Translating evidence for low back pain management into a consumer-focussed resource for use in community pharmacies: a cluster-randomised controlled trial

"Listen to me, learn from me": a priority setting partnership for shaping interdisciplinary pain training to strengthen chronic pain care

ABSTRACT

What are the care-seeking priorities of people living with chronic pain and carers and how can these shape interdisciplinary workforce training to improve high-value pain care? Phase 1: Australian people living with chronic pain (n = 206; 90% female) and carers (n = 10; 40% female) described their pain care priorities (eDelphi, round 1). A coding framework was inductively derived from 842 pain care priorities (9 categories, 52 priorities), including validation; communication; multidisciplinary approaches; holistic care; partnerships; practitioner knowledge; self-management; medicines; and diagnosis. Phase 2: In eDelphi round 2, panellists (n = 170; valid responses) rated the importance (1 = less important; 9 = more important) of the represented framework. In parallel, cross-discipline health professionals (n = 267; 75% female) rated the importance of these same priorities. Applying the RAND-UCLA method (panel medians: 1-3: "not important," 4-6: "equivocal," or 7-9: "important"), "important" items were retained where the panel median score was >7 with panel agreement ≥70%, with 44 items (84.6%) retained. Specific workforce training targets included the following: empathic validation; effective, respectful, safe communication; and ensuring genuine partnerships in coplanning personalised care. Panellists and health professionals agreed or strongly agreed (95.7% and 95.2%, respectively) that this framework meaningfully reflected the importance in care seeking for pain. More than 74% of health professionals were fairly or extremely confident in their ability to support care priorities for 6 of 9 categories (66.7%). Phase 3: An interdisciplinary panel (n = 5) mapped an existing foundation-level workforce training program against the framework, identifying gaps and training targets. Recommendations were determined for framework adoption to genuinely shape, from a partnership perspective, Australian interdisciplinary pain training.

What messages predict intention to self-manage low back pain? A study of attitudes towards patient education

ABSTRACT

This observational study evaluated people's attitudes towards educational statements and tested whether this predicted intention to self-manage low back pain (LBP). People with or without LBP who were older than 18 years and fluent in written English were recruited. Participants completed an online survey asking demographic questions and questions on the presence or absence of LBP, its duration, and intensity. We assessed attitude toward educational statements and conducted linear regression analyses to investigate the relationship between attitude toward each statement and intention to self-manage. We recruited 656 participants, n = 345 (53.6%), with LBP of varying duration. On average, participants had a positive attitude toward all statements except one; participants with chronic LBP had a negative attitude toward a statement relating to the cause of LBP. The effect of attitude on intention to self-manage was dependent on whether someone had LBP and for how long. For example, increased intention to self-manage was predicted by a positive attitude toward educational statements related to staying active (β = 0.22 [CI 0.11-0.33]) in participants without pain, statements about reassurance (β = 0.33 [CI 0.16-0.49]) for participants with acute or subacute LBP, and statements about the severity of back pain (β = 0.25 [CI 0.18-0.33]) for participants with chronic LBP. We noted differences in attitude toward educational messages and individuals' intention to self-manage LBP depending on pain duration. Self-management could be encouraged with specific reassurance in people with acute or subacute LBP and education about severity in people with chronic LBP.

Implementation initiatives to improve low back pain care in Australia: a scoping review

OBJECTIVE

This scoping review aimed to comprehensively review strategies for implementation of low back pain (LBP) guidelines, policies and models of care in the Australian healthcare system.

METHODS

A literature search was conducted in MEDLINE, EMBASE, CINAHL, Amed and Web of Science to identify studies that aimed to implement or integrate evidence-based interventions/practices to improve LBP care within Australian settings.

