Clinical decision making in cervical nerve root involvement: Towards a better-informed clinical reasoning process

The general aim of this dissertation is to advance the clinical decision-making process in the conservative management of people with cervical nerve root involvement. Chapter 1 provides a general introduction and describes the outline of the dissertation. The dissertation consists of two parts, focused on 1) diagnostic considerations, and 2) prognostic and therapeutic considerations. Part 1: Diagnostic considerations for people with cervical nerve root Involvement: Part 1 includes three chapters that focus on the diagnostic decision-making process in cervical nerve root involvement. Chapter 2 describes a prospective diagnostic study that investigated the diagnostic accuracy of patient interview items and frequently used clinical tests to diagnose cervical nerve root involvement, providing insight into the diagnostic value of these items. Chapter 3 describes the development and internal validation of three diagnostic models for cervical nerve root involvement, based on 1) patient interview items, 2) the clinical examination, and 3) a combined model containing items from the patient interview and the clinical examination. The findings indicated that the diagnostic models could cautiously be used to improve the assessment of the likelihood of cervical nerve root involvement, pending external validation. Chapter 4 describes an external validation study, which showed poor discriminative performance and calibration for the three previously developed diagnostic models. Therefore, clinical use of the models could not be recommended. Part 2: Prognostic and therapeutic considerations for people with cervical nerve root Involvement: Part 2 consists of four chapters, in which the focus is on the prognostic and therapeutic decision-making. Chapter 5 describes a prospective cohort study that examined the clincal course of cervical nerve root involvement for conservative management, and describes the development and internal validation of three prognostic models. The models showed adequate predictive performance, with modest discrimination and explained variance. As a caution, we expressed the need for confirmation of these findings through external validation of the models. Chapters 6 and 7 describe two modified Delphi studies that were conducted to reach expert consensus on preferred questionnaires to assess various psychological factors in people with musculoskeletal pain. Chapter 6 resulted in expert panel recommendations to assess fear of movement, coping, self-efficacy and catastrophizing. Chapter 7 provides expert recommendations for the assessment of depression and anxiety. For somatization, no recommendations were made because the expert panel voiced concerns about the clarity of the construct and expressed unfamiliarity with questionnaires to measure somatization. Chapter 8 describes a systematic review with meta-analyses of preclinical studies that provides an overview of the current state of knowledge on the effects of aerobic exercise on neuroimmune processes in traumatic peripheral neuropathies. The findings suggest beneficial effects of aerobic exercise on neuroimmune responses at various anatomical locations in animals with a traumatic peripheral neuropathy. The findings should be interpreted with caution, given the small sample sizes and unclear risk of bias of the included studies. Chapter 9 concerns a general discussion of the main findings and implications for clinical practice, and discusses directions for future research. The dissertation also holds Dutch and English summaries (Chapter 10), Appendices and Supplementary material (Chapter 11) and Addenda (Chapter 12).