining what is happening to me whereas I always have been cautious about having a perfect lifestyle?” I was a high-level athlete, I was exercising, I do not drink alcohol nor smoke … I decided I would find the mechanical cause of my symptoms.

Part 2: The end of the vicious circle and the beginning of physiotherapy

During these 3 years, I developed a fear of movement. I feared experiencing my back pain. To be safe, I avoided every activity which is wrongly thought to be dangerous: I stopped lifting heavy things, I never bended forward without bending the knees, I stopped physical activity … I avoided using my back to protect it. Despite all my precautions, I was still experiencing several pain episodes and still could not identify its cause. Until June 2021 where for the first time, anti-inflammatory medication did not help any more. I was suffering day and night, and I could barely sleep because pain was waking me up. I was then prescribed an MRI and its conclusion was that I had a disc herniation. I was then immediately referred to a specialist to have injections. The issue was that this option terrified me as one of my relatives had a bad experience with it. In consequence, I decided to get a second opinion with different doctors. One of them suggested me to try physiotherapy.

Part 3: what I learned with physiotherapy.

I did not know what physiotherapy was, but I had great expectations about it. During the first session, I learn that, as many of us, I was misinformed about back pain and that bed-rest may be unhelpful. As well as physiotherapy session, I started to progressively go back to normal life and be less cautious about using my back (I started lifting things, go back to sport …). As I was really involved in the process, I did my exercises between sessions with great diligence. I felt better but not done: my progression was really fluctuating, and I had that feeling of weakness in my left leg that never left me. I also was struggling to understand why I was not cured despite taking that therapeutic approach seriously. It was when I read a scientific paper about back pain that it finally made sense. I understood that my back pain was not necessarily linked with a mechanical factor but could also be linked with psychological factors. I realized that in one hand I was expecting too much of my physiotherapist which created an adverse pressure; and in the other hand I was doing my exercises in a robotic way without trying to feel their effects on me and hence not knowing what was good for me and what was not. As I was frustrated by not finding a mechanical cause since all these years; I kept digging in the psychological field winding up until 2018. Here I realized this year was emotionally overwhelming as I lost one of my parents, few months before the onset of my pain. As I am introverted, it may be likely that my uneasiness expressed throughout my back pain. After accepting all this, I approached my physiotherapy sessions with a new perspective: being more connected to my feelings in my body and being resilient. Since then, sessions have been more helpful.

Part 4: My life today

I am now able to cope and manage my pain, which means identify what exercises are helpful for me according to how I feel. I am not yet cured, I may never be, but I am happy to be back to an (almost) normal life!

Tennis Elbow = Lateral Elbow pain / tendinopathy LET = Epicondylalgia

Several names exist for this issue: Tennis elbow, lateral elbow pain / tendinopathy, epicondylalgia, epicondylitis … They all refer to the same diagnosis.

Is it frequent?

It is a frequent issue among 35-54 years old people. It affects 1-3% of general population with an increased risk among smokers, manual workers, or tennis players.

How long is it?

For many persons, symptoms are self-limiting. Studies show that 83 to 90% of people without any treatment improve significantly at one year, although sometimes incomplete recovery. However, 1/3 of people still experience discomfort after 1 year despite treatment. A large proportion of people experience recurrence of symptoms after initial episode. Estimates suggest that 5% of people do not respond to conservative interventions and undergo a surgery with variable outcomes.

What is it, what is happening?

Tennis elbow is multimodal, it is not only a mechanical or structural issue. Current models suggest changes in the tendon’s matrix and cells, in combination with changes of the pain system and modifications of sensory and motor system.

How is it diagnosed?

It is diagnosed through a clinical examination by reproducing symptoms loading affected tendons. Pain can be reproduced on the epicondyle with palpation, resisted contraction of extensors of wrist or middle or second finger, and gripping. An in-depth clinical examination may be required to exclude other possible causes.

Shall I undergo imaging?

MRI and Ultrasound imaging have a very good capacity to exclude this pathology but a poor capacity to identify it when signs on imaging are present. Indeed, the same changes on imagery can be found in asymptomatic people. Studies show that we find the same changes in MRI in 50% of cases and in 53% with US in asymptomatic persons! However, when symptoms are present changes can be found in 90% of cases. In addition, studies show that severity of changes on imaging are not related to severity of symptoms for this pathology and other chronic tendinopathies. Hence the fact that imagery can exclude this problem but not diagnose it.

Which factors can affect improvement?

