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Philosophiae Doctor - PhD / Lumbo-sacral radiculopathy (LSR) is clinically defined as low back and referred leg symptoms accompanied by an objective sensory and/or motor deficit due to nerve root compromise. LSR is a common condition encountered by physiotherapists in clinical practice and the assessment and diagnosis remains a challenge owing to the complex anatomy of the lumbo-sacral spine segment and the various differentials. Moreover, LSR imposes a significant impact on patients’ health, functional ability, socio-economic status and quality of life. There are several diagnostic tools and procedures which are commonly utilised in practice, including diagnostic neuropathic pain screening questionnaires, clinical neurological tests, electro-diagnostics and imaging. However, the diagnostic utility and correlation of these tests have not been fully explored and remains debatable among clinicians and researchers in the fields of musculo-skeletal health and neurology. The aim of this study was to determine a correlation of the S-LANSS score, clinical neurological examination (CNE) findings and magnetic resonance imaging (MRI) reports in the diagnosis of LSR among patients who presented with low back and referred leg symptoms. The study was conducted in three phases. In phase one, two systematic literature reviews were conducted; firstly, to establish the evidence-based accuracy of CNE in diagnosing LSR, and secondly, to establish the evidence-based accuracy of MRI in diagnosing LSR. In both systematic literature reviews, the diagnostic tests accuracy (DTA) protocol was used in planning, design and execution of literature search, selection of relevant studies, quality assessment, data analysis and presentation of the results. In phase two, clinical validation of an adopted S-LANSS scale and lumbar MRI reporting protocol were established, and a standardised evidence based lumbar CNE protocol developed.The face and content validity of the original S-LANSS score was established among a sample of Kenyan physiotherapists and patients who presented with low back and referred leg symptoms, using both quantitative and qualitative research designs. This was followed by a test-re-test reliability study on the adapted version of the S- LNASS score. The face and content validity of the adopted lumbar MRI reporting protocol was established among a sample of Kenyan radiologists followed by an inter-rater reliability. An evidence-based lumbar CNE protocol was developed; standardised and inter-examiner reliability was also examined among a sample of Kenyan physiotherapists. Finally, in phase three, a cross-sectional blinded validity study was conducted in six different physiotherapy departments. Participants (patients, physiotherapists and radiologists) were recruited using strict in- and exclusion criteria and data was collected using a pain and demographic questionnaire, the S-LANSS scale, the CNE protocol, the Oswestry Disability Index (ODI) and the MRI lumbar spine reporting protocol. Data was captured, cleaned and analysed using SPSS version 21. Descriptive analysis was done using frequencies, means and percentages, while inferential analysis was conducted using Spearman’s rank correlation coefficient test r to establish the correlation between the diagnostic tests. Cross tabulations, receiver operating curves (ROC) and scatter plots were used to establish the sensitivity and/or specificity of S-LANSS scale and individual CNE tests as defined by MRI. In phase three, which formed the main study of the research project, a total of 102 participants were recruited in this study with a gender distribution of 57% females and 43% males. The majority (67%) had neuropathic pain according to the S-LANSS scale and their pain intensity ranged from moderate (4-6) to severe (7-9) as recorded on a Numeric Pain rating Scale (NPRS), and was more common among manual workers. Similarly, patients whose pain had a neuropathic component had moderate to severe disability. The S-LANSS scale and lower limb neuro-dynamic tests were the most sensitive tests 0.79 and 0.75 respectively, while deep tendon reflexes were the most specific tests (0.87). The S-LANSS and CNE correlated fairly but significantly with MRI (r=0.36, P=0.01).LSR is a common condition and its assessment and diagnosis remains a clinical challenge among physiotherapists. MRI is a high-cost diagnostic tool but is being used by many clinicians in making decisions regarding the management of patients. Rapid and low-cost neuropathic pain screening by the use of the S-LANSS scale, together with use of evidence-based CNE of neuro-conduction and neuro-dynamic tests may be used in confirming nerve-root related MRI findings. These may be used in making a decision on whether to manage a patient conservatively using pharmacological agents and manual physiotherapy and therapeutic exercise, or consider surgery in the initial management of patients with clinical suspicion of LSR. This is especially valuable in the resource-poor settings like Kenya and other sub-Saharan African countries where MRI is costly or unavailable.