RESULTS

Twenty-five studies met the inclusion criteria. Most studies targeted primary care settings (n = 13). Other settings included tertiary care (n = 4), community (n = 4), pharmacies (n = 3). One study targeted both primary and tertiary care settings (n = 1). Only 40% of the included studies reported an underpinning framework, model or theory. Implementation strategies most frequently used were evaluative and iterative strategies (n = 14, 56%) and train and educate stakeholders (n = 13, 52%), followed by engage consumers (n = 6, 24%), develop stakeholder relationships (n = 4, 16%), change in infrastructure (n = 4, 16%) and support clinicians (n = 3, 12%). The most common implementation outcomes considered were acceptability (n = 11, 44%) and adoption (n = 10, 40%), followed by appropriateness (n = 7, 28%), cost (n = 3, 12%), feasibility (n = 1, 4%) and fidelity (n = 1, 4%). Barriers included time constraints, funding, and teamwork availability. Facilitators included funding and collaboration between stakeholders.

CONCLUSIONS

Implementation research targeting LBP appears to be a young field, mostly focusing on training and educating stakeholders in primary care. Outcomes on sustainability and penetration of evidence-based interventions are lacking. There is a need for implementation research guided by established frameworks that consider interrelationships between organisational and system contexts beyond the clinician-patient dyad.

Advice and education provide small short-term improvements in pain and disability in people with non-specific spinal pain: a systematic review

QUESTIONS

What is the effect of advice/education compared with placebo or no advice/education on pain and disability in people with non-specific spinal pain? To what extent do characteristics of the patients, trial or intervention modify the estimate of the treatment effects?

DESIGN

A systematic review with meta-analyses of randomised controlled trials.

PARTICIPANTS

Adults with non-specific back and/or neck pain with or without radiating leg/arm pain of any duration were included. Trials recruiting pregnant women or surgical patients in the immediate postoperative phase were ineligible.

INTERVENTION

Advice or education.

OUTCOME MEASURES

The primary outcomes were self-reported pain and disability, and the secondary outcome was adverse events. The following potential effect modifiers were examined: risk of bias, duration of pain, location of pain, intensity of intervention and mode of intervention.

RESULTS

Twenty-seven trials involving 7,006 participants were included. Eighteen of the included trials were assessed as being at low risk of bias (≥ 6 on the PEDro scale). There was low-quality evidence that advice had a small effect on pain (MD -8.2, 95% CI -12.5 to -3.9, n = 2,241) and moderate-quality evidence that advice had a small effect on disability (MD -4.5, 95% CI -7.9 to -1.0, n = 2,579) compared with no advice or placebo advice in the short-term. None of the items that were assessed modified the treatment effects.

CONCLUSION

Advice provides short-term improvements in pain and disability in non-specific spinal pain, but the effects are small and may be insufficient as the sole treatment for patients with spinal pain.

REGISTRATION

PROSPERO CRD42020162008.

A systematic review of community pharmacy initiatives to improve treatment of depression and pain: Focus on types of programs and patient-reported outcomes

INTRODUCTION

Depression and pain are common, disabling, mutually exacerbating conditions. Many patients living with these conditions present to community pharmacies on a regular schedule to purchase both prescribed and over-the-counter medications. Community-pharmacy based programs have been developed to improve depression and pain outcomes.

METHODS

The PRISMA guidelines were utilized to answer the following question: In patients with depression and/or pain, what is the effect of the existing community pharmacy programs on depression and/or pain outcomes. Queried databases included Pubmed, EMBASE, and PsychINFO. DistillerSR was used to organize the screening, abstraction, and review of data. All potential articles were evaluated by two authors, and conflicts were discussed to achieve resolution. In addition to primary outcomes, sources of potential bias and quality indicators were abstracted for every article.

RESULTS

Three thousand nine hundred and twenty articles were reviewed, and 13 studies met eligibility criteria (n = 7 for depression; n = 6 for pain). Most studies demonstrated improvement in measures of depression or pain. However, compared to usual care or other control conditions, most of the depression and pain-specific interventions did not provide additional symptomatic benefit. The community pharmacy-based interventions were superior for other outcomes including medication adherence, reducing stigma, improvement in self-efficacy, and improvement in general management of disease.

CONCLUSION

Community pharmacies may be uniquely positioned to deliver interventions that improve outcomes associated with successful depression and pain treatment outcomes. However, the benefits of published community pharmacy-based treatments for actually improving depression and pain severity has not yet been established. Innovative interventions and additional research may be needed to achieve clinical success for pharmacy interventions for depression and pain.