Universal treatment efficient for every person with tennis elbow unfortunately does not exist. The fact that this issue varies greatly among individuals suggest that a tailored treatment may be more beneficial. 6 factors influencing outcomes have been identified:

  1. The stage of the problem: reactive / degenerative or in between. It may change the treatment suggested
  2. Severity of initial symptoms. When they are more intense and disabling, the long-term prognostic is not as good.
  3. When Central Sensitization (CS) is present, the prognosis worsens. CS is a complex modification of central nervous system making light stimuli very painful, with changes in temperature perception leading (among other) cold to become painful.
  4.  When shoulder or neck pain is associated, it may affect outcomes too. Neck pain is frequently associated with altered long-term results, while shoulder pain is frequently associated with altered short-term outcomes.
  5. Associated neuromuscular impairments lower prognosis. Strength deficit of extensor of wrist, grip, or all affected limb and a speed deficit and muscular reaction time of both arms in patient with unilateral tennis elbow have been reported. If these are not assessed and treated when present, they may contribute to chronicity.
  6. Psychosocial factors and work-related factors have been linked with increased risk of developing tennis elbow and with a lower one-year prognosis. They include use of tools, heavy loads, repetitive movements, activities involving strength with wrist flexion and low control on work.

In addition, we know that tendons’ health is largely affected by lifestyle. The following elements are risk factors of developing tendon issues:

  • Smoking
  • Obesity
  • High fatty food intake
  • Hish processed food intake
  • Physical inactivity
  • High cholesterol levels
  • Diabetes
  • Sudden changes in activity levels

What are available treatment options?

Pharmacotherapy: Results of oral nonsteroidal anti- inflammatory medication in the treatment of tennis elbow are conflicting. They are speculated to be more efficient in reactive phase.

Corticosteroid medication: We have strong evidence that corticoid injection therapy allows a short-term pain relief but lead to poorer outcomes at 6 month and 1 year and an increase in recurrences when compared to no treatment or physiotherapy. In addition, adding a multi- modal physical therapy program do not ameliorate the late delay in recovery or recurrence observed after a single corticosteroid injection. Therefore, corticosteroid injections are not recommended as a first line treatment.

Antidepressant or antiepileptic drugs may be appropriate for patients with severe pain where central sensitization is suspected, although no studies have been conducted in this population to date but it has on other groups like people with fibromyalgia.

Prolotherapy PRP and nitric oxide patches have demonstrated long term effects on patients with persistent epicondylalgia (>3 months). However, their efficacy depends on the technique used in combination as when used with stretching only they have not demonstrated any effects.
Despite current interest there is growing evidence that injection of autologous blood or platelet- rich blood products is not effective in treating tennis elbow.

Manual therapy (MT): We have moderate evidence of immediate effects of MT on pain and pain-free grip and short term benefits when used in conjunction with gradual exercises. There is also evidence that MT of cervical and thoracic spine has additional benefits in addition to local treatment when these areas present limitations.

Therapeutic exercises: Exercises are paramount in the treatment of tennis elbow with evidence of exercises alone or as a component of a multimodal approach. For patients with persistent epicondylalgia, exercises have shown a quicker reduction in pain, less sick leave, less medical appointments, and an increased work capacity. Despite clear benefits, currently there is no recommendations on type, intensity, frequency, or optimal duration for exercises. Current guidelines recommend a gradual increase in resistance, with focus on wrist extensors. There are conflicting views on pain during exercise, some authors insist on avoiding pain while others think it should stay tolerable (5<10). Given the heterogeneity of the clinical presentation and pathology it is more likely that optimal dosage may differ for each person according to stage, severity, and functional demand before injury.

Education: Natural history is self-limiting. Delays may be long 12 weeks of rehabilitation, sometimes 1 year to obtain an improvement of symptoms that may be incomplete. Recurrences may happen. Some factors increase the risk to develop the condition or that delay recovery. Rehabilitation is multimodal and tailored to individuals. Initial rest (regarding provoking activities) is important then gradual loading is required to recover the function of the limb. It is crucial to gradually reintroduce more strenuous tasks and to reduce tendon load if recurrence is experienced.

Bibliographie / Sources :

(Coombes, Bisset, & Vicenzino, 2015; Hoogvliet, Randsdorp, Dingemanse, Koes, & Huisstede, 2013; Vuvan, Vicenzino, Mellor, Heales, & Coombes, 2019)

Coombes, B. K., Bisset, L., & Vicenzino, B. (2015). Management of Lateral Elbow Tendinopathy: One Size Does Not Fit All. Journal of Orthopaedic & Sports Physical Therapy, 45(11), 938–949.