Introdução: O aperfeiçoamento da assistência pré-natal e neonatal contribuiu para maior sobrevida dos recém-nascidos com riscos para alterações do desenvolvimento. A detecção precoce e eficaz destes riscos é fundamental para a intervenção oportuna e minimização dos danos funcionais. A avaliação com melhor valor preditivo para anormalidades é pelos General Movements (GMs), porém a mais utilizada no Brasil é a Escala Motora Infantil de Alberta (EMIA). Objetivo: Verificar a validade dos GMs e da EMIA com um e três meses de idade para predizer o desfecho do desenvolvimento motor pela EMIA aos seis e 12 meses. Método: Estudo observacional longitudinal com 45 recém-nascidos e lactentes do Hospital Universitário da Universidade de São Paulo, avaliados do nascimento até os cinco meses de idade (corrigida, se prematuros) pelos GMs, e de um a 12 meses pela EMIA. Foi realizada análise descritiva e testes de kappa e curva roc para a comparação entre as avaliações. Resultados: Os participantes (masculino = 51,1%) apresentaram idade gestacional média de 34 semanas; 57,7% apresentaram alteração em pelo menos uma avaliação pelos GMs, com predomínio do repertório pobre (RP) e fidgety movements (FM) ausentes, enquanto 46,6% apresentaram alguma alteração na EMIA. A maioria (85,7%) apresentou avaliações normais aos 12 meses de idade pela EMIA; e os com avaliações anormais também tiveram GMs alterados em toda sua trajetória. Houve pobre confiabilidade entre os GMs e a EMIA no primeiro (kappa: 0,165) e no terceiro mês, ligeira confiabilidade (kappa: 0,259). Comparando os writhing movements (WM) com a EMIA com um mês, para prever desfecho aos seis meses de idade, foi encontrado uma sensibilidade dos WM de 78,6% e uma especificidade de 100%. Valores melhores de sensibilidade e especificidade também foram encontrados nos WM para desfecho com 12 meses de idade (sensibilidade de 75% e especificidade em 100%). Os lactentes que apresentavam alguma alteração nas avaliações eram encaminhados para fisioterapia. Conclusão: Foi possível observar um grande número de participantes com GMs alterados, porém com diminuição/normalização nas avaliações pela EMIA, podendo ser devido a intervenção fisioterapêutica nos casos mais graves. A avaliação com melhores valores para predição do desenvolvimento são os GMs na fase dos WMs. Não existe correlação entre a avaliação dos GMs com 1 mês e EMIA 1 com mês, nem entre estes dois métodos aos 3 meses / Introduction: Improvement of prenatal and neonatal care has contributed to a greater survival of newborns with risks for developmental disorders. Early and effective detection of these risks is essential for timely intervention and minimization of functional impairment. The most predictive value for abnormalities is the General Movements (GMs), but the most used in Brazil is the Alberta Infant Motor Scale (AIMS). Objective: To verify the validity of GMs and EMIA at one and three months of age to predict the outcome of motor development by EMIA at six and 12 months. Method: A longitudinal observational study with 45 newborns and infants of the University Hospital of the University of São Paulo, evaluated from birth to five months of age (corrected, if premature) by GMs, and from one to 12 months by EMIA. Descriptive analysis and kappa and roc curve tests were performed to compare the evaluations. Results: Participants (male = 51.1%) had a mean gestational age of 34 weeks; 57.7% presented alterations in at least one evaluation by GMs, with a predominance of poor repertoire (RP) and fidgety movements (FM) absent, while 46.6% had some alteration in EMIA. The majority (85.7%) presented normal evaluations at 12 months of age by EMIA; And those with abnormal ratings also had altered GMs throughout their trajectory. There was poor reliability between GMs and EMIA in the first (kappa: 0.165) and in the third month, slight reliability (kappa: 0.259). Comparing writhing movements (WM) with EMIA at one month, to predict outcome at six months of age, a WM sensitivity of 78.6% and a specificity of 100% was found. Better sensitivity and specificity values were also found in WM for 12-month-old outcome (75% sensitivity and 100% specificity). Infants who presented some alterations in the assessments were referred to physical therapy. Conclusion: It was possible to observe a large number of participants with altered GMs, but with a decrease / normalization in the evaluations by EMIA, and may be due to physiotherapeutic intervention in the most severe cases. The best predictive values for development prediction are GMs in the WM phase. There is no correlation between the evaluation of GMs at 1 month and EMIA 1 with month, nor between these two methods at 3 months

