Pain education to prevent chronic low back pain: a study protocol for a randomised controlled trial

INTRODUCTION

Low back pain (LBP) is the leading cause of disability worldwide. Of those patients who present to primary care with acute LBP, 40% continue to report symptoms 3 months later and develop chronic LBP. Although it is possible to identify these patients early, effective interventions to improve their outcomes are not available. This double-blind (participant/outcome assessor) randomised controlled trial will investigate the efficacy of a brief educational approach to prevent chronic LBP in 'at-risk' individuals.

METHODS/ANALYSIS

Participants will be recruited from primary care practices in the Sydney metropolitan area. To be eligible for inclusion participants will be aged 18-75 years, with acute LBP (<4 weeks' duration) preceded by at least a 1 month pain-free period and at-risk of developing chronic LBP. Potential participants with chronic spinal pain and those with suspected serious spinal pathology will be excluded. Eligible participants who agree to take part will be randomly allocated to receive 2×1 h sessions of pain biology education or 2×1 h sessions of sham education from a specially trained study physiotherapist. The study requires 101 participants per group to detect a 1-point difference in pain intensity 3 months after pain onset. Secondary outcomes include the incidence of chronic LBP, disability, pain intensity, depression, healthcare utilisation, pain attitudes and beliefs, global recovery and recurrence and are measured at 1 week post-intervention, and at 3, 6 and 12 months post LBP onset.

ETHICS/DISSEMINATION

Ethical approval was obtained from the University of New South Wales Human Ethics Committee in June 2013 (ref number HC12664). Outcomes will be disseminated through publication in peer-reviewed journals and presentations at international conference meetings.

TRIAL REGISTRATION NUMBER

https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12612001180808.

Development of a method for measuring femoral torsion using real-time ultrasound

Excessive femoral torsion has been associated with various musculoskeletal and neurological problems. To explore this relationship, it is essential to be able to measure femoral torsion in the clinic accurately. Computerized tomography (CT) and magnetic resonance imaging (MRI) are thought to provide the most accurate measurements but CT involves significant radiation exposure and MRI is expensive. The aim of this study was to design a method for measuring femoral torsion in the clinic, and to determine the reliability of this method. Details of design process, including construction of a jig, the protocol developed and the reliability of the method are presented. The protocol developed used ultrasound to image a ridge on the greater trochanter, and a customized jig placed on the femoral condyles as reference points. An inclinometer attached to the customized jig allowed quantification of the degree of femoral torsion. Measurements taken with this protocol had excellent intra- and inter-rater reliability (ICC2,1 = 0.98 and 0.97, respectively). This method of measuring femoral torsion also permitted measurement of femoral torsion with a high degree of accuracy. This method is applicable to the research setting and, with minor adjustments, will be applicable to the clinical setting.

A qualitative study of influences on older women's practitioner choices for back pain care

BACKGROUND

Back pain is an increasingly prevalent health concern amongst Australian women for which a wide range of treatment options are available, offered by biomedical, allied health and complementary and alternative medicine (CAM) providers. Although there is an emerging literature on patterns of provider utilisation, less is known about the reasons why women with back pain select their chosen practitioner. In this paper we explore the influences on back pain sufferers' decision-making about treatment seeking with practitioners for their most recent episode of back pain.

METHODS

Drawing on 50 semi-structured interviews with women aged 60-65 years from the Australian Longitudinal Study on Women's Health (ALSWH) who have chronic back pain, we focus on the factors which influence their choice of practitioner. Analysis followed a framework approach to qualitative content analysis, augmented by NVivo 9 qualitative data analysis software. Key themes were identified and tested for rigour through inter-rater reliability and constant comparison.

RESULTS

The women identified four predominant influences on their choice of practitioner for back pain: familiarity with treatment or experiences with individual practitioners; recommendations from social networks; geographical proximity of practitioners; and, qualifications and credentials of practitioners. The therapeutic approach or evidence-base of the practices being utilised was not reported by the women as central to their back pain treatment decision making.

