Perspectives of emergency department clinicians on the challenges of addressing low back pain in the emergency setting: A qualitative study

Emergency department physiotherapists: consideration of perceived barriers and facilitators to help optimise their role in the Australian emergency department

QUESTIONS

What are the current barriers and facilitators to the role of ED physiotherapists? How do ED physiotherapists believe their role may be optimised within the context of the ED?

DESIGN

Mixed methods study using a cross sectional survey.

PARTICIPANTS

Australian physiotherapists currently providing services to patients within an Australian emergency department.

INTERVENTION

N/A.

OUTCOME MEASURES

The survey included questions related to the level of integration of ED physiotherapy into emergency department teams and wider health system, and open answer questions to identify the factors which impact and influence ED physiotherapy practice, and the future of ED physiotherapy.

RESULTS

1 - Organisational culture, 2 - training and credentialling, 3 - governance, legislation and policies, 4 - funding, and 5 - advocacy and research were the five major themes generated from participant comments on existing facilitators and barriers to their role and the role of ED physiotherapists nationally. Six themes were generated from participant comments regarding the strategies to overcome barriers and facilitate an increased contribution by ED physiotherapists in the future: 1 - Training opportunities and specialisation pathways, 2 - Organisational culture, 3 - Governance, legislation and policies, 4 - Funding, 5 - Advocacy, 6 - Medicolegal Risks.

CONCLUSION

Australian emergency department physiotherapists perceive their roles and emergency physiotherapy service provision to be impacted by complex and multi-factorial influences. The overall contribution of ED physiotherapy is susceptible to influence from non-linear interactions of various agents and factors which span all levels of the health system.

TRIAL REGISTRATION

N/A.

Interventions to improve the quality of low back pain care in emergency departments: a systematic review and meta-analysis

Low back pain (LBP) is a common reason people visit Emergency Departments (ED). However, the care provided is often not aligned with guideline recommendations. Despite increasing research aiming to promote guideline-based care in EDs, interventions to best implement recommendations are unknown. This study aimed to identify ED LBP implementation interventions that have been trialed and evaluate their effects on ED-relevant outcomes. A systematic review and meta-analysis, including studies that evaluated interventions to improve the quality of care provided to adults presenting to ED with LBP. Databases searched until May 2023 were Cochrane Library, CINAHL, EMBASE (via OVID), and PEDro. Interventions were categorized according to whether they had a patient, clinician, health service, or multiple-level focus. Where possible, meta-analysis was undertaken. Certainty around the results was assessed using the GRADE criteria. Twenty-eight studies were included. Interventions were categorized as patient (n = 2), clinician (n = 8), health service (n = 12), or multiple-level (n = 6) targeted. Overall, interventions successfully reduced the likelihood of receiving an opioid in ED (OR 0.65; 95% CI 0.55-0.75). However, no significant effect on lumbar imaging was demonstrated (OR 0.85; 95% CI 0.64-1.12). Subgroup analyses showed that studies reporting high baseline imaging rates ≥ 36% and those that included systems-based changes significantly reduced imaging (OR 0.60; 95% CI 0.39-0.93; and OR 0.65; 95% CI 0.45-0.94, respectively). A small reduction in ED length of stay was observed in the group exposed to the LBP interventions (mean difference - 0.38 h; 95% CI - 0.58 to - 0.17). Overall, certainty of evidence was deemed low to very low. Interventions were mostly single-system focused with a preference for education-based implementation strategies targeting patients or clinicians. The interventions reduced the use of opioid medication for LBP in ED, but the effects on lumbar imaging rates were uncertain. Further high-quality research is needed to improve LBP care in this setting.

Utilisation and experience of emergency medical services by patients with back pain: A scoping review

BACKGROUND

Back pain is recognised as a common reason for people to access emergency medical services (EMS). EMS focus on identifying and treating serious and life-threatening conditions. Back pain frequently has a non-specific cause, however back pain is also a symptom for potentially serious pathology best suited for management by EMS.

OBJECTIVES

This scoping review explores how and why patients with back pain access EMS, the care provided, and patients' and clinicians' perceptions of EMS.

METHODS

The established methodology advocated by the Joanna Briggs Institute was followed. Literature was identified via a comprehensive search of six databases as well as grey literature searching. Data was extracted to form a narrative review supported by summary tables and figures.

RESULTS

The review included 144 papers across the last 36 years, with half the papers published since 2018, the majority from the USA and Australia. Rates of back pain presentation range from 1 to 9% depending on the definition used, with the rate of serious pathology higher than in primary care. Patients present due to concerns about their condition, positive perceptions of the care provided by EMS and difficulty in accessing primary care. Imaging and opioids are widely used, blood markers may aid diagnosis of serious pathology, whilst physiotherapists in Emergency Departments may support management of patients without serious pathology.

