Opportunities to improve asthma and COPD prevention and care: insights from the patient journey obtained through focus groups

BACKGROUND

The healthcare experiences of patients hold valuable insights for improving the quality of services related to their well-being. We therefore invited and explored the perspectives of patients living with asthma and chronic obstructive pulmonary disease (COPD) on their interaction with the systems supporting health, in order to identify opportunities to improve services to prevent, treat and manage these conditions.

METHODS

Two virtual focus groups were held in August 2021, one for adult asthma and one for COPD, to learn of patients' experiences receiving care for these conditions in the Vancouver Coastal Health (VCH) region of British Columbia. Participants were recruited through online postings or their clinician. We discussed the care pathway for each condition and invited participants to share their experiences of the past 5 years, specifically their reflections on the process, including feelings, points of praise and frustration, and opportunities for improvement in this context. Composite patient journey maps were developed for each condition to reflect the experiences shared. Audio recordings of the focus groups were transcribed and used in qualitative data analysis.

RESULTS

Thematic analysis revealed the following as possible areas for improvement: low public awareness of asthma and COPD and associated risk factors, non-standardised diagnosis pathways that delay diagnosis, and inconsistency in delivering valued aspects of care such as supports for self-management, trust-inspiring acute care, empowering patient communication and timely access to care.

CONCLUSION

We successfully used focus groups to generate composite journey maps of the experiences of patients living with asthma (n=8) and COPD (n=9) to identify features that these patients consider important for improving the healthcare system for asthma and COPD in VCH. Health professionals, decision makers and patient advocates in VCH and beyond can consider these insights when evaluating, and planning changes to, current practices and policies in service delivery.

Relational practices for meaningful inclusion in health research: Results of a deliberative dialogue study

INTRODUCTION

The importance of including people affected by research (e.g., community members, citizens or patient partners) is increasingly recognized across the breadth of institutions involved in connecting research with action. Yet, the increasing rhetoric of inclusion remains situated in research systems that tend to reward traditional dissemination and uphold power dynamics in ways that centre particular (privileged) voices over others. In research explicitly interested in doing research with those most affected by the issue or outcomes, research teams need to know how to advance meaningful inclusion. This study focused on listening to voices often excluded from research processes to understand what meaningful inclusion looks and feels like, and asked what contributes to being or feeling tokenized.

METHODS

In this deliberative dialogue study, 16 participants with experience of navigating social exclusions and contributing to research activities reflected on what makes for meaningful experiences of inclusion. Using a co-production approach, with a diversely representative research team of 15 that included patient and community partners, we used critically reflective dialogue to guide an inclusive process to study design and implementation, from conceptualization of research questions through to writing.

RESULTS

We heard that: research practices, partnerships and systems all contribute to experiences of inclusion or exclusion; the insufficiency or absence of standards for accountability amplifies the experience of exclusion; and inclusive practices require intention, planning, reflection and resources.

CONCLUSIONS

We offer evidence-informed recommendations for the deeply relational work and practices for inclusivity, focused on promising practices for cultivating welcoming systems, spaces and relationships.

PATIENT OR PUBLIC CONTRIBUTION

This work reflects a co-production approach, where people who use and are affected by research results actively partnered in the research process, including study design, data-generating activities, analysis and interpretation, and writing. Several of these partners are authors of this manuscript.

Decisional needs assessment for patient-centred pain care in Canada: the DECIDE-PAIN study protocol

INTRODUCTION

The 2021 Action Plan for Pain from the Canadian Pain Task Force advocates for patient-centred pain care at all levels of healthcare across provinces. Shared decision-making is the crux of patient-centred care. Implementing the action plan will require innovative shared decision-making interventions, specifically following the disruption of chronic pain care during the COVID-19 pandemic. The first step in this endeavour is to assess current decisional needs (ie, decisions most important to them) of Canadians with chronic pain across their care pathways.

METHODS AND ANALYSIS

DesignGrounded in patient-oriented research approaches, we will perform an online population-based survey across the ten Canadian provinces. We will report methods and data following the CROSS reporting guidelines.SamplingThe Léger Marketing company will administer the online population-based survey to its representative panel of 500 000 Canadians to recruit 1646 adults (age ≥18 years old) with chronic pain according to the definition by the International Association for the Study of Pain (eg, pain ≥12 weeks). ContentBased on the Ottawa Decision Support Framework, the self-administered survey has been codesigned with patients and contain six core domains: (1) healthcare services, consultation and postpandemic needs, (2) difficult decisions experienced, (3) decisional conflict, (4) decisional regret, (5) decisional needs and (6) sociodemographic characteristics. We will use several strategies such as random sampling to improve survey quality. AnalysisWe will perform descriptive statistical analysis. We will identify factors associated with clinically significant decisional conflict and decision regret using multivariate analyses.

