1
|
Gamble AR, McKay MJ, Anderson DB, Pappas E, Alvarez Cooper I, Macpherson S, Harris IA, Filbay SR, McCaffery K, Thompson R, Hoffmann TC, Maher CG, Zadro JR. Development of a patient decision aid for children and adolescents following anterior cruciate ligament rupture: an international mixed-methods study. BMJ Open 2024; 14:e081421. [PMID: 38684251 DOI: 10.1136/bmjopen-2023-081421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
AIM To develop and user test an evidence-based patient decision aid for children and adolescents who are considering anterior cruciate ligament (ACL) reconstruction. DESIGN Mixed-methods study describing the development of a patient decision aid. SETTING A draft decision aid was developed by a multidisciplinary steering group (including various types of health professionals and researchers, and consumers) informed by the best available evidence and existing patient decision aids. PARTICIPANTS People who ruptured their ACL when they were under 18 years old (ie, adolescents), their parents, and health professionals who manage these patients. Participants were recruited through social media and the network outreach of the steering group. PRIMARY AND SECONDARY OUTCOMES Semistructured interviews and questionnaires were used to gather feedback on the decision aid. The feedback was used to refine the decision aid and assess acceptability. An iterative cycle of interviews, refining the aid according to feedback and further interviews, was used. Interviews were analysed using reflexive thematic analysis. RESULTS We conducted 32 interviews; 16 health professionals (12 physiotherapists, 4 orthopaedic surgeons) and 16 people who ruptured their ACL when they were under 18 years old (7 were adolescents and 9 were adults at the time of the interview). Parents participated in 8 interviews. Most health professionals, patients and parents rated the aid's acceptability as good-to-excellent. Health professionals and patients agreed on most aspects of the decision aid, but some health professionals had differing views on non-surgical management, risk of harms, treatment protocols and evidence on benefits and harms. CONCLUSION Our patient decision aid is an acceptable tool to help children and adolescents choose an appropriate management option following ACL rupture with their parents and health professionals. A clinical trial evaluating the potential benefit of this tool for children and adolescents considering ACL reconstruction is warranted.
Collapse
Affiliation(s)
- Andrew R Gamble
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health and Institute for Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Marnee J McKay
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - David B Anderson
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Evangelos Pappas
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
| | | | - Sophie Macpherson
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Ian A Harris
- Sydney Musculoskeletal Health and Institute for Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, UNSW, Sydney, New South Wales, Australia
| | - Stephanie R Filbay
- Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - Kirsten McCaffery
- Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Rachel Thompson
- Discipline of Behavioural and Social Sciences in Health, School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Tammy C Hoffmann
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Christopher G Maher
- Sydney Musculoskeletal Health and Institute for Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Joshua R Zadro
- Sydney Musculoskeletal Health and Institute for Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
2
|
Zadro JR, Ferreira GE, Muller R, Sousa Filho LF, Malliaras P, West CA, O'Keeffe M, Maher CG. Education can reassure people with rotator cuff-related shoulder pain: a 3-arm, randomised, online experiment. Pain 2024; 165:951-958. [PMID: 38112759 DOI: 10.1097/j.pain.0000000000003102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 09/18/2023] [Indexed: 12/21/2023]
Abstract
ABSTRACT We aimed to investigate the immediate effect of best practice education (with and without pain science messages) and structure-focused education on reassurance among people with rotator cuff-related shoulder pain. We conducted a 3-arm, parallel-group, randomised experiment. People with rotator cuff-related shoulder pain were randomised (1:1:1) to (1) best practice education (highlights that most shoulder pain is not serious or a good indicator of tissue damage and recommends simple self-management strategies); (2) best practice education plus pain science messages (which attempt to improve understanding of pain); and (3) structure-focused education (highlighting that structural changes are responsible for pain and should be targeted with treatment). Coprimary outcomes were self-reported reassurance that no serious condition is causing their pain and continuing with daily activities is safe. Secondary outcomes measured management intentions, credibility and relevance of the education, and similarity to previous education. Two thousand two hundred thirty-seven participants were randomised and provided primary outcome data. Best practice education increased reassurance that no serious condition is causing their pain (estimated mean effect 0.5 on a 0-10 scale, 95% confidence interval [CI] 0.2-0.7) and continuing with daily activities is safe (0.6, 95% CI 0.3-0.8) compared with structure-focused education . Adding pain science messages to best practice education slightly increased both measures of reassurance (0.2, 95% CI 0.0-0.4). Clinicians treating patients with rotator cuff-related shoulder pain should highlight that most shoulder pain is not serious or a good indicator of tissue damage and recommend simple self-management strategies. The benefit of adding pain science messages is small.
Collapse
Affiliation(s)
- Joshua R Zadro
- Sydney Musculoskeletal Health and Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Giovanni E Ferreira
- Sydney Musculoskeletal Health and Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Ryan Muller
- VA Connecticut Healthcare System, West Haven, CT, United States
| | | | - Peter Malliaras
- Department of Physiotherapy, Monash University, Melbourne, Australia
| | - Courtney A West
- Sydney Musculoskeletal Health and Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Mary O'Keeffe
- Sydney Musculoskeletal Health and Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Christopher G Maher
- Sydney Musculoskeletal Health and Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| |
Collapse
|
3
|
Vella SP, Simpson P, Bendall JC, Pickles K, Copp T, Swain MS, Maher CG, Machado GC. Perceptions and experiences of paramedics managing people with non-traumatic low back pain: a qualitative study of Australian paramedics. BMJ Open 2024; 14:e084060. [PMID: 38508615 PMCID: PMC10952929 DOI: 10.1136/bmjopen-2024-084060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 02/26/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Paramedics are often first providers of care to patients experiencing non-traumatic low back pain (LBP), though their perspectives and experiences with managing these cases remain unclear. OBJECTIVES This study explored paramedic views of the management of non-traumatic LBP including their role and experience with LBP management, barriers to referral and awareness of ambulance service guidelines. DESIGN Qualitative study using semistructured interviews conducted between January and April 2023. SETTING New South Wales Ambulance service. PARTICIPANTS A purposive sample of 30 paramedics of different specialities employed by New South Wales Ambulance were recruited. RESULTS Paramedic accounts demonstrated the complexity, challenge, frustration and reward associated with managing non-traumatic LBP. Paramedics perceived that their primary role focused on the assessment of LBP, and that calls to ambulance services were often driven by misconceptions surrounding the management of LBP, and a person's pain severity. Access to health services, patient factors, defensive medicine, paramedic training and education and knowledge of guidelines influenced paramedic management of LBP. CONCLUSION Paramedics often provide care to non-traumatic LBP cases yet depending on the type of paramedic speciality find these cases to be frustrating, challenging or rewarding to manage due to barriers to referral including access to health services, location, patient factors and uncertainty relating to litigation. Future research should explore patient perspectives towards ambulance service use for the management of their LBP.
Collapse
Affiliation(s)
- Simon P Vella
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health Districts, Camperdown, New South Wales, Australia
| | - Paul Simpson
- School of Health Sciences, Western Sydney University, Penrith, New South Wales, Australia
| | - Jason C Bendall
- NSW Ambulance, Clinical Systems, Sydney, New South Wales, Australia
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Kristen Pickles
- Faculty of Medicine and Health, Sydney Health Literacy Lab, Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Tessa Copp
- Faculty of Medicine and Health, Sydney Health Literacy Lab, Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael S Swain
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Christopher G Maher
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health Districts, Camperdown, New South Wales, Australia
| | - Gustavo C Machado
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health Districts, Camperdown, New South Wales, Australia
| |
Collapse
|
4
|
Teng MJ, Zadro JR, Pickles K, Copp T, Shaw MJ, Khoudair I, Horsley M, Warnock B, Hutchings OR, Petchell JF, Ackerman IN, Drayton A, Liu R, Maher CG, Traeger AC. RECITAL: a non-inferiority randomised control trial evaluating a virtual fracture clinic compared with in-person care for people with simple fractures (study protocol). BMJ Open 2024; 14:e080800. [PMID: 38316591 PMCID: PMC10859974 DOI: 10.1136/bmjopen-2023-080800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 01/15/2024] [Indexed: 02/07/2024] Open
Abstract
INTRODUCTION Most simple undisplaced fractures can be managed without surgery by immobilising the limb with a splint, prescribing medication for pain, and providing advice and early rehabilitation. Recent systematic reviews based on retrospective observational studies have reported that virtual fracture clinics can deliver follow-up care that is safe and cost-effective. However, no randomised controlled trial has investigated if a virtual fracture clinic can provide non-inferior physical function outcomes compared with an in-person clinic for patients with simple fractures. METHODS AND ANALYSIS 312 participants will be recruited from 2 metropolitan hospitals located in Sydney, Australia. Adult patients will be eligible if they have an acute simple fracture that can be managed with a removable splint and is deemed appropriate for follow-up at either the virtual or in-person fracture clinic by an orthopaedic doctor. Patients will not be eligible if they have a complex fracture that requires a cast or surgery. Eligible participants will be randomised to receive their follow-up care either at the virtual or the in-person fracture clinic. Participants at the virtual fracture clinic will be reviewed within 5 days of receiving a referral through video calls with a physiotherapist. Participants at the in-person fracture clinic will be reviewed by an orthopaedic doctor within 7-10 days of receiving a referral. The primary outcome will be the patient's function measured using the Patient-Specific Functional Scale at 12 weeks. Secondary outcomes will include health-related quality of life, patient-reported experiences, pain, health cost, healthcare utilisation, medication use, adverse events, emergency department representations and surgery. ETHICS AND DISSEMINATION The study has been approved by the Sydney Local Health District Ethics Review Committee (RPAH Zone) (X23-0200 and 2023/ETH01038). The trial results will be submitted for publication in a reputable international journal and will be presented at professional conferences. TRIAL REGISTRATION NUMBER ACTRN12623000934640.
Collapse
Affiliation(s)
- Min Jiat Teng
- Institute for Musculoskeletal Health, Sydney School of Public Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
- RPA Virtual Hospital, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Joshua R Zadro
- Institute for Musculoskeletal Health, Sydney School of Public Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Kristen Pickles
- Sydney Health Literacy Lab, Sydney School of Public Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Tessa Copp
- Sydney Health Literacy Lab, Sydney School of Public Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Miranda J Shaw
- RPA Virtual Hospital, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Isabella Khoudair
- RPA Virtual Hospital, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Mark Horsley
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Benjamin Warnock
- RPA Virtual Hospital, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Owen R Hutchings
- RPA Virtual Hospital, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Jeffrey F Petchell
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Ilana N Ackerman
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Alison Drayton
- Consumer Representative, Sydney, New South Wales, Australia
| | - Rong Liu
- RPA Virtual Hospital, Sydney Local Health District, Sydney, New South Wales, Australia
- University of New South Wales, The George Institute for Global Health, Newtown, New South Wales, Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health, Sydney School of Public Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Adrian C Traeger
- Institute for Musculoskeletal Health, Sydney School of Public Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| |
Collapse
|
5
|
Jones CMP, Lin CWC, Blease C, Lawson J, Abdel Shaheed C, Maher CG. Reply to Ballou and Kube. Pain 2024; 165:488-489. [PMID: 38207197 DOI: 10.1097/j.pain.0000000000003146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Affiliation(s)
- Caitlin M P Jones
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
| | | | - Charlotte Blease
- Department of Women's and Children's Health, Uppsala University, Sweden
- Digital Psychiatry, Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, United States
| | - Jen Lawson
- Patient Advocate, Kalamazoo, MI, United States
| | | | - Christopher G Maher
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
6
|
Vella SP, Melman A, Coombs D, Maher CG, Swain MS, Monk E, Machado GC. The effectiveness of allied health and nurse practitioner models-of-care in managing musculoskeletal conditions in the emergency department: a systematic review and meta-analysis. BMC Emerg Med 2024; 24:13. [PMID: 38233743 PMCID: PMC10795385 DOI: 10.1186/s12873-023-00925-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 12/26/2023] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Musculoskeletal conditions are the most common health condition seen in emergency departments. Hence, the most effective approaches to managing these conditions is of interest. This systematic review aimed to evaluate the effectiveness of allied health and nursing models of care for the management of musculoskeletal pain in ED. METHODS MEDLINE, EMBASE, CINAHL and LILACS databases were searched from inception to March 2023 for published randomised trials that compared the effectiveness of allied health and nursing models of care for musculoskeletal conditions in ED to usual ED care. Trials were eligible if they enrolled participants presenting to ED with a musculoskeletal condition including low back pain, neck pain, upper or lower limb pain and any soft tissue injury. Trials that included patients with serious pathology (e.g. malignancy, infection or cauda equina syndrome) were excluded. The primary outcome was patient-flow; other outcomes included pain intensity, disability, hospital admission and re-presentation rates, patient satisfaction, medication prescription and adverse events. Two reviewers performed search screening, data extraction, quality and certainty of evidence assessments. RESULTS We identified 1746 records and included 5 randomised trials (n = 1512 patients). Only one trial (n = 260) reported on patient-flow. The study provides very-low certainty evidence that a greater proportion of patients were seen within 20 min when seen by a physician (98%) than when seen by a nurse (86%) or physiotherapist (77%). There was no difference in pain intensity and disability between patients managed by ED physicians and those managed by physiotherapists. Evidence was limited regarding patient satisfaction, inpatient admission and ED re-presentation rates, medication prescription and adverse events. The certainty of evidence for secondary outcomes ranged from very-low to low, but generally did not suggest a benefit of one model over another. CONCLUSION There is limited research to judge the effectiveness of allied health and nursing models of care for the management of musculoskeletal conditions in ED. Currently, it is unclear as to whether allied health and nurse practitioners are more effective than ED physicians at managing musculoskeletal conditions in ED. Further high-quality trials investigating the impact of models of care on service and health outcomes are needed.
Collapse
Affiliation(s)
- Simon P Vella
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
- Sydney Musculoskeletal Health and Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia.
- Royal Prince Alfred Hospital, Level 10N, King George V Building, Missenden Road, Camperdown, NSW, 2050, Australia.
| | - Alla Melman
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Sydney Musculoskeletal Health and Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia
| | - Danielle Coombs
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Sydney Musculoskeletal Health and Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia
| | - Christopher G Maher
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Sydney Musculoskeletal Health and Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia
| | - Michael S Swain
- Department of Chiropractic, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Elizabeth Monk
- St George Hospital Emergency Department, Sydney, Australia
| | - Gustavo C Machado
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Sydney Musculoskeletal Health and Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia
| |
Collapse
|
7
|
Abdel Shaheed C, Hayes C, Maher CG, Ballantyne JC, Underwood M, McLachlan AJ, Martin JH, Narayan SW, Sidhom MA. Opioid analgesics for nociceptive cancer pain: A comprehensive review. CA Cancer J Clin 2023. [PMID: 38108561 DOI: 10.3322/caac.21823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 10/05/2023] [Accepted: 10/20/2023] [Indexed: 12/19/2023] Open
Abstract
Pain is one of the most burdensome symptoms in people with cancer, and opioid analgesics are considered the mainstay of cancer pain management. For this review, the authors evaluated the efficacy and toxicities of opioid analgesics compared with placebo, other opioids, nonopioid analgesics, and nonpharmacologic treatments for background cancer pain (continuous and relatively constant pain present at rest), and breakthrough cancer pain (transient exacerbation of pain despite stable and adequately controlled background pain). They found a paucity of placebo-controlled trials for background cancer pain, although tapentadol or codeine may be more efficacious than placebo (moderate-certainty to low-certainty evidence). Nonsteroidal anti-inflammatory drugs including aspirin, piroxicam, diclofenac, ketorolac, and the antidepressant medicine imipramine, may be at least as efficacious as opioids for moderate-to-severe background cancer pain. For breakthrough cancer pain, oral transmucosal, buccal, sublingual, or intranasal fentanyl preparations were identified as more efficacious than placebo but were more commonly associated with toxicities, including constipation and nausea. Despite being recommended worldwide for the treatment of cancer pain, morphine was generally not superior to other opioids, nor did it have a more favorable toxicity profile. The interpretation of study results, however, was complicated by the heterogeneity in the study populations evaluated. Given the limited quality and quantity of research, there is a need to reappraise the clinical utility of opioids in people with cancer pain, particularly those who are not at the end of life, and to further explore the effects of opioids on immune system function and quality of life in these individuals.