CONCLUSIONS

Choice of practitioner appears to be unrelated to the therapeutic approaches, treatment practices or the scientific basis of therapeutic practices. Moreover, anecdotal lay reports of effectiveness and the 'treatment experience' may be more influential than formal qualifications in guiding women's choice of practitioner for their back pain. Further work is needed on the interpersonal, collective and subjective underpinnings of practitioner choice, particularly over time, in order to better understand why women utilise certain practitioners for back pain.

Randomised controlled trial protocol of foot and ankle exercise for children with Charcot-Marie-Tooth disease

INTRODUCTION

Charcot-Marie-Tooth disease (CMT) is one of the most commonly inherited neuromuscular diseases--there is no effective treatment. Foot and ankle weakness is a major problem for children with CMT, thus interventions that focus on maintaining and increasing strength may provide a solution.

RESEARCH QUESTION

Is progressive resistance strength training an effective and safe intervention to improve strength, disability, gait and quality of life of children with CMT?

PARTICIPANTS AND SETTING

Sixty children (6 to 17 years) with confirmed CMT who reside in Sydney, Australia will be recruited via referral from a paediatric neurologist, advertisements or the Australasian Paediatric CMT Registry.

INTERVENTION

Participants will be randomised to undergo a 24-week, thrice weekly, high-intensity progressive resistance foot and ankle exercise programme (HIGH) or low-intensity foot and ankle exercise control programme (LOW).

MEASUREMENTS

Out-come measures will be conducted at baseline, 6, 12 and 24 months.The primary outcome is isometric dorsiflexion strength measured by hand-held dynamometry. Secondary outcomes include disability, gait, quality of life, functional ankle instability and muscle volume and fatty infiltration of the anterior compartment of the lower leg (determined by MRI).

PROCEDURE

Randomisation and allocation will be by a computer-generated algorithm, maintained and assigned by an external phone-based system, concealed to the investigators. Participants, parents and the outcome assessors will be blinded to group assignment.

ANALYSIS

Treatment effect between groups is by intention-to-treat with a linear regression approach to analysis of covariance using 95% CI and p < 0.05.

DISCUSSION

This study is the first randomised controlled trial to evaluate the risks and benefits of strengthening the affected muscles in children with CMT.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry.

REGISTRATION NUMBER

ACTRN12613000552785.

Does progressive resistance and balance exercise reduce falls in residential aged care? Randomized controlled trial protocol for the SUNBEAM program

Introduction

Falls are common among older adults. It is reported that approximately 60% of residents of aged care facilities fall each year. This is a major cause of morbidity and mortality, and a significant burden for health care providers and the health system. Among community dwelling older adults, exercise appears to be an effective countermeasure, but data are limited and inconsistent among studies in residents of aged care communities. This trial has been designed to evaluate whether the SUNBEAM program (Strength and Balance Exercise in Aged Care) reduces falls in residents of aged care facilities.

Research question

Is the program more effective and cost-effective than usual care for the prevention of falls?

Design

Single-blinded, two group, cluster randomized trial.

Participants and setting

300 residents, living in 20 aged care facilities.

Intervention

Progressive resistance and balance training under the guidance of a physiotherapist for 6 months, then facility-guided maintenance training for 6 months.

Control

Usual care.

Measurements

Number of falls, number of fallers, quality of life, mobility, balance, fear of falling, cognitive well-being, resource use, and cost-effectiveness. Measurements will be taken at baseline, 6 months, and 12 months.

Analysis

The number of falls will be analyzed using a Poisson mixed model. A logistic mixed model will be used to analyze the number of residents who fall during the study period. Intention-to-treat analysis will be used.

Discussion

This study addresses a significant shortcoming in aged care research, and has potential to impact upon a substantial health care problem. Outcomes will be used to inform care providers, and guide health care policies.

Selection criteria for patients with chronic ankle instability in controlled research: a position statement of the International Ankle Consortium

While research on chronic ankle instability (CAI) and awareness of its impact on society and health care systems has grown substantially in the last 2 decades, the inconsistency in participant or patient selection criteria across studies presents a potential obstacle to addressing the problem properly. This major gap within the literature limits the ability to generalize this evidence to the target patient population. Therefore, there is a need to provide standards for patient or participant selection criteria in research focused on CAI with justifications using the best available evidence. The International Ankle Consortium provides this position paper to present and discuss an endorsed set of selection criteria for patients with CAI based on the best available evidence to be used in future research and study designs. These recommendations will enhance the validity of research conducted in this clinical population with the end goal of bringing the research evidence to the clinician and patient.