ETHICS AND DISSEMINATION

Ethics was approved by the Research Ethics Board at the Research Centre of the Centre Hospitalier Universitaire de Sherbrooke (project #2022-4645). We will codesign knowledge mobilisation products with research patient partners (eg, graphical summaries and videos). Results will be disseminated via peer-reviewed journals and national and international conferences to inform the development of innovative shared decision-making interventions for Canadians with chronic pain.

Partnering with people living with rheumatoid arthritis for care of their hands: Four case reports using relative motion orthoses

STUDY DESIGN

Case report.

INTRODUCTION

Despite better disease control with more effective medications, people with rheumatoid arthritis (RA) continue to experience persistent and fluctuating levels of pain, swelling and functional limitations in their hands.

PURPOSE

To describe therapists and people living with RA working together to understand what could be occurring in their hands because of the RA and how relative motion (RM) orthoses may be used to self-manage common hand RA related problems.

METHODS

Case reports are used to demonstrate how patient self-report, clinical exam, and observation of hand movement and function are integrated into the design of RM orthoses for individuals with RA. The cases are supported by photos and videos, including a personal narrative video exploring 1 persons' personal perspective on their use of RM orthoses.

RESULTS

Case reports illustrate adaptive and/or protective RME orthoses use for RA related finger malalignment, tendon subluxation, joint pain and instability in the hand. The narrative video also introduces a person living with RA, who speaks candidly about her multiple RM orthoses and how she decides which orthosis is "best" for a given activity and the current level of RA related problems in her hands.

DISCUSSION

It is not unusual for individuals with RA to have multiple RM orthoses, made for different purposes and fabricated from different materials. Mulitple RM orthosis options allows a person to select what is "best" for them, depending on the context of use and priorities or needs.

CONCLUSION

Partnering with people living with RA to understand how to use simple, low-profile, adaptive and protective RM orthoses may be an effective way to support self-management of common RA related hand problems.

OP0248 SEVERE COVID-19 OUTCOMES AMONG PATIENTS WITH AUTOIMMUNE RHEUMATIC DISEASES: A POPULATION-BASED STUDY

Background

Individuals with autoimmune rheumatic diseases (ARDs) may be at greater risk of severe COVID-19 outcomes than individuals in the general population.

Objectives

This study assesses the risk of COVID-19-related hospitalization, intensive care unit (ICU) admission, and COVID-19-specific mortality in patients with ARDs compared to matched general population comparators.

Methods

We conducted a population-based cohort study, using administrative datasets from British Columbia, Canada (February 2020-August 2021). Among all test-positive SARS-CoV-2 adults, we used ICD codes to identify all individuals with an ARD: rheumatoid arthritis (RA), psoriasis/psoriatic arthritis (PsO/PsA), ankylosing spondylitis (AS), and systemic autoimmune rheumatic diseases (SARDs), including systemic lupus erythematosus (SLE), Sjogren’s syndrome, systemic sclerosis, myositis, and adult systemic vasculitides. Individuals with an ARD were matched 1:5 to general population test-positive SARS-CoV-2 individuals on age (± 5 years), sex, month/year of initial positive SARS-CoV-2 test, and health authority. Conditional logistic regression models adjusting for socioeconomic status, Charlson comorbidity index, hypertension, rural address, and number of previous COVID-19 PCR tests were performed to assess risk of COVID-19-related hospitalizations, ICU admissions, and COVID-19-specific mortality (mortality with primary ICD code for COVID-19).

Results

The risk of COVID-19-related hospitalization was significantly increased for patients with ARDs overall (aOR: 1.30) (Table 1). Within ARDs, the patient group at greatest risk of hospitalization was adult systemic vasculitides (aOR: 2.18). The risk of ICU admission was significantly increased for patients with ARDs overall (aOR: 1.30). Within ARDs, the patient group at greatest risk of ICU admission was those with AS (aOR: 2.03). The risk of COVID-19-specific mortality was significantly increased for patients with ARDs overall (aOR: 1.24). Within ARDs, the patient group at greatest risk of COVID-19-specific mortality was those with AS (aOR: 2.15).