Collapse
Affiliation(s)
- Christina Abdel Shaheed
- Faculty of Medicine and Health, School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Christopher Hayes
- College of Health, Medicine, and Wellbeing, University of Newcastle, Newcastle, New South Wales, Australia
| | - Christopher G Maher
- Faculty of Medicine and Health, School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Jane C Ballantyne
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Martin Underwood
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
- University Hospitals of Coventry and Warwickshire, Coventry, United Kingdom
| | - Andrew J McLachlan
- Faculty of Medicine and Health, Sydney Pharmacy School, University of Sydney, Sydney, New South Wales, Australia
| | - Jennifer H Martin
- College of Health, Medicine, and Wellbeing, University of Newcastle, Newcastle, New South Wales, Australia
| | - Sujita W Narayan
- Faculty of Medicine and Health, School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, Australia
- Faculty of Medicine and Health, Sydney Pharmacy School, University of Sydney, Sydney, New South Wales, Australia
| | - Mark A Sidhom
- Cancer Therapy Centre, Liverpool Hospital, Liverpool, New South Wales, Australia
- South Western Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| |
Collapse
|
8
|
Ferreira GE, Zadro JR, Traeger AC, Jones CP, West CA, O'Keeffe M, Jenkins H, McAuley J, Maher CG. Adding Brief Pain Science or Ergonomics Messages to Guideline Advice Did Not Increase Feelings of Reassurance in People With Acute Low Back Pain: A Randomized Experiment. J Orthop Sports Phys Ther 2023; 53:1-11. [PMID: 37751303 DOI: 10.2519/jospt.2023.12090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
OBJECTIVE: To investigate the effects of adding pain science or ergonomics messages to guideline advice on feelings of reassurance and management intentions among people with acute low back pain (LBP). DESIGN: Three-arm parallel-group randomized experiment. METHODS: We recruited people with acute LBP (pain for ≤6 weeks) to participate in an online experiment. Participants were randomized at a 1:1:1 ratio to one of three groups: guideline advice alone or guideline advice with the addition of brief pain science or ergonomics messages. The intervention was delivered via prerecorded videos in all 3 groups. Coprimary outcomes were reassurance that (1) no serious condition is causing LBP and (2) continuing with daily activities is safe. Secondary outcomes were perceived risk of developing chronic pain, management intentions (bed rest, see a health professional, see a specialist, and imaging), credibility, and relevance of the advice in addressing the participant's concerns. RESULTS: Two thousand two hundred ninety-seven responses (99.3% of 2,313 randomized) were analyzed. Adding brief pain science or ergonomics messages to guideline advice did not change reassurance that LBP was not caused by serious disease. The addition of ergonomics advice provided worse reassurance that it is safe to continue with daily activities compared to guideline advice (mean difference [MD], -0.33; 95% CI: 0.13, 0.53). There was no difference between groups on management intentions. CONCLUSION: Adding pain science or ergonomics messages to guideline advice did not increase reassurance or change management intentions in people with acute LBP. Ergonomics messages may lead to reduced feelings of reassurance. J Orthop Sports Phys Ther 2023;53(12)1-11. Epub 26 September 2023. doi:10.2519/jospt.2023.12090.
Collapse
|
9
|
Williams CM, Henschke N, Maher CG, van Tulder MW, Koes BW, Macaskill P, Irwig L. Red flags to screen for vertebral fracture in patients presenting with low-back pain. Cochrane Database Syst Rev 2023; 11:CD008643. [PMID: 38014846 PMCID: PMC10683370 DOI: 10.1002/14651858.cd008643.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
EDITORIAL NOTE See https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD014461.pub2/full for a more recent review that covers this topic and has superseded this review. BACKGROUND Low-back pain (LBP) is a common condition seen in primary care. A principal aim during a clinical examination is to identify patients with a higher likelihood of underlying serious pathology, such as vertebral fracture, who may require additional investigation and specific treatment. All 'evidence-based' clinical practice guidelines recommend the use of red flags to screen for serious causes of back pain. However, it remains unclear if the diagnostic accuracy of red flags is sufficient to support this recommendation. OBJECTIVES To assess the diagnostic accuracy of red flags obtained in a clinical history or physical examination to screen for vertebral fracture in patients presenting with LBP. SEARCH METHODS Electronic databases were searched for primary studies between the earliest date and 7 March 2012. Forward and backward citation searching of eligible studies was also conducted. SELECTION CRITERIA Studies were considered if they compared the results of any aspect of the history or test conducted in the physical examination of patients presenting for LBP or examination of the lumbar spine, with a reference standard (diagnostic imaging). The selection criteria were independently applied by two review authors. DATA COLLECTION AND ANALYSIS Three review authors independently conducted 'Risk of bias' assessment and data extraction. Risk of bias was assessed using the 11-item QUADAS tool. Characteristics of studies, patients, index tests and reference standards were extracted. Where available, raw data were used to calculate sensitivity and specificity with 95% confidence intervals (CI). Due to the heterogeneity of studies and tests, statistical pooling was not appropriate and the analysis for the review was descriptive only. Likelihood ratios for each test were calculated and used as an indication of clinical usefulness. MAIN RESULTS Eight studies set in primary (four), secondary (one) and tertiary care (accident and emergency = three) were included in the review. Overall, the risk of bias of studies was moderate with high risk of selection and verification bias the predominant flaws. Reporting of index and reference tests was poor. The prevalence of vertebral fracture in accident and emergency settings ranged from 6.5% to 11% and in primary care from 0.7% to 4.5%. There were 29 groups of index tests investigated however, only two featured in more than two studies. Descriptive analyses revealed that three red flags in primary care were potentially useful with meaningful positive likelihood ratios (LR+) but mostly imprecise estimates (significant trauma, older age, corticosteroid use; LR+ point estimate ranging 3.42 to 12.85, 3.69 to 9.39, 3.97 to 48.50 respectively). One red flag in tertiary care appeared informative (contusion/abrasion; LR+ 31.09, 95% CI 18.25 to 52.96). The results of combined tests appeared more informative than individual red flags with LR+ estimates generally greater in magnitude and precision. AUTHORS' CONCLUSIONS The available evidence does not support the use of many red flags to specifically screen for vertebral fracture in patients presenting for LBP. Based on evidence from single studies, few individual red flags appear informative as most have poor diagnostic accuracy as indicated by imprecise estimates of likelihood ratios. When combinations of red flags were used the performance appeared to improve. From the limited evidence, the findings give rise to a weak recommendation that a combination of a small subset of red flags may be useful to screen for vertebral fracture. It should also be noted that many red flags have high false positive rates; and if acted upon uncritically there would be consequences for the cost of management and outcomes of patients with LBP. Further research should focus on appropriate sets of red flags and adequate reporting of both index and reference tests.
Collapse
Affiliation(s)
| | | | | | - Maurits W van Tulder
- MOVE Research Institute Amsterdam, Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Bart W Koes
- Center for Muscle and Health, University of Southern Denmark, Odense, Denmark
| | - Petra Macaskill
- Screening and Test Evaluation Program (STEP), School of Public Health, Sydney, Australia
| | - Les Irwig
- School of Public Health, University of Sydney, Sydney, Australia
| |
Collapse
|
10
|
Kharel P, Zadro JR, Chen Z, Himbury MA, Traeger AC, Linklater J, Maher CG. Awareness and use of five imaging decision rules for musculoskeletal injuries: a systematic review. Int J Emerg Med 2023; 16:85. [PMID: 37957570 PMCID: PMC10644430 DOI: 10.1186/s12245-023-00555-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 10/26/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Several validated decision rules are available for clinicians to guide the appropriate use of imaging for patients with musculoskeletal injuries, including the Canadian CT Head Rule, Canadian C-Spine Rule, National Emergency X-Radiography Utilization Study (NEXUS) guideline, Ottawa Ankle Rules and Ottawa Knee Rules. However, it is unclear to what extent clinicians are aware of the rules and are using these five rules in practice. OBJECTIVE To determine the proportion of clinicians that are aware of five imaging decision rules and the proportion that use them in practice. DESIGN Systematic review. METHODS This was a systematic review conducted in accordance with the 'Preferred reporting items for systematic reviews and meta-analyses' (PRISMA) statement. We performed searches in MEDLINE (via Ovid), CINAHL (via EBSCO), EMBASE (via Ovid), Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science and Scopus databases to identify observational and experimental studies with data on the following outcomes among clinicians related to five validated imaging decision rules: awareness, use, attitudes, knowledge, and barriers and facilitators to implementation. Where possible, we pooled data using medians to summarise these outcomes. RESULTS We included 39 studies. Studies were conducted in 15 countries (e.g. the USA, Canada, the UK, Australasia, New Zealand) and included various clinician types (e.g. emergency physicians, emergency nurses and nurse practitioners). Among the five decision rules, clinicians' awareness was highest for the Canadian C-Spine Rule (84%, n = 3 studies) and lowest for the Ottawa Knee Rules (18%, n = 2). Clinicians' use was highest for NEXUS (median percentage ranging from 7 to 77%, n = 4) followed by Canadian C-Spine Rule (56-71%, n = 7 studies) and lowest for the Ottawa Knee Rules which ranged from 18 to 58% (n = 4). CONCLUSION Our results suggest that awareness of the five imaging decision rules is low. Changing clinicians' attitudes and knowledge towards these decision rules and addressing barriers to their implementation could increase use.
Collapse
Affiliation(s)
- Priti Kharel
- Sydney Musculoskeletal Health, The University of Sydney, Royal Prince Alfred Hospital, Level 10 North, King George V Building, Missenden Road, PO Box M179, Sydney, NSW, 2050, Australia.
| | - Joshua R Zadro
- Sydney Musculoskeletal Health, The University of Sydney, Royal Prince Alfred Hospital, Level 10 North, King George V Building, Missenden Road, PO Box M179, Sydney, NSW, 2050, Australia
| | - Zhang Chen
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Madii A Himbury
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Adrian C Traeger
- Sydney Musculoskeletal Health, The University of Sydney, Royal Prince Alfred Hospital, Level 10 North, King George V Building, Missenden Road, PO Box M179, Sydney, NSW, 2050, Australia
| | | | - Christopher G Maher
- Sydney Musculoskeletal Health, The University of Sydney, Royal Prince Alfred Hospital, Level 10 North, King George V Building, Missenden Road, PO Box M179, Sydney, NSW, 2050, Australia
| |
Collapse
|
11
|
Jones CMP, Lin CWC, Blease C, Lawson J, Abdel Shaheed C, Maher CG. Time to reflect on open-label placebos and their value for clinical practice. Pain 2023; 164:2139-2142. [PMID: 37713359 DOI: 10.1097/j.pain.0000000000003017] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 06/24/2023] [Indexed: 09/17/2023]
Affiliation(s)
- Caitlin M P Jones
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, Australia
- The Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Chung-Wei Christine Lin
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, Australia
- The Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Charlotte Blease
- Department of Women's and Children's Health, Uppsala University Sweden
- Digital Psychiatry, Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, United States
| | - Jen Lawson
- Patient Advocate, Kalamazoo, Michigan, United States
| | - Christina Abdel Shaheed
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, Australia
- The Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
- The University of Sydney, School of Public Health, Sydney, Australia
| | - Christopher G Maher
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, Australia
- The Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| |
Collapse
|
12
|
Maher CG, Archambeau A, Buchbinder R, French SD, Morphet J, Nicholas MK, O'Sullivan P, Pirotta M, Yelland MJ, Zeller L, Marles E, Bhasale AL, Lane C. Introducing Australia's clinical care standard for low back pain 1. J Physiother 2023; 69:205-207. [PMID: 37684144 DOI: 10.1016/j.jphys.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 07/10/2023] [Indexed: 09/10/2023] Open
Affiliation(s)
| | | | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Simon D French
- Department of Chiropractic, Macquarie University, Sydney, Australia
| | - Julia Morphet
- School of Nursing and Midwifery, Monash University, Melbourne, Australia
| | | | - Peter O'Sullivan
- Pain Management Research Institute, Kolling Institute of Medical Research, University of Sydney, Sydney, Australia
| | - Marie Pirotta
- Marie Pirotta, School of Allied Health, Curtin University, Perth, Australia
| | - Michael J Yelland
- Department of General Practice, University of Melbourne, Melbourne, Australia
| | - Leo Zeller
- School of Medicine, Griffith University, Gold Coast, Australia
| | | | - Alice L Bhasale
- Royal Brisbane and Women's Hospital, Metro North Health, Brisbane, Australia
| | - Christina Lane
- Australian Commission on Safety and Quality in Health Care, Sydney, Australia
| |
Collapse
|
13
|
Oliveira CB, Ferreira GE, Buchbinder R, Machado GC, Maher CG. Do national health priorities align with Global Burden of Disease estimates on disease burden? An analysis of national health plans and official governmental websites. Public Health 2023; 222:66-74. [PMID: 37523950 DOI: 10.1016/j.puhe.2023.06.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/19/2023] [Accepted: 06/27/2023] [Indexed: 08/02/2023]
Abstract
OBJECTIVE To investigate the alignment of national health priorities with a country's burden of disease as measured by disability-adjusted life years (DALYs). METHODS We identified priorities in national health plans and the 20 most burdensome conditions measured by DALYs from the 2017 Global Burden of Disease Study. We computed point-biserial correlations (rpb) between DALYs and being nominated as a health priority and the pooled proportion (95% confidence intervals [CIs]) of the 20 most burdensome conditions nominated as a priority across countries. RESULTS We identified national health plans and official governmental websites in 145 countries. There was little to no correlation (rpb = 0.06, 95% CI: 0.02 to 0.09) between national DALY data and whether a condition was nominated as a health priority. The pooled proportion of the 20 most burdensome conditions nominated as priorities across countries was 46%. HIV/AIDS had the greatest number of nominations as a national health priority (62 countries) as well as the greatest match with the burden of disease (among the top 20 most burdensome conditions in 51 [82%] countries). Low back pain, headache disorders and congenital birth defects had the lowest proportion of nominations as health priorities in countries where they were in the top 20 most burdensome conditions (6%, 6% and 11%, respectively). CONCLUSION Globally, there were low correlations between national health priorities and GBD estimates on disease burden. Failing to prioritise health priorities according to burden may mean that insufficient resources have been directed to improve health outcomes for people with those health conditions.