Hoogvliet, P., Randsdorp, M. S., Dingemanse, R., Koes, B. W., & Huisstede, B. M. A. (2013). Does effectiveness of exercise therapy and mobilization techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review. British Journal of Sports Medicine, 47(17), 1112–1119.

Vuvan, V., Vicenzino, B., Mellor, R., Heales, L. J., & Coombes, B. K. (2019). Unsupervised Isometric Exercise versus Wait-and-See for Lateral Elbow Tendinopathy. Medicine and Science in Sports and Exercise, 52(2), 287–295.

Unsupervised isometric exercise versus wait-and-see for LET

(Vuvan, Vicenzino, Mellor, Heales, & Coombes, 2019)

Aims: To investigate the effect of an 8-week unsupervised program of isometric exercise compared to a wait-and-see approach on pain, disability, global improvement, and pain-free grip strength in participants with unilateral LET.

Methods: RCT in Australia. Inclusion: 18-70 years old, unilateral LET >6 weeks, pain >2 on average, provoked by 2 of grip, palpation, stretch, resisted contraction, reduced pain free grip strength. Exclusion: other diagnosis, other MSK complaint > to LET, major neurologic inflammatory, systemic condition, treatment in preceding 3 months, major trauma, fracture, or surgery in the last year. All participants were provided written and verbal general advice regarding self-management and ergonomics. Ex group: additional information about 8 week daily progressive isometric exercise program standardized and tailored to max voluntary contraction of each subject. Recording of exercises on a diary with adherence and symptoms. Adherence measured by % of 56 sessions done. Blinding of assessor, computer randomization (stratified <5 or >6 pain at baseline). PRTEE, GROC, and pain-free grip strength (3 measures 30 sec rest, mean). 20 / group = enough power to detect change. Stat analysis. 533 responders, 40 included n=21 exercise n=19 wait-and-see. Follow-up 98%.

Results: The exercise group had better PRTEE scores at 8 weeks compared to the wait–and-see group (SMD -0.92, 95% CI -1.58 to -0.26, P = 0.006). No ≠ in GROC nor in pain-free grip strength. 90% completed greater than 71% of prescribed sessions. No participants reported a serious adverse event. Use of co-interventions was similar between groups

Limitations: Power enough for PRTEE unknown for GROC & PFGS. Only non-severe patients. Program <10min / day.

In practice: This protocol of self-management isometrics for LET has moderate effect on PRTEE when compared to wait and see, but not on GROC nor pain-free grip strength at 8 weeks.

Vuvan, V., Vicenzino, B., Mellor, R., Heales, L. J., & Coombes, B. K. (2019). Unsupervised Isometric Exercise versus Wait-and-See for Lateral Elbow Tendinopathy. Medicine and Science in Sports and Exercise, 52(2), 287–295.

Does effectiveness of exercise therapy and mobilization techniques offer guidance for treatment of L & M epicondylitis?

(Hoogvliet, Randsdorp, Dingemanse, Koes, & Huisstede, 2013)

Aims: To assess the evidence for effectiveness of exercise therapy and mobilisation techniques for both medial and lateral epicondylitis.

Methods: SR on 4 DB, 2 reviewers independently extracted data and assessed the methodological quality. English, German, French, Dutch language. Quality assessed according to a scale (Furlan). Heterogeneity made synthesis impossible, hence best evidence synthesis.

Results: Moderate evidence for a short-term effect of stretching plus strengthening exercises compared to ultrasound plus friction massage. Short-term and mid-term effect of manipulation of the cervical and thoracic spine as add-on therapy to concentric and eccentric stretching plus mobilisation of the wrist and forearm in patients with LE. For all other interventions, only limited, conflicting or no evidence was found

Limitations: No meta-analysis, poor level of evidence (1 paper high, other moderate low).

In practice: We do not have strong evidence for treatment of epicondylitis. To our current knowledge the best available option is exercise therapy + stretching +/- manual therapy as adjunct.

Hoogvliet, P., Randsdorp, M. S., Dingemanse, R., Koes, B. W., & Huisstede, B. M. A. (2013). Does effectiveness of exercise therapy and mobilization techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review. British Journal of Sports Medicine, 47(17), 1112–1119.

Management of lateral elbow tendinopathy

(Coombes, Bisset, & Vicenzino, 2015)

Aims: To collate evidence and expert opinion on the pathophysiology, clinical presentation, and differential diagnosis of LET. Factors that might provide prognostic value or direction for physical rehabilitation are canvassed. Clinical recommendations for physical rehabilitation are provided, including the prescription of exercise and adjunctive physical therapy and pharmacotherapy.