Table 1.

Risk of severe COVID-19 outcomes among patients with ARDs

HospitalizationsICU admissionsCOVID-19-specific mortalityn (%)aOR (95% CI)n (%)aOR (95% CI)n (%)aOR (95% CI)ARDs (6,279)780 (12.4)1.30 (1.19, 1.43)225 (3.6)1.30 (1.11, 1.51)229 (3.7)1.24 (1.05, 1.47)ARD comparators (31,130)2,843 (9.1)1.00807 (2.6)1.00847 (2.7)1.00RA(2,067)321 (15.5)1.34 (1.15, 1.54)95 (4.6)1.30 (1.03, 1.65)103 (5.0)1.18 (0.92, 1.52)RA comparators (10,197)1,151 (11.3)1.00336 (3.3)1.00400 (3.9)1.00PsO/PsA(2,695)263 (9.8)1.17 (1.01, 1.37)65 (2.4)0.90 (0.68, 1.19)68 (2.5)0.93 (0.68, 1.26)PsO/PsA comparators (13,411)1,052 (7.8)1.00332 (2.5)1.00309 (2.3)1.00AS(529)51 (9.6)1.36 (0.95, 1.94)20 (3.8)2.03 (1.18, 3.50)13 (2.5)2.15 (1.02, 4.55)AS comparators (2,631)180 (6.8)1.0048 (1.8)1.0032 (1.2)1.00SARDs(1,118)168 (15.0)1.62 (1.32, 2.00)52 (4.7)1.74 (1.24, 2.44)49 (4.4)1.44 (1.00, 2.10)SARDs comparators (5,532)490 (8.9)1.00135 (2.4)1.00157 (2.8)1.00SLE(239)37 (15.5)1.88 (1.18, 3.00)11 (4.6)1.67 (0.75, 3.74)<50.85 (0.17, 4.29)SLE comparators (1,187)77 (6.5)1.0026 (2.2)1.0013 (1.1)1.00Sjogren’s(96)15 (15.6)2.07 (0.94, 4.58)<5*<5*Sjogren’s comparators (477)35 (7.4)1.0014 (2.9)1.0015 (3.2)1.00Myositis(30)5 (16.7)3.18 (0.69, 14.55)<5*<5*Myositis comparators (150)12 (8.0)1.00<51.007 (4.7)1.00Vasculitides(82)25 (30.5)2.18 (1.17, 4.05)8 (9.8)1.70 (0.70, 4.16)<5*Vasculitides comparators (404)64 (15.8)1.0021 (5.2)1.0016 (4.0)1.00

Results for systemic sclerosis not presented; sample size too small.

*Unable to be calculated (small sample size)

Conclusion

The risk of severe COVID-19 outcomes is increased in some ARDs, although magnitude differs across individual diseases. Strategies to mitigate risk, such as booster vaccination, prompt diagnosis, and early intervention with available therapies (e.g., oral antivirals) should be prioritized in these groups according to risk.

Acknowledgements

This work was supported by the Michael Smith Foundation for Health Research (grant COV-2020-1075) and the BC SUPPORT Unit (grant C19-PE-V3).

Disclosure of Interests

None declared

Current Practices in and Barriers to Physiotherapists’ Use of Resistance Exercise with Older Adults in Acute Care

Purpose: The purpose of this cross-sectional study was to describe physiotherapists’ current use of resistance exercise (REx) with older adults in acute care and to identify barriers to its use with this population. Methods: We developed an online questionnaire guided by the theoretical domains framework and distributed it to physiotherapists across British Columbia. We used thematic analysis to code open-text questionnaire responses. Results:One hundred five physiotherapists completed the questionnaire (78% female; mean age 39.9 [SD 10.3] years; mean years of experience 12.4 [SD 10.3]). Respondents reported frequently performing functional testing (95%) and assessing muscle strength (70%) in older adults, but few often prescribed REx (34%). The greatest barriers to use of REx that respondents identified were lack of prioritization of REx among other duties and perceived poor patient motivation. Open-text data analysis revealed that respondents felt that some patients were unable to perform REx and that physiotherapists lacked a clear definition of REx and sufficient support personnel. Conclusions: Addressing treatment priorities, patient motivation, and staffing resources can support physiotherapists in increasing REx use, an important strategy for reducing the incidence of hospital-associated deconditioning among older adults in acute care settings.