Collapse
Affiliation(s)
- C B Oliveira
- Faculty of Medicine, University of Western São Paulo (UNOESTE), Presidente Prudente, Sao Paulo, Brazil; Physical Therapy Department, Faculty of Science and Technology, Sao Paulo State University, Presidente Prudente, Brazil; Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia.
| | - G E Ferreira
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia; Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - R Buchbinder
- Musculoskeletal Health and Wiser Health Care Units, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - G C Machado
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia; Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - C G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia; Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
14
|
Traeger AC, Gilbert SE, Harris IA, Maher CG. Response to Durbhakula and colleagues. Pain Med 2023; 24:1127-1128. [PMID: 37195461 DOI: 10.1093/pm/pnad061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 05/03/2023] [Indexed: 05/18/2023]
Affiliation(s)
- Adrian C Traeger
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, 2050, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, 2050, Australia
| | - Stephen E Gilbert
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, 2050, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, 2050, Australia
| | - Ian A Harris
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, 2050, Australia
- South West Sydney Clinical School, University of New South Wales, Liverpool, 2170, Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, 2050, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, 2050, Australia
| |
Collapse
|
15
|
Maher CG, Jones CMP, Coombs D, Ferreira G. Considerable Uncertainty About the Burden of Gout in the Middle East and North Africa Region. J Rheumatol 2023; 50:1201-1202. [PMID: 37061231 DOI: 10.3899/jrheum.2022-1306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2023]
Affiliation(s)
- Christopher G Maher
- The University of Sydney, Sydney Musculoskeletal Health, Camperdown, New South Wales, Australia.
| | - Caitlin M P Jones
- The University of Sydney, Sydney Musculoskeletal Health, Camperdown, New South Wales, Australia
| | - Danielle Coombs
- The University of Sydney, Sydney Musculoskeletal Health, Camperdown, New South Wales, Australia
| | - Giovanni Ferreira
- The University of Sydney, Sydney Musculoskeletal Health, Camperdown, New South Wales, Australia
| |
Collapse
|
16
|
Han CS, Hancock MJ, Downie A, Jarvik JG, Koes BW, Machado GC, Verhagen AP, Williams CM, Chen Q, Maher CG. Red flags to screen for vertebral fracture in people presenting with low back pain. Cochrane Database Syst Rev 2023; 8:CD014461. [PMID: 37615643 PMCID: PMC10448864 DOI: 10.1002/14651858.cd014461.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
BACKGROUND Low back pain is a common presentation across different healthcare settings. Clinicians need to confidently be able to screen and identify people presenting with low back pain with a high suspicion of serious or specific pathology (e.g. vertebral fracture). Patients identified with an increased likelihood of having a serious pathology will likely require additional investigations and specific treatment. Guidelines recommend a thorough history and clinical assessment to screen for serious pathology as a cause of low back pain. However, the diagnostic accuracy of recommended red flags (e.g. older age, trauma, corticosteroid use) remains unclear, particularly those used to screen for vertebral fracture. OBJECTIVES To assess the diagnostic accuracy of red flags used to screen for vertebral fracture in people presenting with low back pain. Where possible, we reported results of red flags separately for different types of vertebral fracture (i.e. acute osteoporotic vertebral compression fracture, vertebral traumatic fracture, vertebral stress fracture, unspecified vertebral fracture). SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 26 July 2022. SELECTION CRITERIA We considered primary diagnostic studies if they compared results of history taking or physical examination (or both) findings (index test) with a reference standard test (e.g. X-ray, magnetic resonance imaging (MRI), computed tomography (CT), single-photon emission computerised tomography (SPECT)) for the identification of vertebral fracture in people presenting with low back pain. We included index tests that were presented individually or as part of a combination of tests. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data for diagnostic two-by-two tables from the publications or reconstructed them using information from relevant parameters to calculate sensitivity, specificity, and positive (+LR) and negative (-LR) likelihood ratios with 95% confidence intervals (CIs). We extracted aspects of study design, characteristics of the population, index test, reference standard, and type of vertebral fracture. Meta-analysis was not possible due to heterogeneity of studies and index tests, therefore the analysis was descriptive. We calculated sensitivity, specificity, and LRs for each test and used these as an indication of clinical usefulness. Two review authors independently conducted risk of bias and applicability assessment using the QUADAS-2 tool. MAIN RESULTS This review is an update of a previous Cochrane Review of red flags to screen for vertebral fracture in people with low back pain. We included 14 studies in this review, six based in primary care, five in secondary care, and three in tertiary care. Four studies reported on 'osteoporotic vertebral fractures', two studies reported on 'vertebral compression fracture', one study reported on 'osteoporotic and traumatic vertebral fracture', two studies reported on 'vertebral stress fracture', and five studies reported on 'unspecified vertebral fracture'. Risk of bias was only rated as low in one study for the domains reference standard and flow and timing. The domain patient selection had three studies and the domain index test had six studies rated at low risk of bias. Meta-analysis was not possible due to heterogeneity of the data. Results from single studies suggest only a small number of the red flags investigated may be informative. In the primary healthcare setting, results from single studies suggest 'trauma' demonstrated informative +LRs (range: 1.93 to 12.85) for 'unspecified vertebral fracture' and 'osteoporotic vertebral fracture' (+LR: 6.42, 95% CI 2.94 to 14.02). Results from single studies suggest 'older age' demonstrated informative +LRs for studies in primary care for 'unspecified vertebral fracture' (older age greater than 70 years: 11.19, 95% CI 5.33 to 23.51). Results from single studies suggest 'corticosteroid use' may be an informative red flag in primary care for 'unspecified vertebral fracture' (+LR range: 3.97, 95% CI 0.20 to 79.15 to 48.50, 95% CI 11.48 to 204.98) and 'osteoporotic vertebral fracture' (+LR: 2.46, 95% CI 1.13 to 5.34); however, diagnostic values varied and CIs were imprecise. Results from a single study suggest red flags as part of a combination of index tests such as 'older age and female gender' in primary care demonstrated informative +LRs for 'unspecified vertebral fracture' (16.17, 95% CI 4.47 to 58.43). In the secondary healthcare setting, results from a single study suggest 'trauma' demonstrated informative +LRs for 'unspecified vertebral fracture' (+LR: 2.18, 95% CI 1.86 to 2.54) and 'older age' demonstrated informative +LRs for 'osteoporotic vertebral fracture' (older age greater than 75 years: 2.51, 95% CI 1.48 to 4.27). Results from a single study suggest red flags as part of a combination of index tests such as 'older age and trauma' in secondary care demonstrated informative +LRs for 'unspecified vertebral fracture' (+LR: 4.35, 95% CI 2.92 to 6.48). Results from a single study suggest when '4 of 5 tests' were positive in secondary care, they demonstrated informative +LRs for 'osteoporotic vertebral fracture' (+LR: 9.62, 95% CI 5.88 to 15.73). In the tertiary care setting, results from a single study suggest 'presence of contusion/abrasion' was informative for 'vertebral compression fracture' (+LR: 31.09, 95% CI 18.25 to 52.96). AUTHORS' CONCLUSIONS The available evidence suggests that only a few red flags are potentially useful in guiding clinical decisions to further investigate people suspected to have a vertebral fracture. Most red flags were not useful as screening tools to identify vertebral fracture in people with low back pain. In primary care, 'older age' was informative for 'unspecified vertebral fracture', and 'trauma' and 'corticosteroid use' were both informative for 'unspecified vertebral fracture' and 'osteoporotic vertebral fracture'. In secondary care, 'older age' was informative for 'osteoporotic vertebral fracture' and 'trauma' was informative for 'unspecified vertebral fracture'. In tertiary care, 'presence of contusion/abrasion' was informative for 'vertebral compression fracture'. Combinations of red flags were also informative and may be more useful than individual tests alone. Unfortunately, the challenge to provide clear guidance on which red flags should be used routinely in clinical practice remains. Further research with primary studies is needed to improve and consolidate our current recommendations for screening for vertebral fractures to guide clinical care.
Collapse
Affiliation(s)
- Christopher S Han
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Mark J Hancock
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Aron Downie
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Jeffrey G Jarvik
- Departments of Radiology and Neurological Surgery, and the UW Clinical Learning, Evidence And Research (CLEAR) Center for Musculoskeletal Disorders, University of Washington School of Medicine, Seattle, USA
| | - Bart W Koes
- Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark
- Department of General Practice, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Gustavo C Machado
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Arianne P Verhagen
- Discipline of Physiotherapy, Graduate School of Health, University of Technology Sydney (UTS), Sydney, Australia
| | | | - Qiuzhe Chen
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| |
Collapse
|
17
|
Pocovi NC, Ayre J, French SD, Lin CWC, Tiedemann A, Maher CG, Merom D, McCaffrey K, Hancock MJ. Physiotherapists should apply health coaching techniques and incorporate accountability to foster adherence to a walking program for low back pain: a qualitative study. J Physiother 2023; 69:182-188. [PMID: 37271689 DOI: 10.1016/j.jphys.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 04/19/2023] [Accepted: 05/15/2023] [Indexed: 06/06/2023] Open
Abstract
QUESTIONS What motivates individuals to start a walking program for the prevention of low back pain? What strategies optimise short-term and long-term adherence to a walking program? What strategies can physiotherapists incorporate into clinical practice to facilitate commencement of and adherence to a walking program? DESIGN Qualitative study. PARTICIPANTS Twenty-two adults recently recovered from an episode of non-specific low back pain who participated in a 6-month, progressive and individualised walking program that was prescribed by a physiotherapist trained in health coaching. METHODS Semi-structured focus groups conducted online following completion of the walking program. Interview questions explored: primary motivations for starting a walking program, identification of which elements were useful in optimising adherence to the program, and identification of the barriers to and facilitators of engagement with the program. Audio recordings were transcribed and thematic analysis was conducted. RESULTS Three major themes were identified. Theme one identified that strong motivators to start a walking program were anticipated improvements in low back pain management and the added general health benefits of a more active lifestyle. Theme two identified that fear of high-impact exercises led to avoidance; however, walking was considered a safe exercise option. Theme three identified accountability, enjoyment of exercise and health benefits were critical to adherence. CONCLUSION Participants recently recovered from low back pain reflected positively on a physiotherapist-prescribed walking program. Participants described what elements of the program were crucial to starting exercise and optimising adherence. These findings have informed a list of practical recommendations for physiotherapists to improve patient commencement and adherence to exercise.
Collapse
Affiliation(s)
- Natasha C Pocovi
- Department of Health Professions, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia.
| | - Julie Ayre
- Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Simon D French
- Department of Chiropractic, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Chung-Wei Christine Lin
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Anne Tiedemann
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Dafna Merom
- School of Science and Health, Western Sydney University, Sydney, Australia
| | - Kirsten McCaffrey
- Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Mark J Hancock
- Department of Health Professions, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| |
Collapse
|
18
|
Kharel P, Zadro JR, Ferreira G, Howell M, Howard K, Wortley S, McLennan C, Maher CG. Can language enhance physical therapists' willingness to follow Choosing Wisely recommendations? A best-worst scaling study. Braz J Phys Ther 2023; 27:100534. [PMID: 37597492 PMCID: PMC10462803 DOI: 10.1016/j.bjpt.2023.100534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 06/18/2023] [Accepted: 08/04/2023] [Indexed: 08/21/2023] Open
Abstract
BACKGROUND Choosing Wisely recommendations could reduce physical therapists' use of low-value care. OBJECTIVE To investigate whether language influences physical therapists' willingness to follow the Australian Physiotherapy Association's (APA) Choosing Wisely recommendations. DESIGN Best-worst Scaling survey METHODS: The six original APA Choosing Wisely recommendations were modified based on four language characteristics (level of detail, strength- qualified/unqualified, framing, and alternatives to low-value care) to create 60 recommendations. Physical therapists were randomised to a block of seven choice tasks, which included four recommendations. Participants indicated which recommendation they were most and least willing to follow. A multinomial logistic regression model was used to create normalised (0=least preferred; 10=most preferred) and marginal preference scores. RESULTS 215 physical therapists (48.5% of 443 who started the survey) completed the survey. Participants' mean age (SD) was 38.7 (10.6) and 47.9% were female. Physical therapists were more willing to follow recommendations with more detail (marginal preference score of 1.1) or that provided alternatives to low-value care (1.3) and less willing to follow recommendations with negative framing (-1.3). The use of qualified ('don't routinely') language (vs. unqualified - 'don't') did not affect willingness. Physical therapists were more willing to follow recommendations to avoid imaging for non-specific low back pain (3.9) and electrotherapy for low back pain (3.8) vs. recommendation to avoid incentive spirometry after upper abdominal and cardiac surgery. CONCLUSION Physical therapists were more willing to follow recommendations that provided more detail, alternatives to low-value care, and were positively framed. These findings can inform the development of future Choosing Wisely recommendations and could help reduce low-value physical therapy.
Collapse
Affiliation(s)
- Priti Kharel
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia; School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
| | - Joshua R Zadro
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia; School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Giovanni Ferreira
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia; School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Martin Howell
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Kirsten Howard
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Sally Wortley
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Charlotte McLennan
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia; School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| |
Collapse
|
19
|
Maher CG, Archambeau A, Buchbinder R, French SD, Morphet J, Nicholas MK, O'Sullivan P, Pirotta M, Yelland MJ, Zeller L, Saad N, Marles E, Bhasale AL, Lane C. Introducing Australia's clinical care standard for low back pain : A new clinical care standard provides evidence-based guidance to help clinicians deliver best care for people with low back pain. Chiropr Man Therap 2023; 31:17. [PMID: 37322536 DOI: 10.1186/s12998-023-00485-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023] Open
Affiliation(s)
- Christopher G Maher
- Sydney Musculoskeletal Health, University of Sydney, Sydney, NSW, Australia.
| | | | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Simon D French
- Department of Chiropractic, Macquarie University, Sydney, NSW, Australia
| | - Julia Morphet
- School of Nursing and Midwifery, Monash University, Melbourne, VIC, Australia
- College of Emergency Nursing Australasia, Melbourne, VIC, Australia
| | - Michael K Nicholas
- Pain Management Research Institute, Kolling Institute of Medical Research, University of Sydney, Sydney, NSW, Australia
| | - Peter O'Sullivan
- School of Allied Health, Curtin University, Perth, WA, Australia
| | - Marie Pirotta
- Department of General Practice, University of Melbourne, Melbourne, VIC, Australia
| | - Michael J Yelland
- School of Medicine, Griffith University, Gold Coast, QLD, Australia
- Arana Hills Medical Centre, Brisbane, QLD, Australia
| | - Leo Zeller
- Metro North Health, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Nivene Saad
- Metro South Health, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Elizabeth Marles
- Australian Commission On Safety and Quality in Health Care, Sydney, NSW, Australia
| | - Alice L Bhasale
- Australian Commission On Safety and Quality in Health Care, Sydney, NSW, Australia
| | - Christina Lane
- Australian Commission On Safety and Quality in Health Care, Sydney, NSW, Australia
| |
Collapse
|
20
|
Gan JFL, McKay MJ, Jones CMP, Harris IA, McCaffery K, Thompson R, Hoffmann TC, Adie S, Maher CG, Zadro JR. Developing a patient decision aid for Achilles tendon rupture management: a mixed-methods study. BMJ Open 2023; 13:e072553. [PMID: 37316308 DOI: 10.1136/bmjopen-2023-072553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/16/2023] Open
Abstract
OBJECTIVE To develop and user-test a patient decision aid portraying the benefits and harms of non-surgical management and surgery for Achilles tendon ruptures. DESIGN Mixed methods. SETTING A draft decision aid was developed using guidance from a multidisciplinary steering group and existing patient decision aids. Participants were recruited through social media. PARTICIPANTS People who have previously sustained an Achilles tendon rupture and health professionals who manage these patients. PRIMARY AND SECONDARY OUTCOMES Semi-structured interviews and questionnaires were used to gather feedback on the decision aid from health professionals and patients who had previously suffered an Achilles tendon rupture. The feedback was used to redraft the decision aid and assess acceptability. An iterative cycle of interviews, redrafting according to feedback and further interviews was used. Interviews were analysed using reflexive thematic analysis. Questionnaire data were analysed descriptively. RESULTS We interviewed 18 health professionals (13 physiotherapists, 3 orthopaedic surgeons, 1 chiropractor, 1 sports medicine physician) and 15 patients who had suffered an Achilles tendon rupture (median time since rupture was 12 months). Most health professionals and patients rated the aid's acceptability as good-excellent. Interviews showcased agreement among health professionals and patients on most aspects of the decision aid: introduction, treatment options, comparing benefits and harms, questions to ask health professionals and formatting. However, health professionals had differing views on details about Achilles tendon retraction distance, factors that modify the risk of harms, treatment protocols and evidence on benefits and harms. CONCLUSION Our patient decision aid is an acceptable tool to both patients and health professionals, and our study highlights the views of key stakeholders on important information to consider when developing a patient decision aid for Achilles tendon rupture management. A randomised controlled trial evaluating the impact of this tool on the decision-making of people considering Achilles tendon surgery is warranted.