Predictive factors for ankle syndesmosis injury in football players: a prospective study

OBJECTIVES

Up to 25% of all ankle injuries involve the ankle syndesmosis and factors that increase risk have yet to be investigated prospectively. This study aimed to identify predictors of ankle syndesmosis injury in football players.

DESIGN

A prospective study.

METHODS

Rugby Union and Australian Football League players were recruited during 2010. Rugby League and different Rugby Union players were recruited during 2011. Baseline data collection included: age, body size, flexibility, strength and balance. Bivariate correlations were performed between all predictors. Variables with r ≥ 0.7 had only one variable entered in further analysis. Remaining predictor variables were analysed for association with the presence/absence of ankle syndesmosis injury. Variables with non-significant association with injury (p>0.2) were included in a backward step-wise Cox regression model.

RESULTS

202 male participants aged 21 ± 3.3 years (mean ± SD) were recruited of whom 12 (5.9%) sustained an ankle syndesmosis injury. The overall incidence rate was 0.59/1000 h sport participation for Rugby Union and Rugby League. Australian Football League training data was not available. No significant predictors were identified; however, participants who sustained an injury during the season performed a higher vertical jump (63.6 ± 8.2 cm) and greater Star Excursion Balance Test reach (80.5 ± 5.3 cm), than participants who did not sustain an injury: 59.1 ± 7.8 cm for Vertical Jump and 77.9 ± 6.1 cm for Star Excursion Balance Test. This was normalised for height.

CONCLUSIONS

Variables such as age, body size, foot posture, flexibility and muscle strength did not increase risk of ankle syndesmosis injury. Jump height and balance performance may play a role in predicting ankle syndesmosis sprains.

Health care utilisation and out-of-pocket expenditure associated with back pain: a nationally representative survey of Australian women

BACKGROUND

Back pain impacts on a significant proportion of the Australian population over the life course and has high prevalence rates among women, particularly in older age. Back pain care is characterised by multiple practitioner and self-prescribed treatment options, and the out-of-pocket costs associated with consultations and self-prescribed treatments have not been examined to date.

OBJECTIVE

To analyse the extent of health care practitioner consultations and self-prescribed treatment for back pain care among Australian women, and to assess the self-reported costs associated with such usage.

METHODS

Survey of 1,310 women (response rate 80.9%) who reported seeking help for back pain from the '1946-51 cohort' of the Australian Longitudinal Study on Women's Health. Women were asked about their use of health care practitioners and self-prescribed treatments for back pain and the costs associated with such usage.

RESULTS

In the past year 76.4% consulted a complementary and alternative practitioner, 56% an allied health practitioner and 59.2% a GP/medical specialist. Overall, women consulted with, on average, 3.0 (SD = 2.0) different health care practitioners, and had, on average, 12.2 (SD = 9.7) discrete health care practitioner consultations for back pain. Average self-reported out-of-pocket expenditure on practitioners and self-prescribed treatments for back pain care per annum was AU$873.10.

CONCLUSIONS

Multiple provider usage for various but distinct purposes (i.e. pain/mobility versus anxiety/stress) points to the need for further research into patient motivations and experiences of back pain care in order to improve and enhance access to and continuity of care. Our results suggest that the cost of back pain care represents a significant burden, and may ultimately limit women's access to multiple providers. We extrapolate that for Australian working-age women, total out-of-pocket expenditure on back pain care per annum is in excess of AU$1.4 billion, thus indicating the prominence of back pain as a major economic, social and health burden.