RetINal Toxicity And HydroxyChloroquine Therapy (INTACT): protocol for a prospective population-based cohort study

PURPOSE

Hydroxychloroquine (HCQ) is an important medication for patients with systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) and other rheumatic diseases. Although it is well-tolerated and cost-effective, the risk of HCQ retinal toxicity is of increasing concern. The aim of this study is to re-examine the HCQ retinal toxicity incidence rate, risk factors and clinical course after discontinuation.

METHODS

We designed a prospective population-based cohort study in adult patients with SLE or RA, currently receiving HCQ for five or more years, who are residents of British Columbia (BC), Canada. Based on administrative data, we identified 5508 eligible participants (1346 SLE and 4162 RA). They will participate in annual or biannual retinal screening over 5 years in alignment with the recently revised American Academy of Ophthalmology guidelines. To standardise procedures for retinal screening, imaging, diagnostic criteria, severity staging and data transfer, a consensus meeting was convened in December 2019 with participation of BC retinal specialists and the research team. Agreement was attained on: use of spectral domain-optical coherence tomography as the primary objective screening modality; classification of images into categories of normal, equivocal or abnormal; and transferring the equivocal and abnormal images plus corresponding subjective test results via cloud-based server from each clinic to a reading centre. Confirmation of HCQ retinal toxicity diagnoses and severity staging will be performed by three independent and masked reviewers. The incidence of HCQ retinal toxicity will be calculated, accounting for the competing risk of death. Hazard ratios for each risk factor will be calculated for the risk of HCQ retinopathy, after adjusting for confounders. We will also estimate the risk of HCQ retinal toxicity progression over 5 years.

ETHICS AND DISSEMINATION

This study has received approval from the University of British Columbia Clinical Research Ethics Board (H20-00736) and the Vancouver Coastal Health Research Institute.

POS0303 PREVENTION OF CHRONIC DISEASES DUE TO INFLAMMATION IN INFLAMMATORY ARTHRITIS: RESULTS OF A DELPHI PROCESS TO SELECT CARE RECOMMENDATIONS FOR AN ELECTRONIC MEDICAL RECORD (EMR) INTERVENTION

Background:

Inflammatory arthritis (IA) predisposes patients to several chronic conditions including cardiovascular diseases (CVD), diabetes (DM), osteoporosis (OP) and infections, likely due to systemic effects of inflammation. Studies have found that patients with IA often receive suboptimal care for screening and managing these conditions.

Objectives:

This is the first phase of a study which will develop and pilot test automated EMR reminders for family physicians. The reminders will prompt family physicians to screen for and address risk factors for these conditions. We conducted a Delphi process to select care recommendations to be addressed by the EMR reminders.

Methods:

We conducted a review of current BC, Canadian and international guidelines for screening and addressing risk factors for CVD, DM, OP and infection. A list of 22 care recommendations, including their level of evidence and risks/benefits of implementation, was reviewed by a panel of six family physicians, three rheumatologists and three IA patients, in a three-round online modified Delphi process. Panelists rated each care recommendation, using 9-point scales, on 1) their clinical importance, 2) their likelihood of improving outcomes, and 3) implementation feasibility. Results were discussed in an online forum. Panelists then rated slightly revised care recommendations, modified based on feedback from the discussion. Care recommendations were retained if the median rating was ≥7 with no disagreement as defined by the RAND/UCLA Method handbook.

Results:

A list of 15 care recommendations was selected by the Delphi process for EMR integration, including recommendations that address CVD risk assessment (1), hypertension screening (1), DM screening (2), fracture risk assessment (1), BMD testing (1), osteoporosis prevention (1) and treatment (1) with bisphosphonates, preventing infections through immunization (2), minimizing steroids (1) and hepatitis screening (1), screening for hydroxychloroquine retinal toxicity (1), and counselling for lifestyle modifications (2). We excluded 7 recommendations which addressed lipid testing (1), BMD testing in steroid users (1), immunizations (2), weight management (1), and DMARD laboratory test monitoring (2). Recommendations were excluded on the basis of importance (1) or feasibility (6).

Conclusion:

The results of the Delphi process will inform the development of reminders, integrated in EMRs, that will support family physicians in their efforts to engage IA patients in addressing risk factors for chronic diseases related to inflammation. We hope to improve the prevention of these diseases, which represent an important cause of morbidity and mortality for people with inflammatory arthritis.