Patient education materials for non-specific low back pain and sciatica: a protocol for a systematic review and meta-analysis

INTRODUCTION

Low back pain accounts for more disability than any other musculoskeletal condition and is associated with severe economic burden. Patients commonly present with negative beliefs about low back pain and this can have detrimental effects on their health outcomes. Providing evidence-based, patient-centred education that meets patient needs could help address these negative beliefs and alleviate the substantial low back pain burden. The primary aim of this review is to investigate the effectiveness of patient education materials on immediate process, clinical and health system outcomes.

METHODS AND ANALYSIS

The search strategy was developed in collaboration with a librarian and systematic searches will be performed in MEDLINE, EMBASE, CINAHL, PsycINFO and SPORTDiscus. We will also search trial registries and grey literature through the OpenGrey database. Study selection will include a title and abstract scan and full-text review by two authors. Only randomised controlled trials will be included in this review. Trials must include patients with low back pain or sciatica and investigate educational interventions with at least one of the following contrasts: (1) education alone versus no intervention; (2) education alone versus another intervention; (3) education in addition to another intervention versus the same intervention with no education. Data extraction, risk of bias and grading of the quality of evidence will be performed independently by two reviewers. Risk of bias will be assessed using the PEDro scale, and the quality of evidence will be assessed with the Grades of Recommendation, Assessment, Development and Evaluation approach. A random-effects model will be used for each contrast, and results will be pooled if the participants, interventions, and outcomes are homogeneous. If heterogeneity is high (I2 >75%), we will evaluate the magnitude and direction of the differences in effect sizes across studies to determine if it remains reasonable to pool the results. Analyses of acute and subacute low back pain (less than 12 weeks duration) will be performed separately from chronic low back pain (12 weeks or greater duration). Likewise, analyses of short-term (less than 6 months) and long-term (6 months or greater) follow-up will be performed separately. Subgroup analyses will be performed on non-specific low back pain, sciatica and mixed populations.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review. This study, along with its results, will be published in a peer-reviewed journal.

Community Pharmacist's Role in Detecting Low Back Pain, and Patient Attitudes-A Cross-Sectional Observational Study in Italian Community Pharmacies

BACKGROUND

Low back pain (LBP) is one of the most frequent diseases for which patients seek advice in a community pharmacy. The study aimed to evaluate the feasibility of the administration by community pharmacists of questionnaires to assess the LBP intensity and disability degree in patients entering community pharmacies and the attitudes they have toward pain management by pharmacological and non-pharmacological strategies.

METHODS

An explorative, cross-sectional, observational, and quantitative study was performed. Twelve Italian community pharmacists were asked to submit a questionnaire on LBP to patients visiting their pharmacies. The questionnaire included a pain intensity scale, and two validated tools: the Roland and Morris Disability Questionnaire (RMDQ) and the Start Back Screening Tool (SBST) to determine the degree and risk of patient disability, respectively.

RESULTS

872 patients filled out the questionnaires in 6 months. No statistical differences between genders (p > 0.30) were recorded for pain intensity (Female: median score 6, IQR 4-7; Male: median scores 5, IQR 4-7; p > 0.30) and disability associated with LBP (RMDQ high-disability level: Females, 14.7%, Males, 15.0%; p > 0.90). Most of the patients (69%) reported a low degree of disability, but the risk of disability was medium and high in 36% and 18% of them, respectively (p < 0.05). About 14% of patients declare to never seek for physician's advice despite their medium-high degree of disability.

CONCLUSION

The study demonstrated the feasibility of validated tools for assessing the degree and risk of disability in LBP patients administrable in community pharmacies. Moreover, the community pharmacy resulted in an important care portal for patients suffering from moderate LBP and for intercepting patients who suffered from severe LBP but had never reported their problem to their physician.