Introdução: O aperfeiçoamento da assistência pré-natal e neonatal contribuiu para maior sobrevida dos recém-nascidos com riscos para alterações do desenvolvimento. A detecção precoce e eficaz destes riscos é fundamental para a intervenção oportuna e minimização dos danos funcionais. A avaliação com melhor valor preditivo para anormalidades é pelos General Movements (GMs), porém a mais utilizada no Brasil é a Escala Motora Infantil de Alberta (EMIA). Objetivo: Verificar a validade dos GMs e da EMIA com um e três meses de idade para predizer o desfecho do desenvolvimento motor pela EMIA aos seis e 12 meses. Método: Estudo observacional longitudinal com 45 recém-nascidos e lactentes do Hospital Universitário da Universidade de São Paulo, avaliados do nascimento até os cinco meses de idade (corrigida, se prematuros) pelos GMs, e de um a 12 meses pela EMIA. Foi realizada análise descritiva e testes de kappa e curva roc para a comparação entre as avaliações. Resultados: Os participantes (masculino = 51,1%) apresentaram idade gestacional média de 34 semanas; 57,7% apresentaram alteração em pelo menos uma avaliação pelos GMs, com predomínio do repertório pobre (RP) e fidgety movements (FM) ausentes, enquanto 46,6% apresentaram alguma alteração na EMIA. A maioria (85,7%) apresentou avaliações normais aos 12 meses de idade pela EMIA; e os com avaliações anormais também tiveram GMs alterados em toda sua trajetória. Houve pobre confiabilidade entre os GMs e a EMIA no primeiro (kappa: 0,165) e no terceiro mês, ligeira confiabilidade (kappa: 0,259). Comparando os writhing movements (WM) com a EMIA com um mês, para prever desfecho aos seis meses de idade, foi encontrado uma sensibilidade dos WM de 78,6% e uma especificidade de 100%. Valores melhores de sensibilidade e especificidade também foram encontrados nos WM para desfecho com 12 meses de idade (sensibilidade de 75% e especificidade em 100%). Os lactentes que apresentavam alguma alteração nas avaliações eram encaminhados para fisioterapia. Conclusão: Foi possível observar um grande número de participantes com GMs alterados, porém com diminuição/normalização nas avaliações pela EMIA, podendo ser devido a intervenção fisioterapêutica nos casos mais graves. A avaliação com melhores valores para predição do desenvolvimento são os GMs na fase dos WMs. Não existe correlação entre a avaliação dos GMs com 1 mês e EMIA 1 com mês, nem entre estes dois métodos aos 3 meses / Introduction: Improvement of prenatal and neonatal care has contributed to a greater survival of newborns with risks for developmental disorders. Early and effective detection of these risks is essential for timely intervention and minimization of functional impairment. The most predictive value for abnormalities is the General Movements (GMs), but the most used in Brazil is the Alberta Infant Motor Scale (AIMS). Objective: To verify the validity of GMs and EMIA at one and three months of age to predict the outcome of motor development by EMIA at six and 12 months. Method: A longitudinal observational study with 45 newborns and infants of the University Hospital of the University of São Paulo, evaluated from birth to five months of age (corrected, if premature) by GMs, and from one to 12 months by EMIA. Descriptive analysis and kappa and roc curve tests were performed to compare the evaluations. Results: Participants (male = 51.1%) had a mean gestational age of 34 weeks; 57.7% presented alterations in at least one evaluation by GMs, with a predominance of poor repertoire (RP) and fidgety movements (FM) absent, while 46.6% had some alteration in EMIA. The majority (85.7%) presented normal evaluations at 12 months of age by EMIA; And those with abnormal ratings also had altered GMs throughout their trajectory. There was poor reliability between GMs and EMIA in the first (kappa: 0.165) and in the third month, slight reliability (kappa: 0.259). Comparing writhing movements (WM) with EMIA at one month, to predict outcome at six months of age, a WM sensitivity of 78.6% and a specificity of 100% was found. Better sensitivity and specificity values were also found in WM for 12-month-old outcome (75% sensitivity and 100% specificity). Infants who presented some alterations in the assessments were referred to physical therapy. Conclusion: It was possible to observe a large number of participants with altered GMs, but with a decrease / normalization in the evaluations by EMIA, and may be due to physiotherapeutic intervention in the most severe cases. The best predictive values for development prediction are GMs in the WM phase. There is no correlation between the evaluation of GMs at 1 month and EMIA 1 with month, nor between these two methods at 3 months

<p>Увод: Процена минималних неуролошких дисфункција (МНД) пружа информације о неуролошком стању детета, помаже у идентификовању вулнерабилности детета ка развоју моторних слабости, тешкоћа у учењу или поремећаја понашања. Деформитети кичменог стуба код деце предшколског узраста су у сталном порасту. Циљ истраживања: Утврђивање преваленце МНД-а у узорку предшколске деце тестирањем по Touwen-у, евалуација постуралног статуса код деце предшколског узраста, као и утврђивање повезаности јављања минималних неуролошких дисфункција и постуралних поремећаја код деце предшколског узраста. Материјал и методе: Истраживање је урађено у предшколској установи &bdquo;Радосно детињство&ldquo; из Новог Сада. Укупан узорак је обухватио 120-оро деце која су подељена у две групе у односу на узраст, 60-оро деце старости од 6 до 7 година (група А) и 60-оро деце старости од 5 до 6 година (група Б). Методом случајног избора су изабрана три вртића из различитих делова града, а деца су насумично одабрана са приближно једнаком заступљеношћу пола. Тестирање је урађено са Touwen-овим тестом модификованим од стране Hadders-Algre. Резултати су груписани у три групе: одсуство, присуство једноставних (присуство једне или две области дисфункције) и присуство комплексних МНД (присуство најмање три области дисфункције). Код све деце урађена је евалуација постуралног статуса, као и антропометријска мерења. Резултати: Постоји статистички значајна разлика у учесталости јављања МНД-а у односу на узраст, одступања су чешће присутна у млађем узрасту. МНД се чешће јављају код дечака у односу на девојчице, али није показана статистички значајна разлика. Код 68,3% деце уочени су елементи лошег држања тела. Најчешћа одступања од нормалног постуралног положаја била су у виду спуштених стопала (45,8%), асиметрије висине рамена (35%), искривљења ахилових тетива ван (30%), повећања слабинске кривине (29,2%) и асиметрије троуглова стаса (20%). Утврђена је статистички значајна позитивна повезаност између јављања минималних неуролошких дисфункција и лошег држања тела код деце предшколског узраста. Закључак: Деца старијих (узраст од 5 до 6 година) група предшколског узраста знатно чешће испољавају знаке минималне неуролошке дисфункције у односу на децу најстаријих (узраст од 6 до 7 година) група. Више од половине деце предшколског узраста показује одступање од нормалног постуралног статуса. Постоји статистички значајна позитивна повезаност између јављања минималних неуролошких дисфункција и лошег држања тела код деце предшколског узраста.</p> / <p>Uvod: Procena minimalnih neuroloških disfunkcija (MND) pruža informacije o neurološkom stanju deteta, pomaže u identifikovanju vulnerabilnosti deteta ka razvoju motornih slabosti, teškoća u učenju ili poremećaja ponašanja. Deformiteti kičmenog stuba kod dece predškolskog uzrasta su u stalnom porastu. Cilj istraživanja: Utvrđivanje prevalence MND-a u uzorku predškolske dece testiranjem po Touwen-u, evaluacija posturalnog statusa kod dece predškolskog uzrasta, kao i utvrđivanje povezanosti javljanja minimalnih neuroloških disfunkcija i posturalnih poremećaja kod dece predškolskog uzrasta. Materijal i metode: Istraživanje je urađeno u predškolskoj ustanovi &bdquo;Radosno detinjstvo&ldquo; iz Novog Sada. Ukupan uzorak je obuhvatio 120-oro dece koja su podeljena u dve grupe u odnosu na uzrast, 60-oro dece starosti od 6 do 7 godina (grupa A) i 60-oro dece starosti od 5 do 6 godina (grupa B). Metodom slučajnog izbora su izabrana