Acknowledgements:

Iman Sheriff’s work on this project was funded by the CRA summer studentship programme. Dr. Lacaille is supported by the Mary Pack Chair in Arthritis Research from UBC and The Arthritis Society of Canada. Thank you to all who participated in the Delphi survey.

Disclosure of Interests:

None declared

Contrast Baths, Intramuscular Hemodynamics, and Oxygenation as Monitored by Near-Infrared Spectroscopy

CONTEXT:

Contrast baths (CB) is a thermal treatment modality used in sports medicine, athletic training, and rehabilitation settings. Proposed physiological effects of CB include increasing tissue blood flow and oxygenation and decreasing tissue swelling and edema to promote better healing, improved limb function, and quicker recovery.

OBJECTIVE:

To investigate the physiological effects of CB on the intramuscular hemodynamics and oxygenation of the lower leg muscles using near-infrared spectroscopy (NIRS), an optical method for monitoring changes in tissue oxygenated (O2Hb), deoxygenated (HHb), and total hemoglobin (tHb) as well as tissue oxygen saturation index (TSI%).

DESIGN:

Descriptive laboratory study.

PATIENTS OR OTHER PARTICIPANTS:

Ten healthy men and women with a mean age of 29 (range = 17 ± 42) years, mean body mass index of 24.6 ± 3.2, and mean adipose tissue thickness of 6.4 ± 2.2 mm.

INTERVENTION(S):

Conventional CB (10-minute baseline, 4 : 1-minute hot : cold ratio) was applied to the left lower leg.

MAIN OUTCOME MEASURE(S):

Changes in chromophore concentrations of O2Hb, HHb, tHb, and TSI% of the gastrocnemius muscle were monitored during 10 minutes of baseline measurement, a 30-minute CB protocol, and 10 minutes of recovery using a spatially resolved NIRS.

RESULTS:

After a 30-minute CB protocol, increases ( P < .05) in tissue O2Hb (7.4 ± 4 μM), tHb (7.6 ± 6.1 μM), and TSI% (3.1% ± 2.3%) were observed as compared with baseline measures.

CONCLUSIONS:

Application of CB induced a transient change in the hemodynamics and oxygenation of the gastrocnemius muscle in healthy individuals. The effect of CB application in improving tissue hemodynamics and oxygenation may, therefore, support the therapeutic benefits of CB in the treatment of muscle injuries.

The design and rationale of SAVE BC: The Study to Avoid CardioVascular Events in British Columbia

Atherosclerotic cardiovascular disease (ASCVD) is highly heritable, particularly when it occurs at a young age. The screening of individuals with premature ASCVD, although often recommended, is not routinely performed. Strategies to address this gap in care are essential. We designed the Study to Avoid CardioVascular Events in British Columbia (SAVE BC) as a prospective, observational study of individuals with a new diagnosis of very premature ASCVD (defined as age ≤ 50 years in males and age ≤ 55 years in females) and their first-degree relatives (FDRs) and spouses. FDRs and spouses will undergo screening for cardiovascular (CV) risk factors and subclinical ASCVD using a structured screening algorithm. All subjects will be followed longitudinally for ≥10 years. The overall goal of SAVE BC is to evaluate the yield of a structured screening program for identifying individuals at risk of premature ASCVD. The primary objectives of SAVE BC are to identify and follow index cases with very premature ASCVD and their FDRs and to determine the diagnostic yield of a structured screening program for these individuals. We will collect data on CV risk factors, medication use, CV events, and healthcare costs in these individuals. SAVE BC will provide insight regarding approaches to identify individuals at risk for premature ASCVD with implications for prevention and treatment in this population.

OMERACT Quality-adjusted Life-years (QALY) Working Group: Do Current QALY Measures Capture What Matters to Patients?

OBJECTIVE

To understand the limitations with current patient-reported outcome measures (PROM) used to generate quality-adjusted life-years (QALY) in rheumatology, and set a research agenda.

METHODS

Two activities were undertaken. The first was a scoping review of published studies that have used PROM to generate QALY in rheumatology between 2011 and 2016. The second was an interactive "eyeball test" exercise at Outcome Measures in Rheumatology 13 that compared subdomains of widely used generic PROM, as identified through the scoping review, to subdomains of the Assessment of SpondyloArthritis Health Index (ASAS-HI) condition-specific PROM for ankylosing spondylitis.