Methods: Not mentioned. Authors’ literature analysis

Results: Frequent pathology among 35- 54 years old people, 1-3% of general population, with increased risk if smokers, tennis player, or manual workers. Self-limiting pathology 83% to 90% of people without treatment improve, even though not fully recover after 1 year. 1/3 of patients may still experience symptoms after 1 year even with treatment. Large proportion of recurrence. 5% de not have benefits of conservative treatment and undergo surgery with variable outcomes.

Multimodal pathology (tendon continuum model + neuro-motor & nociceptive changes).

Examination: Symptom reproduction with loading of tendon (palpation, resisted contraction, stretching). Rule-out other causes. Check elbow, shoulder, neck, thoracic spine. PRTEE & Pain-free grip test & PSFS to measure function.

Imagery can rule out not diagnose. Lack of association between severity of imaging and symptoms. Prognostic factors: location on continuum tendon model, initial severity and functional impairment, central sensitization, associated with shoulder / neck pain, associated neuromuscular impairments, psychosocial / work factors. Treatments: oral NSAIDS in acute phase, injections not recommended (delay in recovery), antidepressant or antiepileptic drugs if central sensitization, PRP no evidence of effectiveness, prolotherapy and nitric oxide patches if associated with load may help if limited outcomes at 6 months. Manual therapy: short term benefits if adjunct to exercises. No data on type, intensity, frequency, or duration of exercise. Currently it is recommended to gradually increase load with focus on wrist extensors. Heterogeneity in presentations => tailored dosage according to severity, stages, and functional demand. Education to reassure, inform, and advice.

Low risk: Education, advice, self-medication = wait & see, + physio after 6-12 week if no improvement.

Moderate risk: 8 to 12 weeks of physiotherapy recommended.

High risk (PRTEE >54): Central sensitization: pain management then physio.

Imagery if not responding to physiotherapy, if not other diagnostic found then try patches or prolotherapy.

Limitations: Guidelines (not a study, methodology unknown)

Coombes, B. K., Bisset, L., & Vicenzino, B. (2015). Management of Lateral Elbow Tendinopathy: One Size Does Not Fit All. Journal of Orthopaedic & Sports Physical Therapy, 45(11), 938–949.

Should exercises be painful in the management of chronic MKS pain? A SR with MA

(Smith, Hendrick, O Smith, & Al., 2017)

Aims: To compare the effect of exercises where pain is allowed / encouraged compared with non-painful exercises on pain, function or disability in patients with chronic musculoskeletal pain within randomised controlled trials.

Method: Systematic review on exercises into pain vs non-pain exercises on pain, function or disability. 9 papers included, total of 385 participants with pain > 3 months (chronic).

Results: Small but significant difference favouring exercises into pain in the short-term, moderate quality evidence, small effect size (-0,27) on patient reported pain.

Appears to be no difference in patient reported pain on medium and long-term due to moderate to low quality evidence. The instructions regarding pain were different, not clear if that had an effect.

Limitations: None of the studies recorded levels of pain during exercise.
The framing of pain vs no pain can potentially affect the outcome, the effects are unclear.
Studies included different areas, LBP, shoulder pain, Achilles pain, plantar heel pain.

In practice: Affects advice / conversations with patients. Pain during exercises in chronic pain not harmful, does not prevent improvements.

Smith, B., Hendrick, P., O Smith, T., & Al., E. (2017). Should Exercises be painful in the management of chronic msk pain. BJSM, 1–10.

Normal kinematics of the upper cervical spine during the Flexion-Rotation Test – In vivo measurements using magnetic resonance imaging

(Takasaki et al., 2011)

Aims: The purpose of this study was 1) to examine measurement reliability of segmental upper cervical movements using magnetic resonance imaging and 2) to investigate the content validity of the FRT

Methods: MRI study measurement on 19 healthy women.

Results: FRT is a valid and reliable (substantial reliability) measure of Upper Cervical Spine UCS Rotation (Better if taken 2 times than one). Normal range 45° each side. Positive test if <33°.

Limitations: Small sample, healthy, only women, young 22yo, 141m average height.

In Practice: FRT is a valid and reliable method to measure C1-C2 rotation.

Takasaki, H., Hall, T., Oshiro, S., Kaneko, S., Ikemoto, Y., & Jull, G. (2011). Normal kinematics of the upper cervical spine during the Flexion-Rotation Test – In vivo measurements using magnetic resonance imaging. Manual Therapy, 16(2), 167–171.