Collapse
Affiliation(s)
- Jan F L Gan
- Discipline of Physiotherapy, School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Marnee J McKay
- Discipline of Physiotherapy, School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Caitlin M P Jones
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Ian A Harris
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Kirsten McCaffery
- Sydney Health Literacy Lab, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Rachel Thompson
- Discipline of Behavioural and Social Sciences in Health, School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Tammy C Hoffmann
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Sam Adie
- South West Sydney Clinical School, University of New South Wales Medicine and Health, Liverpool, New South Wales, Australia
| | - Christopher G Maher
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Joshua R Zadro
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
21
|
Abdel Shaheed C, Mathieson S, Wilson R, Furmage AM, Maher CG. Who should judge treatment effects as unimportant? J Physiother 2023:S1836-9553(23)00034-6. [PMID: 37263906 DOI: 10.1016/j.jphys.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 11/30/2022] [Accepted: 04/06/2023] [Indexed: 06/03/2023] Open
Affiliation(s)
- Christina Abdel Shaheed
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Institute for Musculoskeletal Health, Sydney, Australia.
| | - Stephanie Mathieson
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Institute for Musculoskeletal Health, Sydney, Australia
| | - Ross Wilson
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Ann-Mason Furmage
- Royal Prince Alfred Hospital Consumer Advisory Group, Sydney Local Health District, Sydney, Australia
| | - Christopher G Maher
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Institute for Musculoskeletal Health, Sydney, Australia
| |
Collapse
|
22
|
Maher CG, Archambeau A, Buchbinder R, French SD, Morphet J, Nicholas MK, O'Sullivan P, Pirotta M, Yelland MJ, Zeller L, Saad N, Marles E, Bhasale AL, Lane C. Introducing Australia's clinical care standard for low back pain. ANZ J Surg 2023. [PMID: 37243309 DOI: 10.1111/ans.18517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 05/04/2023] [Indexed: 05/28/2023]
Affiliation(s)
- Christopher G Maher
- Sydney Musculoskeletal Health, University of Sydney, Sydney, New South Wales, Australia
| | | | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Simon D French
- Department of Chiropractic, Macquarie University, Sydney, New South Wales, Australia
| | - Julia Morphet
- School of Nursing and Midwifery, Monash University, Melbourne, Victoria, Australia
- College of Emergency Nursing Australasia, Melbourne, Victoria, Australia
| | - Michael K Nicholas
- Pain Management Research Institute, Kolling Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Peter O'Sullivan
- School of Allied Health, Curtin University, Perth, Western Australia, Australia
| | - Marie Pirotta
- Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
| | - Michael J Yelland
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
- Arana Hills Medical Centre, Brisbane, Queensland, Australia
| | - Leo Zeller
- Metro North Health, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Nivene Saad
- Metro South Health, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Elizabeth Marles
- Australian Commission on Safety and Quality in Health Care, Sydney, New South Wales, Australia
| | - Alice L Bhasale
- Australian Commission on Safety and Quality in Health Care, Sydney, New South Wales, Australia
| | - Christina Lane
- Australian Commission on Safety and Quality in Health Care, Sydney, New South Wales, Australia
| |
Collapse
|
23
|
Zadro JR, Michaleff ZA, O'Keeffe M, Ferreira GE, Traeger AC, Gamble AR, Afeaki F, Li Y, Wen E, Yao J, Zhu K, Page R, Harris IA, Maher CG. How do people perceive different advice for rotator cuff disease? A content analysis of qualitative data collected in a randomised experiment. BMJ Open 2023; 13:e069779. [PMID: 37147087 PMCID: PMC10163512 DOI: 10.1136/bmjopen-2022-069779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2023] Open
Abstract
OBJECTIVES To explore how people perceive different advice for rotator cuff disease in terms of words/feelings evoked by the advice and treatment needs. SETTING We performed a content analysis of qualitative data collected in a randomised experiment. PARTICIPANTS 2028 people with shoulder pain read a vignette describing someone with rotator cuff disease and were randomised to: bursitis label plus guideline-based advice, bursitis label plus treatment recommendation, rotator cuff tear label plus guideline-based advice and rotator cuff tear label plus treatment recommendation. Guideline-based advice included encouragement to stay active and positive prognostic information. Treatment recommendation emphasised that treatment is needed for recovery. PRIMARY AND SECONDARY OUTCOMES Participants answered questions about: (1) words/feelings evoked by the advice; (2) treatments they feel are needed. Two researchers developed coding frameworks to analyse responses. RESULTS 1981 (97% of 2039 randomised) responses for each question were analysed. Guideline-based advice (vs treatment recommendation) more often elicited words/feelings of reassurance, having a minor issue, trust in expertise and feeling dismissed, and treatment needs of rest, activity modification, medication, wait and see, exercise and normal movements. Treatment recommendation (vs guideline-based advice) more often elicited words/feelings of needing treatment/investigation, psychological distress and having a serious issue, and treatment needs of injections, surgery, investigations, and to see a doctor. CONCLUSIONS Words/feelings evoked by advice for rotator cuff disease and perceived treatment needs may explain why guideline-based advice reduces perceived need for unnecessary care compared to a treatment recommendation.
Collapse
Affiliation(s)
- Joshua R Zadro
- Sydney Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Zoe A Michaleff
- Northern NSW Local Health District, Lismore, New South Wales, Australia
| | - Mary O'Keeffe
- Sydney Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Giovanni E Ferreira
- Sydney Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Adrian C Traeger
- Sydney Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Andrew R Gamble
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Frederick Afeaki
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Yaozhuo Li
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Erya Wen
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jiawen Yao
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Kejie Zhu
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Richard Page
- University Hospital Geelong and St. John of God Hospital Geelong, Barwon Centre for Orthopaedic Research and Education (B-CORE), IMPACT, Deakin University, Geelong, Victoria, Australia
| | - Ian A Harris
- Sydney Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Christopher G Maher
- Sydney Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| |
Collapse
|
24
|
Maher CG, Archambeau A, Buchbinder R, French SD, Morphet J, Nicholas MK, O'Sullivan P, Pirotta M, Yelland MJ, Zeller L, Saad N, Marles E, Bhasale AL, Lane C. Introducing Australia's clinical care standard for low back pain. Med J Aust 2023; 218:354-356. [PMID: 37120763 DOI: 10.5694/mja2.51915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/27/2023] [Accepted: 02/16/2023] [Indexed: 05/01/2023]
Affiliation(s)
| | | | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC
| | - Simon D French
- Department of Chiropractic, Macquarie University, Sydney, NSW
| | - Julie Morphet
- School of Nursing and Midwifery, Monash University, Melbourne, VIC
- College of Emergency Nursing Australasia, Melbourne, VIC
| | - Michael K Nicholas
- Pain Management Research Institute, Kolling Institute of Medical Research, University of Sydney, Sydney, NSW
| | | | - Marie Pirotta
- Department of General Practice, University of Melbourne, Melbourne, VIC
| | - Michael J Yelland
- School of Medicine, Griffith University, Gold Coast, QLD
- Arana Hills Medical Centre, Brisbane, QLD
| | - Leo Zeller
- Metro North Health, Royal Brisbane and Women's Hospital, Brisbane, QLD
| | - Nivene Saad
- Metro South Health, Princess Alexandra Hospital, Brisbane, QLD
| | - Elizabeth Marles
- Australian Commission on Safety and Quality in Health Care, Sydney, NSW
| | - Alice L Bhasale
- Australian Commission on Safety and Quality in Health Care, Sydney, NSW
| | - Christina Lane
- Australian Commission on Safety and Quality in Health Care, Sydney, NSW
| |
Collapse
|
25
|
Maher CG, Archambeau A, Buchbinder R, French SD, Morphet J, Nicholas MK, O'Sullivan P, Pirotta M, Yelland MJ, Zeller L, Saad N, Marles E, Bhasale AL, Lane C. Introducing Australia's clinical care standard for low back pain. J Med Imaging Radiat Oncol 2023. [PMID: 37125441 DOI: 10.1111/1754-9485.13532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/06/2023] [Indexed: 05/02/2023]
Affiliation(s)
- Christopher G Maher
- Sydney Musculoskeletal Health, University of Sydney, Sydney, New South Wales, Australia
| | - Aline Archambeau
- Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Simon D French
- Department of Chiropractic, Macquarie University, Sydney, New South Wales, Australia
| | - Julie Morphet
- School of Nursing and Midwifery, Monash University, Melbourne, Victoria, Australia
- College of Emergency Nursing Australasia, Melbourne, Victoria, Australia
| | - Michael K Nicholas
- Pain Management Research Institute, Kolling Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Peter O'Sullivan
- School of Allied Health, Curtin University, Perth, Western Australia, Australia
| | - Marie Pirotta
- Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
| | - Michael J Yelland
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
- Arana Hills Medical Centre, Brisbane, Queensland, Australia
| | - Leo Zeller
- Metro North Health, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Nivene Saad
- Metro South Health, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Elizabeth Marles
- Australian Commission on Safety and Quality in Health Care, Sydney, New South Wales, Australia
| | - Alice L Bhasale
- Australian Commission on Safety and Quality in Health Care, Sydney, New South Wales, Australia
| | - Christina Lane
- Australian Commission on Safety and Quality in Health Care, Sydney, New South Wales, Australia
| |
Collapse
|
26
|
de Campos TF, da Silva TM, Maher CG, Pocovi NC, Hancock MJ. Prognosis of a new episode of low-back pain in a community inception cohort. Eur J Pain 2023; 27:602-610. [PMID: 36692107 PMCID: PMC10946505 DOI: 10.1002/ejp.2083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 01/05/2023] [Accepted: 01/19/2023] [Indexed: 01/25/2023]
Abstract
BACKGROUND Most studies investigating the prognosis of low back pain (LBP) enrol people presenting for care, rather than all people who have an episode of LBP. We aimed to describe the prognosis of an acute episode of LBP in a community inception cohort. METHODS We used data from two previous studies investigating recurrence of LBP. Participants without current LBP were contacted monthly to assess if they had experienced a new episode of LBP. 366 participants reporting a new episode of LBP were included in the current study. The primary outcome was duration of the new episode of LBP. Secondary outcomes were average and worst pain during the episode and the proportion of participants seeking care. RESULTS The median duration of the episode was 5 days (95% CI 3.99 to 6.02). The cumulative probability of recovery was 70.0% (95% CI 65.3 to 74.7) before 1 week, 86.1% (95% CI 82.6 to 89.6) before 3 weeks, 90.9% (95% CI 88.0 to 93.8) before 6 weeks, and 93.5% (95% CI 90.8 to 96.0) before 12 weeks. The mean average pain intensity was 3.7 (SD ± 1.5), and the mean worst pain intensity was 5.6 (SD ± 1.9). The proportion of patients who sought care was 39.5% (95% CI 33.9 to 46.4). CONCLUSIONS This study found most episodes of LBP recover rapidly and more quickly than typically reported for clinical populations. The worst pain during the episode was typically moderate despite the rapid recovery for most people. Approximately 40% of the participants who experienced an episode of LBP sought care. SIGNIFICANCE This study describes the prognosis of an acute episode of LBP in a community inception cohort. This study found the majority of episodes of LBP, in community-dwelling adults, recover rapidly (median of 5 days) and more quickly than typically reported for clinical populations. The community should be reassured about the favourable prognosis of acute LBP.