CONCLUSIONS

Back pain is a common reason for EMS presentation. Whilst non-specific back pain is the most common diagnosis further research to support the recognition and care of serious cases would be beneficial.

Adherence to recommended guidelines for low back pain presentations to an Australian emergency department: Barriers and enablers

OBJECTIVE

This study sought to evaluate the adherence to guidelines for the management of mechanical Low Back Pain within a single tertiary metropolitan Emergency Department setting. Our objectives were: METHODS: A two-stage multi-methods study design was undertaken. Stage 1 involved a retrospective chart audit of patients presenting with a diagnosis of mechanical Low Back Pain to establish documented adherence to clinical guidelines. Stage 2 explored clinicians' perspectives towards factors influencing adherence to the guidelines via a study-specific survey and follow up focus groups.

RESULTS

The audit demonstrated low adherence to the following guidelines: (i) appropriate prescription of analgesia, (ii) targeted education and advice, and (iii) attempts to mobilise. Three major themes were identified as factors influencing adherence to the guidelines: (1) clinician driven influences and factors, (2) workflow processes, and (3) patient expectations and behaviours.

CONCLUSION

There was low adherence to some published guidelines and factors influencing adherence to the guidelines were multi-factorial. Understanding the factors that influence care decisions and developing strategies to address these can improve Emergency Department management of mechanical Low Back Pain.

Process evaluation of the implementation of an evidence-based model of care for low back pain in Australian emergency departments

BACKGROUND

The Sydney Health Partners Emergency Department (SHaPED) trial targeted ED clinicians and evaluated a multifaceted strategy to implement a new model of care. The objective of this study was to investigate attitudes and experiences of ED clinicians as well as barriers and facilitators for implementation of the model of care.

DESIGN

A qualitative study.

METHODS

The EDs of three urban and one rural hospital in New South Wales, Australia participated in the trial between August and November 2018. A sample of clinicians was invited to participate in qualitative interviews via telephone and face-to-face. The data collected from the interviews were coded and grouped in themes using thematic analysis methods.

RESULTS

Non-opioid pain management strategies (i.e., patient education, simple analgesics, and heat wraps) were perceived to be the most helpful strategy for reducing opioid use by ED clinicians. However, time constraints and rotation of junior medical staff were seen as the main barriers for uptake of the model of care. Fear of missing a serious pathology and the clinicians' conviction of a need to provide something for the patient were seen as barriers to reducing lumbar imaging referrals. Other barriers to guideline endorsed care included patient's expectations and characteristics (e.g., older age and symptoms severity).

CONCLUSIONS

Improving knowledge of non-opioid pain management strategies was seen as a helpful strategy for reducing opioid use. However, clinicians also raised barriers related to the ED environment, clinicians' behaviour, and cultural aspects, which should be addressed in future implementation efforts.

Hsa_circ_0134111 promotes intervertebral disc degeneration via sponging miR-578

Intervertebral disc degeneration (IDD) is a chronic degenerative and age-dependent process characterized by aberrant apoptosis, proliferation, synthesis, and catabolism of the extracellular matrix of the nucleus pulposus (NP) cells. Recently, studies showed that circular RNAs play important roles in the development of many diseases. However, the role of circRNAs in IDD development remains unknown. We showed that circ_0134111 level was overexpressed in IDD tissue samples as compar-ed to control tissues. The upregulation of circ_0134111 was more drastic in the moderate and severe IDD cases than in those with mild IDD. In addition, we showed that interleukin-1β and tumor necrosis factor-α exposure significantly enhanced circ_0134111 expression in NP cells. Furthermore, ectopic expression of circ_0134111 induced proliferation, pro-inflammatory cytokine secretion, and ECM degradation in the NP cells. We also showed that circ_0134111 directly interacted with microRNA (miR)-578 in NP cells where elevated expression of circ_0134111 enhanced the ADAMTS-5 and MMP-9 expression. Moreover, miR-578 expression was significantly decreased in IDD patients and the miR-578 expression was negatively correlated with circ_0134111 expression in the IDD samples. Interleukin-1β and tumor necrosis factor-α exposure significantly decreased miR-578 levels in NP cells, in which ectopic miR-578 expression inhibited cell growth, pro-inflammatory cytokine expression, and ECM degradation. Finally, we showed that circ_0134111 overexpression induced the IDD-related phenotypic changes through inhibiting miR-578. These data suggested that circ_0134111 could promote the progression of IDD through enhancing aberrant NP cell growth, inflammation, and ECM degradation partly via regulating miR-578.