tri vrtića iz različitih delova grada, a deca su nasumično odabrana sa približno jednakom zastupljenošću pola. Testiranje je urađeno sa Touwen-ovim testom modifikovanim od strane Hadders-Algre. Rezultati su grupisani u tri grupe: odsustvo, prisustvo jednostavnih (prisustvo jedne ili dve oblasti disfunkcije) i prisustvo kompleksnih MND (prisustvo najmanje tri oblasti disfunkcije). Kod sve dece urađena je evaluacija posturalnog statusa, kao i antropometrijska merenja. Rezultati: Postoji statistički značajna razlika u učestalosti javljanja MND-a u odnosu na uzrast, odstupanja su češće prisutna u mlađem uzrastu. MND se češće javljaju kod dečaka u odnosu na devojčice, ali nije pokazana statistički značajna razlika. Kod 68,3% dece uočeni su elementi lošeg držanja tela. Najčešća odstupanja od normalnog posturalnog položaja bila su u vidu spuštenih stopala (45,8%), asimetrije visine ramena (35%), iskrivljenja ahilovih tetiva van (30%), povećanja slabinske krivine (29,2%) i asimetrije trouglova stasa (20%). Utvrđena je statistički značajna pozitivna povezanost između javljanja minimalnih neuroloških disfunkcija i lošeg držanja tela kod dece predškolskog uzrasta. Zaključak: Deca starijih (uzrast od 5 do 6 godina) grupa predškolskog uzrasta znatno češće ispoljavaju znake minimalne neurološke disfunkcije u odnosu na decu najstarijih (uzrast od 6 do 7 godina) grupa. Više od polovine dece predškolskog uzrasta pokazuje odstupanje od normalnog posturalnog statusa. Postoji statistički značajna pozitivna povezanost između javljanja minimalnih neuroloških disfunkcija i lošeg držanja tela kod dece predškolskog uzrasta.</p> / <p>Introduction: Assessment of minor neurological dysfunction (MND) provides information about a child&#39;s neurological condition, which helps to identify the vulnerability of the child to the development of motor impairment, difficulties in learning or behavioral disorders. Spinal deformities in preschool children are constantly increasing. Aim: Determining the prevalence of MND in a sample of preschool children using Touwen&rsquo;s test, the evaluation of postural status in preschool children, as well as determining the relation between the occurrence of minor neurological dysfunction and postural disorders in preschool children. Material and methods: The examination was carried out in the preschool institution &ldquo;Radosno detinjstvo&rdquo; in the city of Novi Sad. The total sample included 120 children who were divided into two groups according to their age, 60 children aged 6 to 7 years (group A) and 60 children aged 5 to 6 years (group B). The children were recruited at three randomly selected kindergartens, and the children were randomly selected with approximately equal gender representation. The testing was done with Touwen&#39;s test modified by Hadders-Algra. The results were classified into three groups: the absence of MND, the presence of simple MND (presence of one or two domains of dysfunction) and the presence of complex MND (presence of at least three domains of dysfunction). Evaluation of postural status and anthropometric measurements were carried out for all the children. Results: There is a statistically significant difference in the prevalence of MND in relation to age, variations were more likely at a younger age. MND is more frequent in boys than in girls, but this difference is not statistically significant. In 68.3% of the children there are elements of bad posture. The most common deviations from the normal postural position are flat feet (45.8%), shoulder height asymmetry (35%), distortion of Achilles tendons to the outside (30%), excessive curvature of lower back (29.2%) and asymmetry of stature triangles (20%). There is a statistically significant positive correlation between the occurrence of minor neurological dysfunction and poor posture in children of preschool age. Conclusion: Children in older preschool groups (5 to 6 years old) more often show signs of minor neurological dysfunction in comparison to the children in the oldest groups (6 to 7 years old). More than half of the preschool children show deviation from normal postural status. There is a statistically significant correlation between the occurrence of minor neurological dysfunction and poor posture in children of preschool age.</p>