Collapse
Affiliation(s)
- Tarcisio F. de Campos
- Department of Health Sciences, Faculty of Medicine, Health and Human SciencesMacquarie UniversityNew South WalesSydneyAustralia
- JW & M Cunningham Orthopaedic Clinical Research FellowSt Vincent's Private HospitalSydneyNew South WalesAustralia
- St Vincent's Private Allied Health ServicesSt Vincent's Private HospitalSydneyNew South WalesAustralia
| | - Tatiane M. da Silva
- Master and Doctoral Programs in Physical TherapyUniversidade Cidade de Sao PauloSao PauloBrazil
| | - Christopher G. Maher
- Sydney School of Public Health, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
| | - Natasha C. Pocovi
- Department of Health Sciences, Faculty of Medicine, Health and Human SciencesMacquarie UniversityNew South WalesSydneyAustralia
| | - Mark J. Hancock
- Department of Health Sciences, Faculty of Medicine, Health and Human SciencesMacquarie UniversityNew South WalesSydneyAustralia
| |
Collapse
|
27
|
Maher CG, Archambeau A, Buchbinder R, French SD, Morphet J, Nicholas MK, O'Sullivan P, Pirotta M, Yelland MJ, Zeller L, Saad N, Marles E, Bhasale AL, Lane C. Introducing Australia's clinical care standard for low back pain. Intern Med J 2023; 53:664-667. [PMID: 37126539 DOI: 10.1111/imj.16090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/05/2023] [Indexed: 05/02/2023]
Affiliation(s)
- Christopher G Maher
- Sydney Musculoskeletal Health, University of Sydney, Sydney, New South Wales, Australia
| | - Aline Archambeau
- Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Simon D French
- Department of Chiropractic, Macquarie University, Sydney, New South Wales, Australia
| | - Julia Morphet
- School of Nursing and Midwifery, Monash University, Melbourne, Victoria, Australia
- College of Emergency Nursing Australasia, Melbourne, Victoria, Australia
| | - Michael K Nicholas
- Pain Management Research Institute, Kolling Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Peter O'Sullivan
- School of Allied Health, Curtin University, Perth, Western Australia, Australia
| | - Marie Pirotta
- Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
| | - Michael J Yelland
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
- General and Musculoskeletal Medicine Practitioner, Arana Hills Medical Centre, Brisbane, Queensland, Australia
| | - Leo Zeller
- Metro North Health, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Nivene Saad
- Metro South Health, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Elizabeth Marles
- Primary Care, Australian Commission on Safety and Quality in Health Care, Sydney, New South Wales, Australia
| | - Alice L Bhasale
- Clinical Care Standards, Australian Commission on Safety and Quality in Health Care, Sydney, New South Wales, Australia
| | - Christina Lane
- Australian Commission on Safety and Quality in Health Care, Sydney, New South Wales, Australia
| |
Collapse
|
28
|
Maher CG, Archambeau A, Buchbinder R, French SD, Morphet J, Nicholas MK, O'Sullivan P, Pirotta M, Yelland MJ, Zeller L, Saad N, Marles E, Bhasale AL, Lane C. Introducing Australia's clinical care standard for low back pain. Emerg Med Australas 2023; 35:370-373. [PMID: 37120762 DOI: 10.1111/1742-6723.14218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 05/01/2023]
Affiliation(s)
- Christopher G Maher
- Sydney Musculoskeletal Health, University of Sydney, Sydney, New South Wales, Australia
| | - Aline Archambeau
- Emergency Department, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Simon D French
- Department of Chiropractic, Macquarie University, Sydney, New South Wales, Australia
| | - Julie Morphet
- School of Nursing and Midwifery, Monash University, Melbourne, Victoria, Australia
- College of Emergency Nursing Australasia, Melbourne, Victoria, Australia
| | - Michael K Nicholas
- Pain Management Research Institute, Kolling Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Peter O'Sullivan
- School of Allied Health, Curtin University, Perth, Western Australia, Australia
| | - Marie Pirotta
- Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
| | - Michael J Yelland
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
- Arana Hills Medical Centre, Brisbane, Queensland, Australia
| | - Leo Zeller
- Metro North Health, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Nivene Saad
- Metro South Health, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Elizabeth Marles
- Australian Commission on Safety and Quality in Health Care, Sydney, New South Wales, Australia
| | - Alice L Bhasale
- Australian Commission on Safety and Quality in Health Care, Sydney, New South Wales, Australia
| | - Christina Lane
- Australian Commission on Safety and Quality in Health Care, Sydney, New South Wales, Australia
| |
Collapse
|
29
|
Melman A, Lord HJ, Coombs D, Zadro J, Maher CG, Machado GC. Global prevalence of hospital admissions for low back pain: a systematic review with meta-analysis. BMJ Open 2023; 13:e069517. [PMID: 37085316 PMCID: PMC10124269 DOI: 10.1136/bmjopen-2022-069517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/23/2023] Open
Abstract
OBJECTIVES To determine the proportion of low back pain presentations that are admitted to hospital from the emergency department (ED), the proportion of hospital admissions due to a primary diagnosis of low back pain and the mean hospital length of stay (LOS), globally. METHODS We searched MEDLINE, CINAHL, EMBASE, Web of Science, PsycINFO and LILACS from inception to July 2022. Secondary data were retrieved from publicly available government agency publications and international databases. Studies investigating admitted patients aged >18 years with a primary diagnosis of musculoskeletal low back pain and/or lumbosacral radicular pain were included. RESULTS There was high heterogeneity in admission rates for low back pain from the ED, with a median of 9.6% (IQR 3.3-25.2; 9 countries). The median percentage of all hospital admissions that were due to low back pain was 0.9% (IQR 0.6-1.5; 30 countries). The median hospital LOS across 39 countries was 6.2 days for 'dorsalgia' (IQR 4.4-8.6) and 5.4 days for 'intervertebral disc disorders' (IQR 4.1-8.4). Low back pain admissions per 100 000 population had a median of 159.1 (IQR 82.6-313.8). The overall quality of the evidence was moderate. CONCLUSION This is the first systematic review with meta-analysis summarising the global prevalence of hospital admissions and hospital LOS for low back pain. There was relatively sparse data from rural and regional regions and low-income countries, as well as high heterogeneity in the results.
Collapse
Affiliation(s)
- Alla Melman
- The University of Sydney, Sydney Musculoskeletal Health, Camperdown, New South Wales, Australia
| | - Harrison J Lord
- Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Danielle Coombs
- The University of Sydney, Sydney Musculoskeletal Health, Camperdown, New South Wales, Australia
| | - Joshua Zadro
- The University of Sydney, Sydney Musculoskeletal Health, Camperdown, New South Wales, Australia
| | - Christopher G Maher
- The University of Sydney, Sydney Musculoskeletal Health, Camperdown, New South Wales, Australia
| | - Gustavo C Machado
- The University of Sydney, Sydney Musculoskeletal Health, Camperdown, New South Wales, Australia
| |
Collapse
|
30
|
Cashin AG, Wand BM, O'Connell NE, Lee H, Rizzo RR, Bagg MK, O'Hagan E, Maher CG, Furlan AD, van Tulder MW, McAuley JH. Pharmacological treatments for low back pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev 2023; 4:CD013815. [PMID: 37014979 PMCID: PMC10072849 DOI: 10.1002/14651858.cd013815.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
BACKGROUND Pharmacological interventions are the most used treatment for low back pain (LBP). Use of evidence from systematic reviews of the effects of pharmacological interventions for LBP published in the Cochrane Library, is limited by lack of a comprehensive overview. OBJECTIVES To summarise the evidence from Cochrane Reviews of the efficacy, effectiveness, and safety of systemic pharmacological interventions for adults with non-specific LBP. METHODS The Cochrane Database of Systematic Reviews was searched from inception to 3 June 2021, to identify reviews of randomised controlled trials (RCTs) that investigated systemic pharmacological interventions for adults with non-specific LBP. Two authors independently assessed eligibility, extracted data, and assessed the quality of the reviews and certainty of the evidence using the AMSTAR 2 and GRADE tools. The review focused on placebo comparisons and the main outcomes were pain intensity, function, and safety. MAIN RESULTS Seven Cochrane Reviews that included 103 studies (22,238 participants) were included. There is high confidence in the findings of five reviews, moderate confidence in one, and low confidence in the findings of another. The reviews reported data on six medicines or medicine classes: paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, benzodiazepines, opioids, and antidepressants. Three reviews included participants with acute or sub-acute LBP and five reviews included participants with chronic LBP. Acute LBP Paracetamol There was high-certainty evidence for no evidence of difference between paracetamol and placebo for reducing pain intensity (MD 0.49 on a 0 to 100 scale (higher scores indicate worse pain), 95% CI -1.99 to 2.97), reducing disability (MD 0.05 on a 0 to 24 scale (higher scores indicate worse disability), 95% CI -0.50 to 0.60), and increasing the risk of adverse events (RR 1.07, 95% CI 0.86 to 1.33). NSAIDs There was moderate-certainty evidence for a small between-group difference favouring NSAIDs compared to placebo at reducing pain intensity (MD -7.29 on a 0 to 100 scale (higher scores indicate worse pain), 95% CI -10.98 to -3.61), high-certainty evidence for a small between-group difference for reducing disability (MD -2.02 on a 0-24 scale (higher scores indicate worse disability), 95% CI -2.89 to -1.15), and very low-certainty evidence for no evidence of an increased risk of adverse events (RR 0.86, 95% CI 0. 63 to 1.18). Muscle relaxants and benzodiazepines There was moderate-certainty evidence for a small between-group difference favouring muscle relaxants compared to placebo for a higher chance of pain relief (RR 0.58, 95% CI 0.45 to 0.76), and higher chance of improving physical function (RR 0.55, 95% CI 0.40 to 0.77), and increased risk of adverse events (RR 1.50, 95% CI 1. 14 to 1.98). Opioids None of the included Cochrane Reviews aimed to identify evidence for acute LBP. Antidepressants No evidence was identified by the included reviews for acute LBP. Chronic LBP Paracetamol No evidence was identified by the included reviews for chronic LBP. NSAIDs There was low-certainty evidence for a small between-group difference favouring NSAIDs compared to placebo for reducing pain intensity (MD -6.97 on a 0 to 100 scale (higher scores indicate worse pain), 95% CI -10.74 to -3.19), reducing disability (MD -0.85 on a 0-24 scale (higher scores indicate worse disability), 95% CI -1.30 to -0.40), and no evidence of an increased risk of adverse events (RR 1.04, 95% CI -0.92 to 1.17), all at intermediate-term follow-up (> 3 months and ≤ 12 months postintervention). Muscle relaxants and benzodiazepines There was low-certainty evidence for a small between-group difference favouring benzodiazepines compared to placebo for a higher chance of pain relief (RR 0.71, 95% CI 0.54 to 0.93), and low-certainty evidence for no evidence of difference between muscle relaxants and placebo in the risk of adverse events (RR 1.02, 95% CI 0.67 to 1.57). Opioids There was high-certainty evidence for a small between-group difference favouring tapentadol compared to placebo at reducing pain intensity (MD -8.00 on a 0 to 100 scale (higher scores indicate worse pain), 95% CI -1.22 to -0.38), moderate-certainty evidence for a small between-group difference favouring strong opioids for reducing pain intensity (SMD -0.43, 95% CI -0.52 to -0.33), low-certainty evidence for a medium between-group difference favouring tramadol for reducing pain intensity (SMD -0.55, 95% CI -0.66 to -0.44) and very low-certainty evidence for a small between-group difference favouring buprenorphine for reducing pain intensity (SMD -0.41, 95% CI -0.57 to -0.26). There was moderate-certainty evidence for a small between-group difference favouring strong opioids compared to placebo for reducing disability (SMD -0.26, 95% CI -0.37 to -0.15), moderate-certainty evidence for a small between-group difference favouring tramadol for reducing disability (SMD -0.18, 95% CI -0.29 to -0.07), and low-certainty evidence for a small between-group difference favouring buprenorphine for reducing disability (SMD -0.14, 95% CI -0.53 to -0.25). There was low-certainty evidence for a small between-group difference for an increased risk of adverse events for opioids (all types) compared to placebo; nausea (RD 0.10, 95% CI 0.07 to 0.14), headaches (RD 0.03, 95% CI 0.01 to 0.05), constipation (RD 0.07, 95% CI 0.04 to 0.11), and dizziness (RD 0.08, 95% CI 0.05 to 0.11). Antidepressants There was low-certainty evidence for no evidence of difference for antidepressants (all types) compared to placebo for reducing pain intensity (SMD -0.04, 95% CI -0.25 to 0.17) and reducing disability (SMD -0.06, 95% CI -0.40 to 0.29). AUTHORS' CONCLUSIONS We found no high- or moderate-certainty evidence that any investigated pharmacological intervention provided a large or medium effect on pain intensity for acute or chronic LBP compared to placebo. For acute LBP, we found moderate-certainty evidence that NSAIDs and muscle relaxants may provide a small effect on pain, and high-certainty evidence for no evidence of difference between paracetamol and placebo. For safety, we found very low- and high-certainty evidence for no evidence of difference with NSAIDs and paracetamol compared to placebo for the risk of adverse events, and moderate-certainty evidence that muscle relaxants may increase the risk of adverse events. For chronic LBP, we found low-certainty evidence that NSAIDs and very low- to high-certainty evidence that opioids may provide a small effect on pain. For safety, we found low-certainty evidence for no evidence of difference between NSAIDs and placebo for the risk of adverse events, and low-certainty evidence that opioids may increase the risk of adverse events.
Collapse
Affiliation(s)
- Aidan G Cashin
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
- School of Health Sciences, Faculty of Medicine & Health, University of New South Wales, Sydney, Australia
| | - Benedict M Wand
- School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Australia
| | - Neil E O'Connell
- Department of Health Sciences, Centre for Health and Wellbeing Across the Lifecourse, Brunel University London, Uxbridge, UK
| | - Hopin Lee
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
| | - Rodrigo Rn Rizzo
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
- School of Health Sciences, Faculty of Medicine & Health, University of New South Wales, Sydney, Australia
| | - Matthew K Bagg
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
- Prince of Wales Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia
- New College Village, University of New South Wales, Sydney, Australia
| | - Edel O'Hagan
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
- Prince of Wales Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia
| | - Christopher G Maher
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, Australia
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | | | - Maurits W van Tulder
- Department of Health Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, Netherlands
| | - James H McAuley
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
- School of Health Sciences, Faculty of Medicine & Health, University of New South Wales, Sydney, Australia
| |
Collapse
|
31
|
Wewege MA, Bagg MK, Jones MD, Ferraro MC, Cashin AG, Rizzo RR, Leake HB, Hagstrom AD, Sharma S, McLachlan AJ, Maher CG, Day R, Wand BM, O'Connell NE, Nikolakopolou A, Schabrun S, Gustin SM, McAuley JH. Comparative effectiveness and safety of analgesic medicines for adults with acute non-specific low back pain: systematic review and network meta-analysis. BMJ 2023; 380:e072962. [PMID: 36948512 PMCID: PMC10540836 DOI: 10.1136/bmj-2022-072962] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2023] [Indexed: 03/24/2023]
Abstract
OBJECTIVE To evaluate the comparative effectiveness and safety of analgesic medicines for acute non-specific low back pain. DESIGN Systematic review and network meta-analysis. DATA SOURCES Medline, PubMed, Embase, CINAHL, CENTRAL, ClinicalTrials.gov, clinicialtrialsregister.eu, and World Health Organization's International Clinical Trials Registry Platform from database inception to 20 February 2022. ELIGIBILITY CRITERIA FOR STUDY SELECTION Randomised controlled trials of analgesic medicines (eg, non-steroidal anti-inflammatory drugs, paracetamol, opioids, anti-convulsant drugs, skeletal muscle relaxants, or corticosteroids) compared with another analgesic medicine, placebo, or no treatment. Adults (≥18 years) who reported acute non-specific low back pain (for less than six weeks). DATA EXTRACTION AND SYNTHESIS Primary outcomes were low back pain intensity (0-100 scale) at end of treatment and safety (number of participants who reported any adverse event during treatment). Secondary outcomes were low back specific function, serious adverse events, and discontinuation from treatment. Two reviewers independently identified studies, extracted data, and assessed risk of bias. A random effects network meta-analysis was done and confidence was evaluated by the Confidence in Network Meta-Analysis method. RESULTS 98 randomised controlled trials (15 134 participants, 49% women) included 69 different medicines or combinations. Low or very low confidence was noted in evidence for reduced pain intensity after treatment with tolperisone (mean difference -26.1 (95% confidence intervals -34.0 to -18.2)), aceclofenac plus tizanidine (-26.1 (-38.5 to -13.6)), pregabalin (-24.7 (-34.6 to -14.7)), and 14 other medicines compared with placebo. Low or very low confidence was noted for no difference between the effects of several of these medicines. Increased adverse events had moderate to very low confidence with tramadol (risk ratio 2.6 (95% confidence interval 1.5 to 4.5)), paracetamol plus sustained release tramadol (2.4 (1.5 to 3.8)), baclofen (2.3 (1.5 to 3.4)), and paracetamol plus tramadol (2.1 (1.3 to 3.4)) compared with placebo. These medicines could increase the risk of adverse events compared with other medicines with moderate to low confidence. Moderate to low confidence was also noted for secondary outcomes and secondary analysis of medicine classes. CONCLUSIONS The comparative effectiveness and safety of analgesic medicines for acute non-specific low back pain are uncertain. Until higher quality randomised controlled trials of head-to-head comparisons are published, clinicians and patients are recommended to take a cautious approach to manage acute non-specific low back pain with analgesic medicines. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42019145257.