Elevated extracellular fluid in the "at risk" arm from taxane-based chemotherapies in women treated for early breast cancer

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Background: Taxane-based regimes has improved survival in early breast cancer and now is used routinely. A common side effect is oedema which potentially increases the risk of lymphoedema in the arm after surgery. This has not been assessed prospectively. The aim of this study was to determine the effect of taxane-based regimens on extracellular fluid (ECF) in the arm on the side of surgery. Methods: Women (n=441) aged 56.8 (SD 11.2) years enrolled prior to surgery for early breast cancer and were reassessed within 1 month and 6, 12, and 18 months following surgery. Assessment included bioimpedance spectroscopy which quantifies ECF in each arm and used to derive the ECF ratio. Based on the ECF ratio, women were categorised as having, or not, swelling preferentially in their at risk arm at each time point and having no taxane-based chemotherapy (n=269), paclitaxel (n=73) or docetaxel chemotherapy (n=88). Results: Pre-surgery, the ECF ratio was not significantly different in women who later did or did not receive taxane-based chemotherapy. Following surgery but prior to commencing chemotherapy, 45 (11%) women had increased ECF in their at-risk arm. Both taxane-based chemotherapies and elevated postoperative arm swelling were associated with swelling at each follow-up timepoint (Table). Conclusions: In addition to pre-existing swelling, both taxel chemotherapies were associated with swelling preferentially in the at-risk arm between 6 and 18 months following surgery. Strategies to prevent or minimise this swelling need to be developed. [Table: see text]

Consultations with complementary and alternative medicine practitioners amongst wider care options for back pain: a study of a nationally representative sample of 1,310 Australian women aged 60-65 years

Back pain is a significant health service issue in Australia and internationally. Back pain sufferers can draw upon a range of health care providers including complementary and alternative medicine (CAM) practitioners. Women are higher users of health services than men and tend to use CAM frequently for musculoskeletal conditions. However, there remain important gaps in our understanding of women's consultation patterns with CAM practitioners for back pain. The objective of this study is to examine the prevalence of use and characteristics of women who use CAM practitioners for back pain. The method used was a survey of a nationally representative sample of women aged 60-65 years from the Australian Longitudinal Study on Women's Health. Women consulted a massage therapist (44.1 %, n = 578) and a chiropractor (37.3 %, n = 488) more than other CAM practitioners for their back pain. Consultations with a chiropractor for back pain were lower for women who consulted a General Practitioner (GP) (OR, 0.56; 95 % CI 0.41, 0.76) or a physiotherapist (OR, 0.53; 95 % CI 0.39, 0.72) than for those who did not consult a GP or a physiotherapist. CAM practitioner consultations for back pain were greater for women who visited a pharmacist (OR, 1.99; 95 % CI 1.23, 3.32) than for women who did not visit a pharmacist. There is substantial use of CAM practitioners alongside conventional practitioners amongst women for back pain, and there is a need to provide detailed examination of the communication between patients and their providers as well as across the diverse range of health professionals involved in back pain care.

Relationship between quantitative sensory testing and pain or disability in people with spinal pain-a systematic review and meta-analysis

Sensitization of the nervous system can present as pain hypersensitivity that may contribute to clinical pain. In spinal pain, however, the relationship between sensory hypersensitivity and clinical pain remains unclear. This systematic review examined the relationship between pain sensitivity measured via quantitative sensory testing (QST) and self-reported pain or pain-related disability in people with spinal pain. Electronic databases and reference lists were searched. Correlation coefficients for the relationship between QST and pain intensity or disability were pooled using random effects models. Subgroup analyses and mixed effects meta-regression were used to assess whether the strength of the relationship was moderated by variables related to the QST method or pain condition. One hundred and forty-five effect sizes from 40 studies were included in the meta-analysis. Pooled estimates for the correlation between pain threshold and pain intensity were -0.15 (95% confidence interval [CI]: -0.18 to -0.11) and for disability -0.16 (95% CI: -0.22 to -0.10). Subgroup analyses and meta-regression did not provide evidence that these relationships were moderated by the QST testing site (primary pain/remote), pain condition (back/neck pain), pain type (acute/chronic), or type of pain induction stimulus (eg, mechanical/thermal). Fair correlations were found for the relationship between pain intensity and thermal temporal summation (0.26, 95% CI: 0.09 to 0.42) or pain tolerance (-0.30, 95% CI: -0.45 to -0.13), but only a few studies were available. Our study indicates either that pain threshold is a poor marker of central sensitization or that sensitization does not play a major role in patients' reporting of pain and disability. Future research prospects are discussed.