The Relationship Between Fear-avoidance Beliefs in Employees with Chronic Musculoskeletal Pain and Work Productivity: A Longitudinal Study

This study aimed to identify risk factors for chronic musculoskeletal pain (CMSP) and sought to examine the effect of fear-avoidance beliefs (FABs) on work productivity in workers with CMSP. We performed a longitudinal study using self-administered questionnaires given to employees in three different industries between April 2016 and March 2017. The questionnaire concerned background characteristics, work-related factors and musculoskeletal pain, the Work Functioning Impairment Scale (WFun), and the Japanese version of the Tampa Scale for Kinesiophobia (TSK-J). We performed logistic regression analysis to evaluate factors affecting CMSP and a multi-way analysis of variance to analyze the relationship between FABs and CMSP and the effect of FABs on the ability to function at work. Age (odds ratio [OR] = 1.02, 95% confidence interval [CI]: 1.00-1.03), mean working hours (OR = 1.18, 95% CI: 1.04-1.33), and changes in working hours (OR = 1.18, 95% CI: 1.02-1.37) were significantly associated with CMSP. Regarding FABs, we found that the stronger the FAB, the greater the WFun score, and that an increase in FABs resulted in a significant increase in WFun scores. This study demonstrated that long or increased working hours may be risk factors for CMSP, and that stronger FABs in those with CMSP are associated with decreased ability to function at work. In addition, measures to reduce FABs in workers with CMSP may be effective.

Community pharmacy interventions for health promotion: effects on professional practice and health outcomes

BACKGROUND

Community pharmacies are an easily accessible and cost-effective platform for delivering health care worldwide, and the range of services provided has undergone rapid expansion in recent years. Thus, in addition to dispensing medication, pharmacy workers within community pharmacies now give advice on a range of health-promoting behaviours that aim to improve health and to optimise the management of long-term conditions. However, it remains uncertain whether these health-promotion interventions can change the professional practice of pharmacy workers, improve health behaviours and outcomes for pharmacy users and have the potential to address health inequalities.

OBJECTIVES

To assess the effectiveness and safety of health-promotion interventions to change community pharmacy workers' professional practice and improve outcomes for users of community pharmacies.

SEARCH METHODS

We searched MEDLINE, Embase, CENTRAL, six other databases and two trials registers to 6 February 2018. We also conducted reference checking, citation searches and contacted study authors to identify any additional studies.

SELECTION CRITERIA

We included randomised trials of health-promotion interventions in community pharmacies targeted at, or delivered by, pharmacy workers that aimed to improve the health-related behaviour of people attending the pharmacy compared to no treatment, or usual treatment received in the community pharmacy. We excluded interventions where there was no interaction between pharmacy workers and pharmacy users, and those that focused on medication use only.

DATA COLLECTION AND ANALYSIS

We used standard procedures recommended by Cochrane and the Effective Practice and Organisation of Care review group for both data collection and analysis. We compared intervention to no intervention or to usual treatment using standardised mean differences (SMD) and 95% confidence intervals (95% CI) (higher scores represent better outcomes for pharmacy user health-related behaviour and quality of life, and lower scores represent better outcomes for clinical outcomes, costs and adverse events). Interpretation of effect sizes (SMD) was in line with Cochrane recommendations.