RESULTS

The scoping review included 39 studies. Five different PROM have been used to generate QALY in rheumatology; however, the EQ-5D and Short Form 6 Dimensions (SF-6D) were used most frequently (in 32 and 9 of included studies, respectively). Special interest group participants identified energy/drive and sleep as 2 key subdomains of the ASAS-HI instrument that may be missed by the EQ-5D, and sexual function as potentially missed by the SF-6D. Participants also expressed concerns that aspects of the process of care and non-health outcomes may be missed. Three ways of incorporating additional subdomains were discussed, including using an alternative generic PROM, modifying an existing generic PROM with "bolt-on" subdomain(s), and generating societal weights for a condition-specific PROM.

CONCLUSION

Three priorities for future research were identified: understanding whether the EQ-5D and SF-6D identify what matters to patients with different rheumatic conditions, analyzing how much patients value process or non-health outcomes, and identifying which approaches to incorporating a greater number of subdomains into the QALY are being undertaken in other disease areas.

Subcutaneous and Intramuscular Hemodynamics and Oxygenation After Cold-Spray Application as Monitored by Near-Infrared Spectroscopy

CONTEXT

Vapocoolant spray, commonly known as cold spray (CS), is a cryotherapy modality used in sports medicine, athletic training, and rehabilitation settings. Proposed physiologic effects of cryotherapy modalities include reductions in tissue blood flow, oxygenation, and cell metabolism in addition to attenuation of pain perception attributed to reduced superficial nerve conduction velocity.

OBJECTIVE

To examine the effects of CS on subcutaneous and intramuscular blood flow and oxygenation on the thigh muscle using near-infrared spectroscopy, an optical method to monitor changes in tissue oxygenated (O2Hb), deoxygenated (HHb), and total (tHb) hemoglobin.

DESIGN

Cross-sectional study.

SETTING

Muscle Biophysics Laboratory.

PATIENTS OR OTHER PARTICIPANTS

Participants were 13 healthy adults (8 men, 5 women; age = 37.4 ± 6 years, body mass index = 27.4 ± 2.6, adipose tissue thickness = 7.2 ± 1.8 mm).

INTERVENTION(S)

Conventional CS was applied to the vastus medialis muscles.

MAIN OUTCOME MEASURE(S)

Changes in chromophore concentrations of O2Hb, HHb, and tHb at superficial and deep layers were monitored for 5 minutes using a 2-channel near-infrared spectroscopy.

RESULTS

Thirty seconds after CS application, we observed a decrease from baseline in O2Hb and tHb only in the superficial layer that was maintained for 3 minutes.

CONCLUSIONS

Application of CS induced a transient change in blood flow and oxygenation of the superficial tissues with no change in deeper tissues over the healthy vastus medialis muscle. The limited physiologic effect of CS on the superficial hemodynamics and oxygenation of limb muscles may limit the therapeutic benefit of this cryotherapy modality to a temporary analgesic effect, a hypothesis that warrants a clinical trial on traumatized muscles.

A survey of physiotherapists' experience using outcome measures in total hip and knee arthroplasty

PURPOSE

To identify physiotherapists' familiarity with and experience using outcome measures (OMs) along the care continuum for patients undergoing total joint arthroplasty (TJA) of the hip and knee. Views on future use and barriers were also captured.

METHODS

A stratified random sample of physiotherapists in one Canadian province completed a questionnaire about 19 standardized and clinically feasible OMs. Analyses included descriptive statistics and chi-square and McNemar tests to compare use of OMs for clinical decision making and program evaluation.

RESULTS

Of 694 physiotherapists surveyed, 298 (43%) responded. Of these, 172 (58%) treated TJA clients and completed the full questionnaire. A majority worked in public practice settings and >1 care phase (e.g., pre-op, acute, rehab). All physiotherapists reported using ≥1 OM and having greater experience using performance-based measures than patient-reported OMs. OMs were used more often for clinical decision making than for program evaluation. Dissatisfaction with available tools was evident from respondents' comments. Several barriers to using OMs were identified in varied clinical settings and care phases.

CONCLUSIONS

While physiotherapists use a variety of OMs along the TJA continuum, there remain challenges to routine use across clinical settings, care phases, and patient sub-groups.