Collapse
Affiliation(s)
- Michael A Wewege
- School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia
| | - Matthew K Bagg
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Perth, WA, Australia
- Perron Institute for Neurological and Translational Science, Perth, WA, Australia
| | - Matthew D Jones
- School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia
| | - Michael C Ferraro
- School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia
| | - Aidan G Cashin
- School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia
| | - Rodrigo Rn Rizzo
- School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia
| | - Hayley B Leake
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia
- IIMPACT in Health, University of South Australia, Adelaide, SA, Australia
| | - Amanda D Hagstrom
- School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Saurab Sharma
- School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia
| | - Andrew J McLachlan
- Sydney Pharmacy School, Faculty of Medicine and Health, University of Sydney, Gadigal Country, Sydney, NSW, Australia
| | - Christopher G Maher
- Sydney Musculoskeletal Health, University of Sydney, Gadigal Country, Sydney, NSW, Australia
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, NSW, Australia
| | - Richard Day
- Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
- St Vincent's Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Benedict M Wand
- Faculty of Medicine, Nursing and Midwifery and Health Sciences, University of Notre Dame Australia, Fremantle, WA, Australia
| | - Neil E O'Connell
- Department of Health Sciences, Centre for Health and Wellbeing Across the Lifecourse, Brunel University London, Uxbridge, UK
| | - Adriani Nikolakopolou
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Centre, University of Freiburg, Freiburg, Germany
| | - Siobhan Schabrun
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia
- School of Physical Therapy, University of Western Ontario, London, ON, Canada
- The Gray Centre for Mobility and Activity, Parkwood Institute, London, ON, Canada
| | - Sylvia M Gustin
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia
- NeuroRecovery Research Hub, School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - James H McAuley
- School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia
| |
Collapse
|
32
|
Pocovi NC, Graham PL, Lin CWC, French SD, Latimer J, Merom D, Tiedemann A, Maher CG, van Dongen JM, Clavisi O, Hancock MJ. Effectiveness and cost-effectiveness of a progressive, individualised walking and education program for prevention of low back pain recurrence in adults: statistical analysis plan for the WalkBack randomised controlled trial. Trials 2023; 24:197. [PMID: 36927497 PMCID: PMC10019396 DOI: 10.1186/s13063-023-07119-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 01/24/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND Exercise for the prevention of low back pain recurrences is recommended, but under-researched. The effectiveness and cost-effectiveness of a walking program for preventing low back pain recurrence remains unknown. This a priori statistical analysis plan describes the methods of analysis for the WalkBack trial. METHODS WalkBack is a prospectively registered, pragmatic, randomised controlled trial. The aim is to investigate the effectiveness and cost-effectiveness of a 6-month progressive and individualised walking and education program (intervention) for the prevention of low back pain recurrences, compared to a no-treatment control group. The primary outcome is days to the first recurrence of an episode of activity-limiting low back pain. Key secondary outcomes include days to any recurrence of low back pain, days to a care-seeking recurrence of low back pain, disability level, health-related quality of life, costs associated with low back pain and adverse events. All participants will be followed for a minimum of 12 months. Analysis will follow the intention-to-treat principle. Cox regression is planned to assess the effects for the outcomes of time to activity-limiting, minimal and care-seeking recurrence. Hazard ratios and median survival times with 95% confidence intervals will be calculated. The effect of the intervention on continuous outcomes will be estimated with repeated-measure linear mixed models. An economic evaluation will be performed from the societal perspective for recurrence prevented (yes/no) and quality-adjusted life years. The proportion of adverse events between groups will be compared using Fisher's exact test. DISCUSSION The WalkBack trial will provide evidence on the effectiveness and cost-effectiveness of a walking intervention to prevent low back pain recurrences. This statistical analysis plan provides transparency on the analysis of the trial. TRIAL REGISTRATION WalkBack - Effectiveness and cost-effectiveness of a progressive individualised walking and education program for the prevention of a recurrence of low back pain. ACTRN12619001134112 . Date Registered: 14/08/2019.
Collapse
Affiliation(s)
- Natasha C Pocovi
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia.
| | - Petra L Graham
- School of Mathematical and Physical Sciences, Macquarie University, Sydney, Australia
| | | | - Simon D French
- Department of Chiropractic, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Jane Latimer
- The University of Sydney, Sydney Musculoskeletal Health, Gadigal Country, Sydney, Australia
| | - Dafna Merom
- School of Health Sciences, Western Sydney University, Sydney, Australia
| | - Anne Tiedemann
- The University of Sydney, Sydney Musculoskeletal Health, Gadigal Country, Sydney, Australia
| | - Christopher G Maher
- The University of Sydney, Sydney Musculoskeletal Health, Gadigal Country, Sydney, Australia
| | - Johanna M van Dongen
- Department of Health Sciences, Vrije University of Amsterdam, Amsterdam, Netherlands
| | | | - Mark J Hancock
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| |
Collapse
|
33
|
Han CS, Maher CG, Steffens D, Diwan A, Magnussen J, Hancock EC, Hancock MJ. Some magnetic resonance imaging findings may predict future low back pain and disability: a systematic review. J Physiother 2023; 69:79-92. [PMID: 36914521 DOI: 10.1016/j.jphys.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 02/03/2023] [Accepted: 02/10/2023] [Indexed: 03/16/2023] Open
Abstract
QUESTIONS Do magnetic resonance imaging (MRI) findings predict future low back pain (LBP), associated disability and global recovery in people with current LBP? Do MRI findings predict these outcomes in people with no current LBP? Do MRI findings predict these outcomes in a mixed sample of people with and without current LBP? DESIGN This review is an update of a previous systematic review investigating the relationship between lumbar spine MRI findings and future LBP. PARTICIPANTS People with or without LBP with lumbar MRI scans. OUTCOME MEASURES MRI findings, pain and disability. RESULTS Of the included studies, 28 reported on participants with current LBP, eight reported on participants with no LBP and four reported on a mixed sample. Most results were based on single studies and did not demonstrate clear relationships between MRI findings and future LBP. In populations with current LBP, pooling demonstrated that the presence of Modic type 1 changes alone or Modic type 1 and 2 changes were associated with slightly worse pain or disability outcomes in the short term, and the presence of disc degeneration was associated with worse pain and disability outcomes in the long term. In populations with current LBP, pooling demonstrated no evidence of an association between the presence of nerve root compression and disability outcomes in the short term, and no evidence of an association between the presence of disc height reduction, disc herniation, spinal stenosis, high-intensity zone and clinical outcomes in the long term. In populations with no LBP, pooling demonstrated that the presence of disc degeneration may increase the likelihood of experiencing pain in the long term. In mixed populations, no pooling was possible; however, single studies demonstrated that Modic type 1, 2 or 3 changes and disc herniation were each associated with worse pain in the long term. CONCLUSIONS The results suggest that some MRI findings may have weak associations with future LBP; however, larger high-quality studies are needed to resolve uncertainty. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42021252919.
Collapse
Affiliation(s)
- Christopher S Han
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia.
| | - Christopher G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Ashish Diwan
- Spine Labs, St. George and Sutherland Clinical School, University of New South Wales, Sydney, Australia
| | - John Magnussen
- Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | | | - Mark J Hancock
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| |
Collapse
|
34
|
Abstract
BACKGROUND Spinal cord stimulation (SCS) is a surgical intervention used to treat persistent low back pain. SCS is thought to modulate pain by sending electrical signals via implanted electrodes into the spinal cord. The long term benefits and harms of SCS for people with low back pain are uncertain. OBJECTIVES To assess the effects, including benefits and harms, of SCS for people with low back pain. SEARCH METHODS On 10 June 2022, we searched CENTRAL, MEDLINE, Embase, and one other database for published trials. We also searched three clinical trials registers for ongoing trials. SELECTION CRITERIA We included all randomised controlled trials and cross-over trials comparing SCS with placebo or no treatment for low back pain. The primary comparison was SCS versus placebo, at the longest time point measured in the trials. Major outcomes were mean low back pain intensity, function, health-related quality of life, global assessment of efficacy, withdrawals due to adverse events, adverse events, and serious adverse events. Our primary time point was long-term follow-up (≥ 12 months). DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 13 studies with 699 participants: 55% of participants were female; mean age ranged from 47 to 59 years; and all participants had chronic low back pain with mean duration of symptoms ranging from five to 12 years. Ten cross-over trials compared SCS with placebo. Three parallel-group trials assessed the addition of SCS to medical management. Most studies were at risk of performance and detection bias from inadequate blinding and selective reporting bias. The placebo-controlled trials had other important biases, including lack of accounting for period and carryover effects. Two of the three parallel trials assessing SCS as an addition to medical management were at risk of attrition bias, and all three had substantial cross-over to the SCS group for time points beyond six months. In the parallel-group trials, we considered the lack of placebo control to be an important source of bias. None of our included studies evaluated the impact of SCS on mean low back pain intensity in the long term (≥ 12 months). The studies most often assessed outcomes in the immediate term (less than one month). At six months, the only available evidence was from a single cross-over trial (50 participants). There was moderate-certainty evidence that SCS probably does not improve back or leg pain, function, or quality of life compared with placebo. Pain was 61 points (on a 0- to 100-point scale, 0 = no pain) at six months with placebo, and 4 points better (8.2 points better to 0.2 points worse) with SCS. Function was 35.4 points (on a 0- to 100-point scale, 0 = no disability or best function) at six months with placebo, and 1.3 points better (3.9 points better to 1.3 points worse) with SCS. Health-related quality of life was 0.44 points out of 1 (0 to 1 index, 0 = worst quality of life) at six months with placebo, and 0.04 points better (0.16 points better to 0.08 points worse) with SCS. In that same study, nine participants (18%) experienced adverse events and four (8%) required revision surgery. Serious adverse events with SCS included infections, neurological damage, and lead migration requiring repeated surgery. We could not provide effect estimates of the relative risks as events were not reported for the placebo period. In parallel trials assessing SCS as an addition to medical management, it is uncertain whether, in the medium or long term, SCS can reduce low back pain, leg pain, or health-related quality of life, or if it increases the number of people reporting a 50% improvement or better, because the certainty of the evidence was very low. Low-certainty evidence suggests that adding SCS to medical management may slightly improve function and slightly reduce opioid use. In the medium term, mean function (0- to 100-point scale; lower is better) was 16.2 points better with the addition of SCS to medical management compared with medical management alone (95% confidence interval (CI) 19.4 points better to 13.0 points better; I2 = 95%; 3 studies, 430 participants; low-certainty evidence). The number of participants reporting opioid medicine use was 15% lower with the addition of SCS to medical management (95% CI 27% lower to 0% lower; I2 = 0%; 2 studies, 290 participants; low-certainty evidence). Adverse events with SCS were poorly reported but included infection and lead migration. One study found that, at 24 months, 13 of 42 people (31%) receiving SCS required revision surgery. It is uncertain to what extent the addition of SCS to medical management increases the risk of withdrawals due to adverse events, adverse events, or serious adverse events, because the certainty of the evidence was very low. AUTHORS' CONCLUSIONS Data in this review do not support the use of SCS to manage low back pain outside a clinical trial. Current evidence suggests SCS probably does not have sustained clinical benefits that would outweigh the costs and risks of this surgical intervention.
Collapse
Affiliation(s)
- Adrian C Traeger
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Stephen E Gilbert
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Ian A Harris
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
- South West Sydney Clinical School, University of New South Wales, Liverpool, Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| |
Collapse
|
35
|
Maher CG, Ferreira G, Jones C. Global Burden of Disease data for Indonesia. Lancet Glob Health 2023; 11:e335. [PMID: 36796974 DOI: 10.1016/s2214-109x(23)00005-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/19/2022] [Indexed: 02/16/2023]
Affiliation(s)
- Christopher G Maher
- The Institute of Musculoskeletal Health, University of Sydney, Sydney 2050, NSW, Australia.
| | - Giovanni Ferreira
- The Institute of Musculoskeletal Health, University of Sydney, Sydney 2050, NSW, Australia
| | - Caitlin Jones
- The Institute of Musculoskeletal Health, University of Sydney, Sydney 2050, NSW, Australia
| |
Collapse
|
36
|
Ferreira GE, Abdel-Shaheed C, Underwood M, Finnerup NB, Day RO, McLachlan A, Eldabe S, Zadro JR, Maher CG. Efficacy, safety, and tolerability of antidepressants for pain in adults: overview of systematic reviews. BMJ 2023; 380:e072415. [PMID: 36725015 PMCID: PMC9887507 DOI: 10.1136/bmj-2022-072415] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To provide a comprehensive overview of the efficacy, safety, and tolerability of antidepressants for pain according to condition. DESIGN Overview of systematic reviews. DATA SOURCES PubMed, Embase, PsycINFO, and the Cochrane Central Register of Controlled Trials from inception to 20 June 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Systematic reviews comparing any antidepressant with placebo for any pain condition in adults. DATA EXTRACTION AND SYNTHESIS Two reviewers independently extracted data. The main outcome measure was pain; for headache disorders it was frequency of headaches. Continuous pain outcomes were converted into a scale of 0 (no pain) to 100 (worst pain) and were presented as mean differences (95% confidence intervals). Dichotomous outcomes were presented as risk ratios (95% confidence intervals). Data were extracted from the time point closest to the end of treatment. When end of treatment was too variable across trials in a review, data were extracted from the outcome or time point with the largest number of trials and participants. Secondary outcomes were safety and tolerability (withdrawals because of adverse events). Findings were classified from each comparison as efficacious, not efficacious, or inconclusive. Certainty of evidence was assessed with the grading of recommendations assessment, development, and evaluation framework. RESULTS 26 reviews (156 unique trials and >25 000 participants) were included. These reviews reported on the efficacy of eight antidepressant classes covering 22 pain conditions (42 distinct comparisons). No review provided high certainty evidence on the efficacy of antidepressants for pain for any condition. 11 comparisons (nine conditions) were found where antidepressants were efficacious, four with moderate certainty evidence: serotonin-norepinephrine reuptake inhibitors (SNRIs) for back pain (mean difference -5.3, 95% confidence interval -7.3 to -3.3), postoperative pain (-7.3, -12.9 to -1.7), neuropathic pain (-6.8, -8.7 to -4.8), and fibromyalgia (risk ratio 1.4, 95% confidence interval 1.3 to 1.6). For the other 31 comparisons, antidepressants were either not efficacious (five comparisons) or the evidence was inconclusive (26 comparisons). CONCLUSIONS Evidence of efficacy of antidepressants was found in 11 of the 42 comparisons included in this overview of systematic reviews-seven of the 11 comparisons investigated the efficacy of SNRIs. For the other 31 comparisons, antidepressants were either inefficacious or evidence on efficacy was inconclusive. The findings suggest that a more nuanced approach is needed when prescribing antidepressants for pain conditions. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42022311073.