MAIN RESULTS

We included 57 randomised trials with 16,220 participants, described in 83 reports. Forty-nine studies were conducted in high-income countries, and eight in middle-income countries. We found no studies that had been conducted in low-income countries. Most interventions were educational, or incorporated skills training. Interventions were directed at pharmacy workers (n = 8), pharmacy users (n = 13), or both (n = 36). The clinical areas most frequently studied were diabetes, hypertension, asthma, and modification of cardiovascular risk. Duration of follow-up of interventions was often unclear. Only five studies gave details about the theoretical basis for the intervention, and studies did not provide sufficient data to comment on health inequalities. The most common sources of bias were lack of protection against contamination - mainly in individually randomised studies - and inadequate blinding of participants. The certainty of the evidence for all outcomes was moderate. We downgraded the certainty because of the heterogeneity across studies and evidence of potential publication bias. Professional practice outcomes We conducted a narrative analysis for pharmacy worker behaviour due to high heterogeneity in the results. Health-promotion interventions probably improve pharmacy workers' behaviour (2944 participants; 9 studies; moderate-certainty evidence) when compared to no intervention. These studies typically assessed behaviour using a simulated patient (mystery shopper) methodology. Pharmacy user outcomes Health-promotion interventions probably lead to a slight improvement in health-related behaviours of pharmacy users when compared to usual treatment (SMD 0.43, 95% CI 0.14 to 0.72; I² = 89%; 10 trials; 2138 participants; moderate-certainty evidence). These interventions probably also lead to a slight improvement in intermediate clinical outcomes, such as levels of cholesterol or glycated haemoglobin, for pharmacy users (SMD -0.43, 95% CI -0.65 to -0.21; I² = 90%; 20 trials; 3971 participants; moderate-certainty evidence). We identified no studies that evaluated the impact of health-promotion interventions on event-based clinical outcomes, such as stroke or myocardial infarction, or the psychological well-being of pharmacy users. Health-promotion interventions probably lead to a slight improvement in quality of life for pharmacy users (SMD 0.29, 95% CI 0.08 to 0.50; I²= 82%; 10 trials, 2687 participants; moderate-certainty evidence). Adverse events No studies reported adverse events for either pharmacy workers or pharmacy users. Costs We found that health-promotion interventions are likely to be cost-effective, based on moderate-certainty evidence from five of seven studies that reported an economic evaluation.

AUTHORS' CONCLUSIONS

Health-promotion interventions in the community pharmacy context probably improve pharmacy workers' behaviour and probably have a slight beneficial effect on health-related behaviour, intermediate clinical outcomes, and quality of life for pharmacy users. Such interventions are likely to be cost-effective and the effects are seen across a range of clinical conditions and health-related behaviours. Nevertheless the magnitude of the effects varies between conditions, and more effective interventions might be developed if greater consideration were given to the theoretical basis of the intervention and mechanisms for effecting behaviour change.

People with low back pain want clear, consistent and personalised information on prognosis, treatment options and self-management strategies: a systematic review

QUESTION

What health information needs are perceived by people with low back pain?

DESIGN

Systematic review of publications examining perceived health information needs related to low back pain identified through Medline, EMBASE, CINAHL and PsycINFO (1990 to 2018).

PARTICIPANTS

Adults with low back pain of any duration.

DATA EXTRACTION AND ANALYSIS

Two reviewers independently extracted descriptive data regarding study design and methodology, and assessed risk of bias. Aggregated findings of the perceived needs of people with low back pain regarding health information were meta-synthesised.

RESULTS

Forty-one studies (34 qualitative, four quantitative and three mixed-methods) were identified. Two major areas of perceived health information needs for low back pain emerged. The first major area was needs related to information content: general information related to low back pain, its cause and underlying pathology; strong desire for diagnosis and imaging; prognosis, future disability and effect on work capacity; precipitants and management of flares; general management approaches; self-management strategies; prevention; and support services. The second major area of needs related to how the information was delivered. People with low back pain wanted clear, consistent information delivered in suitable tone and understandable language.

CONCLUSION

Available data suggest that the information needs of people with low back pain are centred around their desire for a diagnosis, potentially contributing to expectations for and overuse of imaging. People with low back pain expressed a strong desire for clear, consistent and personalised information on prognosis, treatment options and self-management strategies, related to healthcare and occupational issues. To correct unhelpful beliefs and optimise delivery of evidence-based therapy, patient and healthcare professional education (potentially by an integrated public health approach) may be warranted.

How best to use and evaluate Patient Information Leaflets given during a consultation: a systematic review of literature reviews

BACKGROUND

In the past, several authors have attempted to review randomized clinical trials (RCT) evaluating the impact of Patient Information Leaflets (PILs) used during a consultation and draw some general conclusions. However, this proved difficult because the clinical situations, size and quality of RCTs were too heterogeneous to pool relevant data.

OBJECTIVE

To overcome this 30-year stalemate, we performed a review of reviews and propose general recommendations and suggestions for improving the quality of PILs, how to use them and methods for evaluating them.