Determination of evidence-based diagnostic thresholds for upper limb lymphedema secondary to treatment for cancer

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Background: Diagnosis of upper limb lymphedema (LE) secondary to treatment for cancer has been complicated by the range of diagnostic thresholds used. Traditional thresholds were arbitrarily chosen but recently normative-based cut-offs have been established. However, the diagnostic power of these thresholds has not been compared to changes identified with lymphoscintigraphy, the gold standard for diagnosis of LE. The aim of this study was to determine thresholds for commonly used clinical diagnostic tools based on lymphatic imaging outcomes. Methods: Women previously diagnosed with LE secondary to treatment for cancer (n=67), and women without LE (n=20) participated. Lymphoscintigraphy was completed and the presence and severity of dermal back flow qualitatively scored as none to mild or moderate to severe by an experienced nuclear medicine physician. On the same day, circumference measurements and segmental bioimpedance spectroscopy (BIS) for 10 cm intervals from the ulnar styloid to 40 cm proximal were recorded. The BIS inter-limb ratio for each segment and the inter-limb circumference differences were compared to diagnostic thresholds based on 2 and 3 standard deviations (SD) above the mean from normative data. Results: The number of BIS segments and circumferences measurements above a 3SD threshold correlated significantly with the dermal backflow score (Rs= 0.710 and 0.824 respectively).The number of abnormal BIS segments detected did not differ significantly between a 2SD and 3SD threshold (χ2=0.23 p=0.63). Of the 20 new abnormal segments detected, 7 were from participants with no or mild evidence of dermal backflow on lymphoscintigraphy including 3 from control participants. In contrast, 46 new abnormal inter-limb circumference differences, all from those with a LE diagnosis, were detected using a 2SD threshold (χ2= 31.785, p<0.001) Conclusions: The need for a standardized, evidenced-based approach for identification of LE is essential. We recommend diagnostic thresholds for segmental BIS be set at 3SD above the mean to minimize false positive diagnoses whereas a lower threshold of 2SD is necessary for the less sensitive inter-limb circumference difference measurements.

Efficacy of a one-year exercise program to prevent bone loss in postmenopausal women prescribed aromatase inhibitor therapy: An RCT

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Background: The aim of this single blinded RCT was to determine the effect of exercise on bone mineral density (BMD) in postmenopausal women prescribed an aromatase inhibitor (AI) for the treatment of breast cancer. Methods: 66 sedentary, postmenopausal women, median age of 54.5 years, with early breast cancer and receiving an aromatase inhibitor participated. Women were stratified for taking tamoxifen prior to AI, and randomised to either the exercise (n = 27) or control (n = 39) group. All participants received daily vitamin D (1000 IU) and calcium carbonate (1200 mg) supplements and a booklet from Osteoporosis Australia outlining the benefits of exercise in preventing osteoporosis. The exercise group attended a gym three times per week for one year, supervised at regular intervals by a personal trainer, and were contacted weekly regarding progress and progression. Training sessions comprised warm-up, impact training, and resistance training. The control group was contacted monthly to monitor health status and to receive their supply of vitamins. The primary outcome was total hip BMD measured with a dual-energy X-ray absorptiometer. The secondary outcomes included trochanteric, femoral neck, lumbar spine and whole body BMD and t-scores. Results: Intention-to-treat analysis revealed that the change in BMD was not significantly different between groups. At baseline, the mean (SD) total hip BMD in the control group was 0.892 (0.115) g/cm2 and 0.878 (0.112) g/cm2 at 1 yr. In contrast, hip BMD in the Exercise group was 0.918 (0.119) g/cm2 at baseline and 0.910 (0.113) g/cm2at 1 yr. The mean (SD) change for both groups was <1%. The mean T-score of the hip for Controls at baseline was -0.42 (0.94) and -0.53 (0.91) at 1 year. The baseline T-score for the Exercise group was -0.20 (0.95) and -0.26 (0.93) at one year. The average compliance with attendance for the exercise group was 71% but ranged from 20 to 100%. Compliance with vitamins for both groups was high. Conclusions: A one year exercise program did not provide additional benefit to bone density in women on AIs compared to receipt of calcium and vitamin D and advice to exercise. Clinical trial information: (ACTRN12608000220369).