Sports and exercise-related tendinopathies: a review of selected topical issues by participants of the second International Scientific Tendinopathy Symposium (ISTS) Vancouver 2012

In September 2010, the first International Scientific Tendinopathy Symposium (ISTS) was held in Umeå, Sweden, to establish a forum for original scientific and clinical insights in this growing field of clinical research and practice. The second ISTS was organised by the same group and held in Vancouver, Canada, in September 2012. This symposium was preceded by a round-table meeting in which the participants engaged in focused discussions, resulting in the following overview of tendinopathy clinical and research issues. This paper is a narrative review and summary developed during and after the second ISTS. The document is designed to highlight some key issues raised at ISTS 2012, and to integrate them into a shared conceptual framework. It should be considered an update and a signposting document rather than a comprehensive review. The document is developed for use by physiotherapists, physicians, athletic trainers, massage therapists and other health professionals as well as team coaches and strength/conditioning managers involved in care of sportspeople or workers with tendinopathy.

"I think it, but don't often write it": the barriers to charting in private practice

PURPOSE

To describe barriers to charting identified by physiotherapists working in private practice in New Brunswick.

METHOD

Physiotherapists were invited to focus-group interviews to discuss the results of a comprehensive chart audit. Sixty-nine physiotherapists who responded were assigned to nine focus groups. Seven of nine audiotaped interviews (49 participants) were of sufficient quality to be transcribed and imported into qualitative data analysis software for thematic analysis.

RESULTS

Participants described the challenges of including charting in their routine client care. Barriers included the disjuncture between charting and thinking, the translation of impairment goals to functional goals, the time it takes to chart, fear of failure, and the difficulty of predicting length of treatment. Strategies to facilitate charting were suggested by participants.

CONCLUSION

Understanding barriers to charting in private practice is necessary to improve the quality of documentation. Barriers described are related to the fast-moving nonverbal, kinaesthetic, and cognitive process that is clinical reasoning in physiotherapy. This tacit, implicit process is mismatched with the charting task, which requires that the implicit become explicit in written form. Strategies to facilitate charting noted by participants address some of these issues; however, a broader, profession-wide discussion is necessary.

Physiotherapy and low back pain in the injured worker: an examination of current practice during the subacute phase of healing

PURPOSE

To describe current physiotherapy practice for injured workers with subacute low back pain (SA-LBP).

METHOD

A chart audit of discharged workers was conducted over three episodes of care: 4-6 weeks (T1), 6-8 weeks (T2), and 8-10 weeks (T3) post-injury. The prevalence and reproducibility of parameters for common interventions were calculated as the percentage of active charts over time. Focus groups were used to validate audit results and deepen our understanding of practice.

RESULTS

In all, 164 charts were audited. The most prevalent interventions were (1) for manual therapy, joint mobilization and traction; (2) for electrophysical agents (EPAs), heat, ultrasound, and interferential therapy; and (3) for exercise, core stabilization exercises. Transcript analyses revealed that participants viewed injured workers with SA-LBP in a positive light, emphasized the importance of physiotherapy, and discussed SA-LBP in five themes: time frame, non-specific diagnosis, mixed client outlook, change in pain presentation, and the transition from a passive to a more active treatment approach.

CONCLUSIONS

The pattern of decreasing passive and increasing active interventions is consistent with the focus-group participants' description of how they approach treatment of clients with SA-LBP. Also noted was a higher prevalence of interventions poorly supported by evidence and lower prevalence of interventions well supported by evidence.

An isokinetic evaluation of trunk strength in elite female field hockey players

A Kin-Corn dynamometer was used to evaluate trunk extensor and flexor strength in 11 elite female field hockey players. Average torques during maximal concentric and eccentric muscle actions through a range of movement from 25° of extension to 30° of flexion were measured at angular velocities of 30°.s(-1) and 60°.s(-1). Strength curve shape, average torque values and derived eccentric/concentric and trunk extensor/flexor ratios were analysed. The strength curves displayed greatest torques in the lengthened position for both muscle groups. Statistical analysis revealed no significant difference in strength between first and second test occasions (p=0.9920). Muscle action (eccentric versus concentric) and group (extensors versus flexors) were significant main effects (p <0.0001). There was no significant difference between torques at 30°.s(-1) and 60°.s(-1). The trunk extensor/flexor ratio approximated 1.75 for eccentric muscle action and 1.82 for concentric muscle actions. Gravity correction did not affect strength data but did affect strength curve shape. The results can be utilised to design individual prophylactic exercise programs for back pain.