METHODOLOGY

We searched five databases for reviews, systematic reviews and meta-analyses describing PILs. We drew general and condition-linked conclusions concerning the impact of PILs. Checklists summarize criteria for quality PILs, and ways of using and evaluating them.

RESULTS

Of 986 articles found, 24 reviews were pertinent; the five oldest considered the impact of PILs irrespective of the condition the patient consulted for; the 19 more recent ones mostly addressed precise clinical situations.

DISCUSSION

Whatever the clinical situation, PILs improve patients' knowledge and satisfaction. For acute conditions, in the short-term PILs also improve adherence to treatment. For chronic diseases, invasive procedures or screening situations, their impact on adherence varies depending on the context, how the PILs are given and the invasiveness of the intervention.

CONCLUSION

PILs are considered to be very useful, especially for acute conditions where the patient is the first to suffer from lack of information. We propose checklists for writing, designing, using and evaluating PILs in RCTs to enable comparisons between different studies.

Bone marrow adipocytes

Adipocytes were identified in human bone marrow more than a century ago, yet until recently little has been known about their origin, development, function or interactions with other cells in the bone marrow. Little functional significance has been attributed to these cells, a paradigm that still persists today. However, we now know that marrow adipose tissue increases with age and in response to a variety of physiologic induction signals. Bone marrow adipocytes have recently been shown to influence other cell populations within the marrow and can affect whole body metabolism by the secretion of a defined set of adipokines. Recent research shows that marrow adipocytes are distinct from white, brown and beige adipocytes, indicating that the bone marrow is a distinct adipose depot. This review will highlight recent data regarding these areas and the interactions of marrow adipose tissue (MAT) with cells within and outside of the bone marrow.

Guidance on how to achieve comprehensible patient information leaflets in four steps

Comprehensible information leaflets can improve a patient's knowledge. However, in clinical studies leaflets are often introduced without meticulously verifying their comprehensibility. In an attempt to provide a feasible guidance on how to design comprehensible leaflets we complied and evaluated an easy-to-use development procedure. In January 2015, a literature search was performed to identify evidence for readily available quality assurance strategies as a starting point for a standardized strategy to develop and validate written patient information. The suggested development strategy is a consecutive four-step procedure that comprised already validated distinct quality assessments: (i) an initial requirement analysis specifying the needs and constraints of the target population and evidence-based preparation of the leaflets, (ii) a readability assessment, (iii) the Suitability Assessment of Materials instrument and (iv) iterative consumer test in the target population. The consecutive combination of pertinent and previously validated quality assessments provides an easy-to-use guidance on how to create comprehensibly written patient information, particularly for small-scale research projects with time and money constraints.

Persistent musculoskeletal pain and productive employment; a systematic review of interventions

A systematic analysis of the literature was undertaken to determine which characteristics of workplace interventions are most effective in assisting people with persistent musculoskeletal pain (PMP) to remain productively employed. Databases of Medline, PsychINFO, CINAHL and Embase were searched using MeSH and other relevant terms. Studies that reported on interventions at, or involving, the workplace were included. Interventions were considered as either focused on the individual or multilevel. Outcome measures assessed included: job loss, productivity, sick leave, pain and cost benefit. A quality assessment was undertaken using GRADE criteria with development of impact statements to synthesise the results. Eighteen relevant articles (14 studies) were identified for inclusion in the review. No high-level evidence for workplace interventions to assist people with PMP were identified. Low numbers of participants and limited studies resulted in downgrading of evidence. However, individually focused interventions will probably reduce job loss and sick leave, but are unlikely to reduce pain. Multilevel focused interventions will probably result in decreased sick leave and provide some cost benefit. The evidence on productivity was limited and of poor quality. Further research is required because sustainable employment for individuals with PMP is important and understanding what works is necessary to ensure effective workplace interventions are developed.