Interrater reliability of the star excursion balance test

CONTEXT

Dynamic postural control has gained popularity as a more useful assessment of function than static postural control. One measurement of dynamic postural control that has increased in frequency of use is the Star Excursion Balance Test (SEBT). Although the intrarater reliability of the SEBT is excellent, few authors have determined interrater reliability. Preliminary evidence has shown poor reliability between assessors.

OBJECTIVE

To determine interrater reliability using a group of investigators at 2 testing sites. A corollary purpose was to examine the interrater reliability when using normalized and nonnormalized performance scores on the SEBT.

DESIGN

Descriptive laboratory study.

SETTING

University research laboratory.

PATIENTS OR OTHER PARTICIPANTS

A total of 29 healthy participants between 18 and 50 years of age.

INTERVENTION(S)

Participants were evaluated by 5 raters at 2 testing sites. After participants performed 4 practice trials, each rater assessed 3 test trials in the anterior, posteromedial, and posterolateral reaching directions of the SEBT.

MAIN OUTCOME MEASURE(S)

Normalized and nonnormalized (leg-length) reaching distances were analyzed. Additionally, the mean and maximum values from the 3 test trials were analyzed, producing a total of 16 variables.

RESULTS

For all 16 measures, the interrater reliability was excellent. For the normalized maximum excursion distances, the intraclass correlation coefficients (1,1) ranged from 0.86 to 0.92. Reliability for the nonnormalized measurements was stronger, ranging from 0.89 to 0.94.

CONCLUSIONS

When the raters have been trained by an experienced rater, the SEBT is a test with excellent reliability when used across multiple raters in different settings. This information adds to the body of knowledge that exists regarding the usefulness of the SEBT as an assessment tool in clinical and research practice. Establishing excellent interrater reliability with normalized and nonnormalized scores strengthens the evidence for using the SEBT, especially at multiple sites.

People seeking treatment for a new episode of neck pain typically have rapid improvement in symptoms: an observational study

QUESTION

What is the clinical course of a new episode of non-specific neck pain in people who are treated with multimodal physical therapies in a primary care setting?

DESIGN

Observational study with 3-month follow-up, run in conjunction with a randomised trial.

PARTICIPANTS

181 adults who consulted a physiotherapist or chiropractor for a new episode of nonspecific neck pain.

OUTCOME MEASURES

Time to recover from the episode of neck pain, time to recover normal activity, and pain and neck-related disability at three months. Clinical and demographic characteristics were investigated as potential predictors of recovery.

RESULTS

Within 3 months, 53% of participants reported complete recovery from the episode of neck pain. On a scale from 0 (none) to 10 (worst), pain improved from 6.1 (SD 2.0) at baseline to 2.5 (SD 2.1) at 2 weeks and to 1.5 (SD 1.8) at 3 months. On a scale from 0 (none) to 50 (worst), disability improved from 15.5 (SD 7.4) at baseline to 5.4 (SD 6.4) at 3 months. Faster recovery was independently associated with better self-rated general health, shorter duration of symptoms, being a smoker, and absence of concomitant upper back pain or headache. Higher disability at 3 months was independently associated with higher disability at baseline, concomitant upper or lower back pain, older age, and previous sick leave for neck pain.

CONCLUSION

People who seek physical treatments for a new episode of neck pain in this primary care setting typically have high pain scores that improve rapidly after commencing treatment. Although almost half of those who seek treatment do not recover completely within three months, residual pain and disability in this group is relatively low. Physiotherapists should reassure people with a new episode of neck pain that rapid improvement in symptoms is common, modifying this advice where applicable based on risk factors.

Communication that values patient autonomy is associated with satisfaction with care: a systematic review

QUESTION

Which communication factors used by clinicians during patient-clinician interactions are associated with satisfaction with care?

DESIGN

Systematic review with meta-analysis of studies investigating the association of verbal or nonverbal factors or interaction styles used by clinicians with patient satisfaction during an encounter between clinician and patient.

PARTICIPANTS

: Clinicians interacting with patients in primary care or rehabilitation settings.