Collapse
Affiliation(s)
- Giovanni E Ferreira
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2050, Australia
- Institute for Musculoskeletal Health, Sydney, NSW, Australia
| | - Christina Abdel-Shaheed
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2050, Australia
- Institute for Musculoskeletal Health, Sydney, NSW, Australia
| | - Martin Underwood
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Nanna B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Richard O Day
- St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Andrew McLachlan
- Sydney Pharmacy School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Sam Eldabe
- James Cook University Hospital, Middlesbrough, UK
| | - Joshua R Zadro
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2050, Australia
- Institute for Musculoskeletal Health, Sydney, NSW, Australia
| | - Christopher G Maher
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2050, Australia
- Institute for Musculoskeletal Health, Sydney, NSW, Australia
| |
Collapse
|
37
|
Han CS, Hancock MJ, Maher CG. Reconsidering non-specific low back pain: where to from here? Spine J 2022; 22:1927-1930. [PMID: 35944828 DOI: 10.1016/j.spinee.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 08/02/2022] [Accepted: 08/02/2022] [Indexed: 02/03/2023]
Affiliation(s)
- Christopher S Han
- The Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, PO Box M179, Missenden Rd, NSW 2050, Sydney, Australia.
| | - Mark J Hancock
- The Faculty of Medicine, Health and Human Sciences Level 3, 75 Talavera Rd, Macquarie University, NSW 2109, Australia
| | - Christopher G Maher
- The Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, PO Box M179, Missenden Rd, NSW 2050, Sydney, Australia
| |
Collapse
|
38
|
Ayre J, Jenkins H, McCaffery KJ, Maher CG, Hancock MJ. Physiotherapists have some hesitations and unmet needs regarding delivery of exercise programs for low back pain prevention in adults: A qualitative interview study. Musculoskelet Sci Pract 2022; 62:102630. [PMID: 35932753 DOI: 10.1016/j.msksp.2022.102630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 07/03/2022] [Accepted: 07/14/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although there is some qualitative research on physiotherapists' experiences of delivering low back pain treatment, we do not know the extent that these findings apply to low back pain prevention. OBJECTIVE To explore physiotherapists' understanding, attitudes and experiences related to delivering low back pain prevention programs. DESIGN Qualitative interview study. METHOD Interviews from 25 Australian physiotherapists (56% female; 44% male) were analysed using framework thematic analysis. RESULTS Theme 1 explored physiotherapists' hesitancy about 'low back pain prevention,' raising concerns this term might inadvertently entrench unhelpful beliefs. They preferred language about minimising the risk and impact of recurrences, and promoting an active lifestyle. Theme 2 emphasised that as pain receded, engaging patients could be challenging. Some discussed that person-centred care and individualised programs helped overcome this challenge. Several wanted more training in counselling skills, and more consistent external messaging about low back pain prevention. Theme 3 highlighted uncertainty about delivering high-value prevention care. Some perceived the programs as potentially placing unnecessary financial burden on some patients. Many physiotherapists were uncertain about how to support patients when they weren't in pain (i.e., remission) and wanted training in tailored exercise prescription. CONCLUSIONS Many of the physiotherapists had some hesitations and unmet needs regarding delivery of exercise programs for secondary prevention of low back pain. Clinicians may find it useful to ask patients directly about their interest in prevention programs and work with interested patients to develop tailored, progressive programs that continue to be motivating, even during periods when there is no pain.
Collapse
Affiliation(s)
- Julie Ayre
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, NSW, Australia.
| | - Hazel Jenkins
- Department of Chiropractic, Faculty of Medicine, Health and Human Sciences, Macquarie University, NSW, Australia
| | - Kirsten J McCaffery
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health, Sydney Local Health District and The University of Sydney, NSW, Australia
| | - Mark J Hancock
- Department of Health Professions, Faculty of Medicine, Health and Human Sciences, Macquarie University, NSW, Australia
| |
Collapse
|
39
|
Jones CMP, Lin CWC, Jamshidi M, Abdel Shaheed C, Maher CG, Harris IA, Patanwala AE, Dinh M, Mathieson S. Effectiveness of Opioid Analgesic Medicines Prescribed in or at Discharge From Emergency Departments for Musculoskeletal Pain : A Systematic Review and Meta-analysis. Ann Intern Med 2022; 175:1572-1581. [PMID: 36252245 DOI: 10.7326/m22-2162] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The comparative benefits and harms of opioids for musculoskeletal pain in the emergency department (ED) are uncertain. PURPOSE To evaluate the comparative effectiveness and harms of opioids for musculoskeletal pain in the ED setting. DATA SOURCES Electronic databases and registries from inception to 7 February 2022. STUDY SELECTION Randomized controlled trials of any opioid analgesic compared with placebo or a nonopioid analgesic administered or prescribed to adults in or on discharge from the ED. DATA EXTRACTION Pain and disability were rated on a scale of 0 to 100 and pooled using a random-effects model. Certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework. DATA SYNTHESIS Forty-two articles were included (n = 6128). In the ED, opioids were statistically but not clinically more effective in reducing pain in the short term (about 2 hours) than placebo and paracetamol (acetaminophen) but were not clinically or statistically more effective than nonsteroidal anti-inflammatory drugs (NSAIDs) or local or systemic anesthetics. Opioids may carry higher risk for harms than placebo, paracetamol, or NSAIDs, although evidence is very uncertain. There was no evidence of difference in harms associated with local or systemic anesthetics. LIMITATIONS Low or very low GRADE ratings for some outcomes, unexplained heterogeneity, and little information on long-term outcomes. CONCLUSION The risk-benefit balance of opioids versus placebo, paracetamol, NSAIDs, and local or systemic anesthetics is uncertain. Opioids may have equivalent pain outcomes compared with NSAIDs, but evidence on comparisons of harms is very uncertain and heterogeneous. Although factors such as route of administration or dosage may explain some heterogeneity, more work is needed to identify which subgroups will have a more favorable benefit-risk balance for one analgesic over another. Longer-term pain management once dose thresholds are reached is also uncertain. PRIMARY FUNDING SOURCE None. (PROSPERO: CRD42021275293).
Collapse
Affiliation(s)
- Caitlin M P Jones
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
| | - Chung-Wei Christine Lin
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
| | - Masoud Jamshidi
- Department of Sports Physiology, University of Tehran, Tehran, Iran (M.J.)
| | - Christina Abdel Shaheed
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
| | - Christopher G Maher
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
| | - Ian A Harris
- Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, UNSW Sydney, Sydney, New South Wales, Australia (I.A.H.)
| | - Asad E Patanwala
- Royal Prince Alfred Hospital, and School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia (A.E.P.)
| | - Michael Dinh
- Sydney Local Health District and The University of Sydney, Sydney, New South Wales, Australia (M.D.)
| | - Stephanie Mathieson
- Institute for Musculoskeletal Health, The University of Sydney, and Sydney Local Health District, Sydney, New South Wales, Australia (C.M.P.J., C.W.C.L., C.A.S., C.G.M., S.M.)
| |
Collapse
|
40
|
Abdel Shaheed C, Maher CG, Furmage A, Hoffmann T, McLachlan AJ. Strengthening the reporting of harms of all interventions in clinical trials. Med J Aust 2022; 217:502-504. [PMID: 36287028 PMCID: PMC9828512 DOI: 10.5694/mja2.51755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 07/18/2022] [Accepted: 07/25/2022] [Indexed: 11/11/2022]
Affiliation(s)
| | | | | | - Tammy Hoffmann
- Institute for Evidence‐Based HealthcareBond UniversityGold CoastQLD
| | | |
Collapse
|
41
|
Kharel P, Zadro JR, Sundaram CS, McCaffery K, Dodd RH, McLennan C, Maher CG. Physiotherapists' attitudes, views, and beliefs about Choosing Wisely recommendations: A qualitative study. Musculoskelet Sci Pract 2022; 61:102610. [PMID: 35750018 DOI: 10.1016/j.msksp.2022.102610] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/19/2022] [Accepted: 06/13/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Explore physiotherapists' attitudes, views, and beliefs towards the Australian Physiotherapy Association's (APA) Choosing Wisely recommendations. DESIGN Qualitative interview study. METHODS We conducted semi-structured interviews with physiotherapists who were registered to practise in Australia. We purposively recruited participants with different demographics, clinical backgrounds, and years of experience to achieve diversity in views and opinions. Interviews explored barriers and facilitators to adopting the APA's Choosing Wisely recommendations, and strategies to increase adoption. Interviews were recorded, transcribed verbatim and analysed thematically. RESULTS We interviewed 19 participants (79.2% of 26 who expressed interest to be interviewed). Mean (SD) age of participants was 33.4 (11.6), mean (SD) years of experience was 10 (11.4), 90% were male (n = 17) and 53% worked in private practice (n = 10). Most participants were slightly (42.1%, n = 8) or at least moderately familiar (42.1%, n = 8) with the recommendations. Barriers to adopting the recommendations included 1) clinicians' beliefs, experience, and knowledge, 2) patients' clinical presentation, their beliefs, and expectations, 3) workplace demands and culture, and 4) vague and restrictive language, and lack of awareness. Facilitators to adopting the recommendations included 1) physiotherapists' beliefs and practise patterns, 2) organisational support, and 3) clear and appropriate recommendations. Suggested strategies to increase adoption of the recommendations were 1) interventions targeting clinicians, 2) amendments to the recommendations and 3) increased awareness and access to the recommendations. CONCLUSION These findings will inform the development and dissemination of future Choosing Wisely recommendations, and development of strategies to replace low-value physiotherapy with high-value physiotherapy. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Priti Kharel
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia.
| | - Joshua R Zadro
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Chindhu S Sundaram
- Quality of Life Office & Centre for Medical Psychology and Evidence-based Decision Making, School of Psychology, Faculty of Science, The University of Sydney, Sydney, New South Wales, Australia
| | - Kirsten McCaffery
- Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Rachael H Dodd
- Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Charlotte McLennan
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| |
Collapse
|
42
|
Zadro JR, O'Keeffe M, Ferreira GE, Traeger AC, Gamble AR, Page R, Herbert RD, Harris IA, Maher CG. Diagnostic labels and advice for rotator cuff disease influence perceived need for shoulder surgery: an online randomised experiment. J Physiother 2022; 68:269-276. [PMID: 36257876 DOI: 10.1016/j.jphys.2022.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 07/05/2022] [Accepted: 09/22/2022] [Indexed: 11/07/2022] Open
Abstract
QUESTION What are the effects of diagnostic labels and advice, and interactions between labels and advice, on perceived need for shoulder surgery for rotator cuff disease? DESIGN 2×2 factorial online randomised experiment. PARTICIPANTS People with shoulder pain. INTERVENTION Participants read a scenario describing a patient with rotator cuff disease and were randomised to bursitis label plus guideline-based advice, bursitis label plus treatment recommendation, rotator cuff tear label plus guideline-based advice, and rotator cuff tear label plus treatment recommendation. Guideline-based advice included encouragement to stay active and positive prognostic information. Treatment recommendation stressed that treatment is needed for recovery. OUTCOME MEASURES Perceived need for surgery (primary outcome), imaging, an injection, a second opinion and to see a specialist; and perceived seriousness of the condition, recovery expectations, impact on work performance and need to avoid work. RESULTS A total of 2,024 responses (99.8% of 2,028 randomised) were analysed. Labelling as bursitis (versus rotator cuff tear) decreased perceived need for surgery (mean effect -0.5 on a 0-to-10 scale, 98.3% CI -0.7 to -0.2), imaging and to see a specialist, and perceived seriousness of the condition and need to avoid work. Guideline-based advice (versus treatment recommendation) decreased perceived need for surgery (mean effect -1.0, 98.3% CI -1.3 to -0.7), imaging, an injection, a second opinion and to see a specialist, and perceived seriousness of the condition and recovery expectations. There was little to no evidence of an advice label interaction for any outcome. CONCLUSION Labels and advice influenced perceived need for surgery and other secondary outcomes in people with rotator cuff disease, with larger effects for advice. There was evidence of little or no interaction between labels and advice for any outcome, but the additive effect of labels and advice appeared large for some outcomes (eg, perceived need for imaging and perceived seriousness of the condition). TRIAL REGISTRATION ACTRN12621001370897.
Collapse
Affiliation(s)
- Joshua R Zadro
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, Australia.
| | - Mary O'Keeffe
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Giovanni E Ferreira
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Adrian C Traeger
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Andrew R Gamble
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Richard Page
- University Hospital Geelong and St. John of God Hospital Geelong, Barwon Centre for Orthopaedic Research and Education (B-CORE), IMPACT, School of Medicine, Deakin University, Geelong, Australia
| | - Robert D Herbert
- Neuroscience Research Australia (NeuRA), University of New South Wales, Australia
| | - Ian A Harris
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, Australia; Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| |
Collapse
|
43
|
Zadro JR, Ferreira GE, O'Keeffe M, Stahl-Timmins W, Elkins MR, Maher CG. How do people use and view infographics that summarise health and medical research? A cross-sectional survey. BMC Med Educ 2022; 22:677. [PMID: 36104815 PMCID: PMC9472431 DOI: 10.1186/s12909-022-03744-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 09/06/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Understanding how people use infographics and their opinion on them has important implications for the design of infographics but has not been investigated. The aim of this study was to describe people's use of and opinions about infographics summarising health and medical research, preferences for information to include in infographics, and barriers to reading full-text articles. METHODS We conducted an online cross-sectional survey of consumers of infographics that summarise health or medical research. Demographic and outcome data were collected and summarised using descriptive statistics. A sensitivity analysis explored whether being a researcher/academic influenced the findings. RESULTS Two hundred fifty-four participants completed the survey (88% completion rate). Participants included health professionals (66%), researchers (34%), academics (24%), and patients/the public (13%). Most used Twitter (67%) and smartphones (89%) to access and view infographics, and thought infographics were useful tools to communicate research (92%) and increase the attention research receives (95%). Although most participants were somewhat/extremely likely (76%) to read the full-text article after viewing an infographic, some used infographics as a substitute for the full text at least half of the time (41%), thought infographics should be detailed enough so they do not have to read the full text (55%), and viewed infographics as tools to reduce the time burden of reading the full text (64%). Researchers/academics were less likely to report behaviours/beliefs suggesting infographics can reduce the need to read the full-text article. CONCLUSIONS Given many people use infographics as a substitute for reading the full-text article and want infographics to be detailed enough so they don't have to read the full text, a checklist to facilitate clear, transparent, and sufficiently detailed infographics summarising some types of health and medical research may be useful.