The Relationship Between Pain Beliefs and Coping with Pain of Algology Patients'

A patient's beliefs, expectations, and attitudes about coping with pain are effective on the patient's pain control. The aim of this investigation was to evaluate the correlation between pain beliefs and coping with pain in algology patients. This descriptive study was carried out with 201 patients at a University Hospital Algology Clinic between May and July 2014. The research instruments used included a Descriptive Characteristics Data Form, Pain Beliefs Questionnaire, and Pain Coping Questionnaire. Data were evaluated by descriptive statistical methods, Spearman's correlation, and the Mann-Whitney U and Kruskal-Wallis tests. According to the findings, the duration of pain in the patients ranged from 1 month to 40 years, with a mean duration of 68.37 ± 89.42 months. Patients' organic beliefs mean score was 3.97 ± 0.78 and the psychological beliefs mean score was 5.01 ± 1.01. There was a significant negative correlation between patients' organic beliefs score and the self-management (p < .001, r = -.388) and conscious cognitive interventions scores (p < .001, r = -.331); with the helplessness score (p < .001, r = .365) there was a positive correlation. There was also a positive correlation between patients' psychological beliefs score and self-management score (p < .05, r = .162). Moreover, there is significant difference between organic beliefs score and patients who use opioid analgesic. Patients who believe that their pain's origin is a organic cause, such as damage and harm in the body, cannot cope with pain and feel more helplessness. Appropriate nursing interventions for individuals' pain beliefs should be implemented to nursing care plans on pain management.

Adipose Tissue Residing Progenitors (Adipocyte Lineage Progenitors and Adipose Derived Stem Cells (ADSC)

The formation of brown, white and beige adipocytes have been a subject of intense scientific interest in recent years due to the growing obesity epidemic in the United States and around the world. This interest has led to the identification and characterization of specific tissue resident progenitor cells that give rise to each adipocyte population in vivo. However, much still remains to be discovered about each progenitor population in terms of their "niche" within each tissue and how they are regulated at the cellular and molecular level during healthy and diseased states. While our knowledge of brown, white and beige adipose tissue is rapidly increasing, little is still known about marrow adipose tissue and its progenitor despite recent studies demonstrating possible roles for marrow adipose tissue in regulating the hematopoietic space and systemic metabolism at large. This chapter focuses on our current knowledge of brown, white, beige and marrow adipose tissue with a specific focus on the formation of each tissue from tissue resident progenitor cells.

Models of care for musculoskeletal health in Australia: now more than ever to drive evidence into health policy and practice

Musculoskeletal health conditions such as arthritis, osteoporosis and pain syndromes impart a profound socioeconomic burden worldwide, particularly in developed nations such as Australia. Despite the identified burden, substantial evidence-practice and care disparity gaps remain in service delivery and access that limit the potential for improved consumer outcomes and system efficiencies. Addressing these gaps requires a whole-of-sector response, supported by evidence-informed health policy. Models of care (MoCs) serve as a policy vehicle to embed evidence into health policy and guide practice through changes in service delivery systems and clinician behaviour. In Australia, MoCs for musculoskeletal health have been developed by networks of multidisciplinary stakeholders and are incrementally being implemented across health services, facilitated by dedicated policy units and clinical champions. A web of evidence is now emerging to support this approach to driving evidence into health policy and practice. Understanding the vernacular of MoCs and the development and implementation of MoCs is important to embracing this approach to health policy. What is known about the topic? The impact of musculoskeletal health conditions is profound. As the awareness around the magnitude of the impact of these conditions increases, the importance of system-wide policy responses and platforms for health service improvements is now recognised. The term ‘models of care’ is not new. It has been used for many years, mainly at the hospital level, for planning and delivering clinical services. However, over the past 8 years an alternative approach using health networks has been adopted for the development and implementation of models of care to achieve broad engagement and a wider and more sustainable scope for implementation. What does this paper add? Here, we provide a rationale for the development of models of care for musculoskeletal health and draw on experience in their development and implementation using a health network model, referring to an emerging web of evidence to support this approach. We describe what models of care are, how they are developed and question whether they make a difference and what the future may hold. What are the implications for practitioners? All indications suggest that models of care are here to stay. Therefore, this paper provides practitioners with a contemporary overview of models of care in Australia, their relevance to musculoskeletal healthcare, particularly related to closing evidence-practice gaps, and opportunities for sector engagement.