RESULTS

Twenty seven studies investigated 129 verbal, nonverbal, and interaction style factors. Of these, 38 factors were consistently associated with satisfaction. Verbal factors concerning clinicians involving, facilitating, and supporting patients were associated with satisfaction with care. Most communication factors presented a fair correlation (r≥0.21 but <0.41) with satisfaction with care. Nonverbal factors such as time spent discussing prevention and time spent reading patient charts had a fair association with satisfaction with care (correlations range from 0.21 to 0.40). A moderate association was found between interaction styles such as caring (pooled r=0.51, 95% CI 0.42 to 0.60) and satisfaction with care. Over half (58%) of the 129 identified factors never associated with satisfaction with care and the remainder associated inconsistently.

CONCLUSION

The number of potential modifiable communication factors associated with satisfaction with care and the magnitude of their association partially support interventions to train clinicians in communication skills that value patient autonomy.

Effectiveness of self-management of low back pain: systematic review with meta-analysis

OBJECTIVE

To determine the effectiveness of self-management for nonspecific low back pain (LBP).

METHODS

We performed a systematic review searching the Medline, Embase, CINAHL, PsycINFO, LILACS, PEDro, AMED, SPORTDiscus, and Cochrane databases from earliest record to April 2011. Randomized controlled trials evaluating self-management for nonspecific LBP and assessing pain and disability were included. The PEDro scale was used to assess the methodologic quality of included trials. Data were pooled where studies were sufficiently homogenous. Analyses were conducted separately for short- (less than 6 months after randomization) and long-term (at least 12 months after randomization) followup. Six criteria for self-management were used to assess the content of the intervention.

RESULTS

The search identified 2,325 titles, of which 13 original trials were included. Moderate-quality evidence showed that self-management is effective for improving pain and disability for people with LBP. The weighted mean difference at short-term followup for pain was -3.2 points on a 0-100 scale (95% confidence interval [95% CI] -5.1, -1.3) and for disability was -2.3 points (95% CI -3.7, -1.0). The long-term effects were -4.8 (95% CI -7.1, -2.5) for pain and -2.1 (95% CI -3.6, -0.6) for disability.

CONCLUSION

There is moderate-quality evidence that self-management has small effects on pain and disability in people with LBP. These results challenge the endorsement of self-management in treatment guidelines.

Diagnostic accuracy of clinical tests for diagnosis of ankle syndesmosis injury: a systematic review

OBJECTIVES

To determine the value of clinical tests for accurate diagnosis of ankle syndesmosis injury.

DESIGN

Systematic review.

DATA SOURCES

An electronic database search was conducted (to 6 August 2012) of databases such as: MEDLINE, CINAHL, EMBASE, PubMed and Cochrane Databases. References from identified articles were examined and seven authors of eligible studies were contacted for additional information.

STUDY SELECTION

Studies of any design, without language restriction, were included; however, systematic reviews were excluded. Eligible studies included participants with a suspected ankle syndesmosis injury but without fracture. Reliability studies compared one or more clinical tests and studies of test accuracy compared the clinical test with a reference standard.

RESULTS

The database search resulted in 114 full text articles which were assessed for eligibility. Three studies were included in the review and raw data of these studies were retrieved after contacting the authors. Eight clinical diagnostic tests were investigated; palpation of the tibiofibular ligaments, external rotation stress test, squeeze, Cotton, fibula translation, dorsiflexion range of motion (ROM) and anterior drawer tests. Two studies investigated diagnostic accuracy and both investigated the squeeze test by with conflicting results. Likelihood ratios (LR) ranging from LR+1.50 to LR-1.50 were found for other tests. High intra-rater reliability was found for the squeeze, Cotton, dorsiflexion ROM and external rotation tests (83-100% close agreement). Inter-rater reliability was good for the external rotation test (ICC2,1>0.70). Fair-to-poor reliability was found for other tests.

CONCLUSIONS

This is the first systematic review to investigate the reliability and accuracy of clinical tests for the diagnosis of ankle syndesmosis injury. Few studies were identified and our findings show that clinicians cannot rely on a single test to identify ankle syndesmosis injury with certainty. Additional diagnostic tests, such as MRI, should be considered before making a final diagnosis of syndesmosis injury.

Rehabilitation for ankle fractures in adults

BACKGROUND

Rehabilitation after ankle fracture can begin soon after the fracture has been treated, either surgically or non-surgically, by the use of different types of immobilisation that allow early commencement of weight-bearing or exercise. Alternatively, rehabilitation, including the use of physical or manual therapies, may start following the period of immobilisation. This is an update of a Cochrane review first published in 2008.

OBJECTIVES

To assess the effects of rehabilitation interventions following conservative or surgical treatment of ankle fractures in adults.

SEARCH METHODS

We searched the Specialised Registers of the Cochrane Bone, Joint and Muscle Trauma Group and the Cochrane Rehabilitation and Related Therapies Field, CENTRAL via The Cochrane Library (2011 Issue 7), MEDLINE via PubMed, EMBASE, CINAHL, PEDro, AMED, SPORTDiscus and clinical trials registers up to July 2011. In addition, we searched reference lists of included studies and relevant systematic reviews.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials with adults undergoing any interventions for rehabilitation after ankle fracture were considered. The primary outcome was activity limitation. Secondary outcomes included quality of life, patient satisfaction, impairments and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results, assessed risk of bias and extracted data. Risk ratios and 95% confidence intervals (95% CIs) were calculated for dichotomous variables, and mean differences or standardised mean differences and 95% CIs were calculated for continuous variables. End of treatment and end of follow-up data were presented separately. For end of follow-up data, short term follow-up was defined as up to three months after randomisation, and long-term follow-up as greater than six months after randomisation. Meta-analysis was performed where appropriate.

MAIN RESULTS

Thirty-eight studies with a total of 1896 participants were included. Only one study was judged at low risk of bias. Eight studies were judged at high risk of selection bias because of lack of allocation concealment and over half the of the studies were at high risk of selective reporting bias.Three small studies investigated rehabilitation interventions during the immobilisation period after conservative orthopaedic management. There was limited evidence from two studies (106 participants in total) of short-term benefit of using an air-stirrup versus an orthosis or a walking cast. One study (12 participants) found 12 weeks of hypnosis did not reduce activity or improve other outcomes.Thirty studies investigated rehabilitation interventions during the immobilisation period after surgical fixation. In 10 studies, the use of a removable type of immobilisation combined with exercise was compared with cast immobilisation alone. Using a removable type of immobilisation to enable controlled exercise significantly reduced activity limitation in five of the eight studies reporting this outcome, reduced pain (number of participants with pain at the long term follow-up: 10/35 versus 25/34; risk ratio (RR) 0.39, 95% confidence interval (CI) 0.22 to 0.68; 2 studies) and improved ankle dorsiflexion range of motion. However, it also led to a higher rate of mainly minor adverse events (49/201 versus 20/197; RR 2.30, 95% CI 1.49 to 3.56; 7 studies).During the immobilisation period after surgical fixation, commencing weight-bearing made a small improvement in ankle dorsiflexion range of motion (mean difference in the difference in range of motion compared with the non-fractured side at the long term follow-up 6.17%, 95% CI 0.14 to 12.20; 2 studies). Evidence from one small but potentially biased study (60 participants) showed that neurostimulation, an electrotherapy modality, may be beneficial in the short-term. There was little and inconclusive evidence on what type of support or immobilisation was the best. One study found no immobilisation improved ankle dorsiflexion and plantarflexion range of motion compared with cast immobilisation, but another showed using a backslab improved ankle dorsiflexion range of motion compared with using a bandage.Five studies investigated different rehabilitation interventions following the immobilisation period after either conservative or surgical orthopaedic management. There was no evidence of effect for stretching or manual therapy in addition to exercise, or exercise compared with usual care. One small study (14 participants) at a high risk of bias found reduced ankle swelling after non-thermal compared with thermal pulsed shortwave diathermy.

AUTHORS' CONCLUSIONS

There is limited evidence supporting early commencement of weight-bearing and the use of a removable type of immobilisation to allow exercise during the immobilisation period after surgical fixation. Because of the potential increased risk of adverse events, the patient's ability to comply with the use of a removable type of immobilisation to enable controlled exercise is essential. There is little evidence for rehabilitation interventions during the immobilisation period after conservative orthopaedic management and no evidence for stretching, manual therapy or exercise compared to usual care following the immobilisation period. Small, single studies showed that some electrotherapy modalities may be beneficial. More clinical trials that are well-designed and adequately-powered are required to strengthen current evidence.