Collapse
Affiliation(s)
- Joshua R Zadro
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, PO Box M179, Level 10 North, King George V Building, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW, 2050, Australia.
| | - Giovanni E Ferreira
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, PO Box M179, Level 10 North, King George V Building, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW, 2050, Australia
| | - Mary O'Keeffe
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, PO Box M179, Level 10 North, King George V Building, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW, 2050, Australia
| | | | - Mark R Elkins
- Faculty of Medicine & Health, The University of Sydney, Sydney, Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, PO Box M179, Level 10 North, King George V Building, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW, 2050, Australia
| |
Collapse
|
44
|
O’Connor DA, Glasziou P, Maher CG, McCaffery KJ, Schram D, Maguire B, Ma R, Billot L, Gorelik A, Traeger AC, Albarqouni L, Checketts J, Vyas P, Clark B, Buchbinder R. Effect of an Individualized Audit and Feedback Intervention on Rates of Musculoskeletal Diagnostic Imaging Requests by Australian General Practitioners: A Randomized Clinical Trial. JAMA 2022; 328:850-860. [PMID: 36066518 PMCID: PMC9449798 DOI: 10.1001/jama.2022.14587] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
IMPORTANCE Audit and feedback can improve professional practice, but few trials have evaluated its effectiveness in reducing potential overuse of musculoskeletal diagnostic imaging in general practice. OBJECTIVE To evaluate the effectiveness of audit and feedback for reducing musculoskeletal imaging by high-requesting Australian general practitioners (GPs). DESIGN, SETTING, AND PARTICIPANTS This factorial cluster-randomized clinical trial included 2271 general practices with at least 1 GP who was in the top 20% of referrers for 11 imaging tests (of the lumbosacral or cervical spine, shoulder, hip, knee, and ankle/hind foot) and for at least 4 individual tests between January and December 2018. Only high-requesting GPs within participating practices were included. The trial was conducted between November 2019 and May 2021, with final follow-up on May 8, 2021. INTERVENTIONS Eligible practices were randomized in a 1:1:1:1:1 ratio to 1 of 4 different individualized written audit and feedback interventions (n = 3055 GPs) that varied factorially by (1) frequency of feedback (once vs twice) and (2) visual display (standard vs enhanced display highlighting highly requested tests) or to a control condition of no intervention (n = 764 GPs). Participants were not masked. MAIN OUTCOMES AND MEASURES The primary outcome was the overall rate of requests for the 11 targeted imaging tests per 1000 patient consultations over 12 months, assessed using routinely collected administrative data. Primary analyses included all randomized GPs who had at least 1 patient consultation during the study period and were performed by statisticians masked to group allocation. RESULTS A total of 3819 high-requesting GPs from 2271 practices were randomized, and 3660 GPs (95.8%; n = 727 control, n = 2933 intervention) were included in the primary analysis. Audit and feedback led to a statistically significant reduction in the overall rate of imaging requests per 1000 consultations compared with control over 12 months (adjusted mean, 27.7 [95% CI, 27.5-28.0] vs 30.4 [95% CI, 29.8-30.9], respectively; adjusted mean difference, -2.66 [95% CI, -3.24 to -2.07]; P < .001). CONCLUSIONS AND RELEVANCE Among Australian general practitioners known to frequently request musculoskeletal diagnostic imaging, an individualized audit and feedback intervention, compared with no intervention, significantly decreased the rate of targeted musculoskeletal imaging tests ordered over 12 months. TRIAL REGISTRATION ANZCTR Identifier: ACTRN12619001503112.
Collapse
Affiliation(s)
- Denise A. O’Connor
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Malvern, Victoria, Australia
| | - Paul Glasziou
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Robina, Queensland, Australia
| | - Christopher G. Maher
- Institute for Musculoskeletal Health, Sydney Local Health District and The University of Sydney, Camperdown, New South Wales, Australia
| | - Kirsten J. McCaffery
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Dina Schram
- Australian Government Department of Health and Aged Care, Canberra, Australian Capital Territory, Australia
| | - Brigit Maguire
- Australian Government Department of Health and Aged Care, Canberra, Australian Capital Territory, Australia
| | - Robert Ma
- Australian Government Department of Health and Aged Care, Canberra, Australian Capital Territory, Australia
| | - Laurent Billot
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Newtown, New South Wales, Australia
| | - Alexandra Gorelik
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Malvern, Victoria, Australia
| | - Adrian C. Traeger
- Institute for Musculoskeletal Health, Sydney Local Health District and The University of Sydney, Camperdown, New South Wales, Australia
| | - Loai Albarqouni
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Robina, Queensland, Australia
| | - Juliet Checketts
- Australian Government Department of Health and Aged Care, Canberra, Australian Capital Territory, Australia
| | - Parima Vyas
- Australian Government Department of Health and Aged Care, Canberra, Australian Capital Territory, Australia
| | - Brett Clark
- Australian Government Department of Health and Aged Care, Canberra, Australian Capital Territory, Australia
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Malvern, Victoria, Australia
| |
Collapse
|
45
|
Zadro JR, Karunaratne S, Harris IA, Jones CM, O'Keeffe M, Ferreira GE, Buchbinder R, McCaffery K, Thompson R, Maher CG, Hoffmann T. The impact of a patient decision aid on intention to undergo surgery for subacromial pain syndrome: An online randomised controlled trial. Patient Educ Couns 2022; 105:2951-2961. [PMID: 35589459 DOI: 10.1016/j.pec.2022.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 04/08/2022] [Accepted: 05/07/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To evaluate the effects of a patient decision aid for people considering shoulder surgery. METHODS Participants with shoulder pain considering shoulder surgery (n = 425) were recruited online and randomised to (i) a decision aid outlining the benefits and harms of shoulder surgery and non-surgical options (then randomised to a side-by-side vs. top-and-bottom display of options); and (ii) general information about shoulder pain from the NHS. Outcomes included treatment intention (primary), knowledge, attitudes, informed choice, and decisional conflict. Linear and logistic regression models were used to evaluate between-groups differences in outcomes. RESULTS 409 participants (96%) had post-intervention data. Mean age was 41.3 years, 44.2% were female. There was no between-group difference in post-intervention treatment intention (MD -0.2, 95% CI: -3.3 to 2.8) and likelihood of intending to have shoulder surgery (OR 0.7, 95% CI: 0.3-1.5). The decision aid slightly improved knowledge (MD 4.4, 95% CI: 0.2-8.6), but not any other secondary outcomes. The display of options did not influence any outcome. CONCLUSIONS In this online trial, a co-designed patient decision aid had no effect on treatment intention, attitudes, informed choice, and decisional conflict, but a small effect on improving knowledge. PRACTICE IMPLICATIONS Research is needed to understand reasons for the lack of anticipated effects. TRIAL REGISTRATION Australia New Zealand Clinical Trials Registry (ACTRN12621000992808).
Collapse
Affiliation(s)
- Joshua R Zadro
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, New South Wales, Australia.
| | - Sascha Karunaratne
- Surgical Outcomes Research Centre, Royal Prince Alfred Hospital, New South Wales, Australia
| | - Ian A Harris
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, New South Wales, Australia; Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, UNSW Sydney, New South Wales, Australia
| | - Caitlin Mp Jones
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, New South Wales, Australia
| | - Mary O'Keeffe
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, New South Wales, Australia
| | - Giovanni E Ferreira
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, New South Wales, Australia
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Victoria, Australia; Monash Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Victoria, Australia
| | - Kirsten McCaffery
- Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia
| | - Rachel Thompson
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, New South Wales, Australia
| | - Tammy Hoffmann
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia
| |
Collapse
|
46
|
Fioratti I, Miyamoto GC, Fandim JV, Ribeiro CPP, Batista GD, Freitas GE, Palomo AS, Reis FJJD, Costa LOP, Maher CG, Saragiotto BT. Feasibility, Usability, and Implementation Context of an Internet-Based Pain Education and Exercise Program for Chronic Musculoskeletal Pain: Pilot Trial of the ReabilitaDOR Program. JMIR Form Res 2022; 6:e35743. [PMID: 35776863 PMCID: PMC9472033 DOI: 10.2196/35743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 05/23/2022] [Accepted: 06/16/2022] [Indexed: 11/13/2022] Open
Abstract
Background Internet-based self-management programs and telerehabilitation initiatives have increased and have been extensively used for delivering health care in many areas. These programs overcome common barriers that patients face with traditional face-to-face health care, such as travel expenditures, lack of time, and high demand on the public health system. During the COVID-19 pandemic, this mode of web-based health care delivery had become more popular. However, there is still a lack of studies testing this mode of delivery in low- and middle-income countries. To gain a better understanding of the context, feasibility, and factors involved in the implementation of a web-based program, pilot and implementation studies are necessary. These studies can better inform whether a strategy is feasible, acceptable, and adequate for its purposes and for optimizing resource allocation. Objective This study aims to evaluate the feasibility, usability, and implementation context of a self-management internet-based program based on exercises and pain education (ReabilitaDOR) in people with chronic musculoskeletal pain and to compare this program with a program using only a web-based self-management booklet. Methods The study design was a parallel pilot study of a prospectively registered, assessor-blinded, 2-arm randomized controlled trial with economic evaluation. This study was performed using waiting lists of physiotherapy and rehabilitation centers and advertisements on social media networks. The participants were 65 patients with chronic musculoskeletal pain aged between 18 and 60 years. The effects of an 8-week telerehabilitation program based on exercises and pain education (intervention group) were compared with those of a program based only on a web-based self-management booklet (control group). The main outcome measures were implementation outcomes of patients’ perceptions of acceptability, appropriateness, feasibility, and usability of the program and the societal costs and feasibility of the main trial at 8-week posttreatment follow-up. Adverse events were also analyzed. Results In total, 56 participants were analyzed at the 8-week follow-up. The intervention group showed responses with a mean of 4.5 (SD 0.6) points for acceptability, 4.5 (SD 0.5) points for appropriateness, and 4.5 (SD 0.6) points for feasibility measured on a 1 to 5 scale. All patients in the intervention group showed satisfactory responses to the system usability outcome. There is satisfactory evidence for the feasibility of the main trial. For costs related to the interventions, health care, patients, and loss of productivity at 8 weeks, we found a total expenditure of US $278.30 per patient in the intervention group and US $141.52 per patient in the control group. No adverse events were reported during the intervention period. Conclusions We found that the ReabilitaDOR program is feasible, appropriate, and acceptable from the users’ implementation perspective. This system was considered usable by all the participants, and the main trial seemed feasible. Cost data were viable to be collected, and the program is likely to be safe. Trial Registration ClinicalTrials.gov NCT04274439; https://clinicaltrials.gov/ct2/show/NCT04274439
Collapse
Affiliation(s)
- Iuri Fioratti
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil
| | - Gisela Cristiane Miyamoto
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Public Health, Amsterdam, Netherlands
| | - Junior Vitorino Fandim
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil
| | | | - Geovana Domingues Batista
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil
| | | | - Andressa Santos Palomo
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil
| | - Felipe José Jandré Dos Reis
- Physical Therapy Department, Instituto Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Postgraduation Program, Clinical Medicine Department, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Pain in Motion Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
| | | | - Christopher G Maher
- Institute for Musculoskeletal Health, The University of Sydney, Sydney, Australia
| | - Bruno Tirotti Saragiotto
- Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil
- Institute for Musculoskeletal Health, The University of Sydney, Sydney, Australia
| |
Collapse
|
47
|
Zadro JR, Maher CG. Overview of the Drivers of Low-Value Care Comment on "Key Factors that Promote Low-Value Care: Views of Experts From the United States, Canada, and the Netherlands". Int J Health Policy Manag 2022; 11:1595-1598. [PMID: 35184511 PMCID: PMC9808350 DOI: 10.34172/ijhpm.2022.6833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 01/26/2022] [Indexed: 01/12/2023] Open
Abstract
Verkerk and colleagues explored the key drivers of low-value care from the perspective of 18 policy-makers and researchers who had led and evaluated at least one initiative to reduce low-value care or had been responsible for reducing low-value care in an organisation. They identified several drivers of low-value care presented in the 2017 Lancet Right Care Series (eg, fee for service payment systems, the pharmaceutical and medical device industry, fear of malpractice litigation, issues with research conduct and reporting, a culture of 'more is better' and 'new technology is better') but did not discuss some other important ones. In this commentary, we aim to extend the work of Verkerk and colleagues and provide some additional perspectives on the drivers of low-value care within the following categories: Economic incentives; Money, finance, and organisation; Knowledge beliefs, assumptions, bias and uncertainty; and Power and human relationships.
Collapse
Affiliation(s)
- Joshua R. Zadro
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Sydney Local Health District, Sydney, NSW, Australia
| | - Christopher G. Maher
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Sydney Local Health District, Sydney, NSW, Australia
| |
Collapse
|
48
|
Ayre J, Jenkins H, McCaffery KJ, Maher CG, Hancock MJ. Unique considerations for exercise programs to prevent future low back pain: the patient perspective. Pain 2022; 163:e953-e962. [PMID: 34799535 DOI: 10.1097/j.pain.0000000000002540] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 11/08/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT There is moderate quality evidence that exercise can help to prevent future low back pain (LBP). This study aimed to explore patient needs and preferences for exercise programs to prevent LBP and the outcomes of these programs that would be most important to a patient. Researchers conducted 26 semistructured interviews with people with LBP. Interviews were audio-recorded, transcribed, and analysed using framework thematic analysis. Three themes were developed. Theme 1 emphasised that everyone's LBP was different, translating to preferences for tailored prevention programs with a high level of initial supervision and individualised biomedical explanations for the program. Theme 2 highlighted important outcomes. Pain was considered not only for intensity but also for the duration, frequency, and severity of flare-ups or episodes. Other important outcomes were general fitness and capacity to engage in everyday activities, social interactions, and work. Theme 3 outlined aspects of exercise programs that were considered important for people with fluctuating pain, including how to foster a sense of "progress," set realistic expectations, and support patients to establish exercise routines that can adapt to fluctuating pain. Theme 4 discussed participants' desire for social connection. Patients want exercise programs for LBP prevention, which are highly individualised, provide meaningful explanations of exercises, and help them maintain exercise in the long-term. Clinicians should discuss with patients the transition from a focus on treatment to the prevention of LBP. This provides greater opportunity to adjust goals and expectations and provide relevant education. Balancing the need for individualised care against affordability presents an ongoing challenge.
Collapse
Affiliation(s)
- Julie Ayre
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Hazel Jenkins
- Department of Chiropractic, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Kirsten J McCaffery
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health, Sydney Local Health District and The University of Sydney, Sydney, Australia
| | - Mark J Hancock
- Department of Health Professions, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| |
Collapse
|
49
|
Han CS, Hancock MJ, Downie A, Jarvik JG, Koes BW, Machado GC, Verhagen AP, Williams CM, Maher CG. Red flags to screen for vertebral fracture in patients presenting with low back pain. Hippokratia 2022. [DOI: 10.1002/14651858.cd014461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Christopher S Han
- Institute for Musculoskeletal Health; The University of Sydney and Sydney Local Health District; Sydney Australia
| | - Mark J Hancock
- Faculty of Medicine, Health and Human Sciences; Macquarie University; Sydney Australia
| | - Aron Downie
- Institute for Musculoskeletal Health; The University of Sydney and Sydney Local Health District; Sydney Australia
- Faculty of Medicine, Health and Human Sciences; Macquarie University; Sydney Australia
| | - Jeffrey G Jarvik
- Radiology and Neurological Surgery, Clinical Learning, Evidence And Research (CLEAR) Center; University of Washington School of Medicine; Seattle USA
| | - Bart W Koes
- Center for Muscle and Health; University of Southern Denmark; Odense Denmark
| | - Gustavo C Machado
- Institute for Musculoskeletal Health; The University of Sydney and Sydney Local Health District; Sydney Australia
| | - Arianne P Verhagen
- Discipline of Physiotherapy, Graduate School of Health; University of Technology ; Sydney Australia
| | | | - Christopher G Maher
- Institute for Musculoskeletal Health; The University of Sydney and Sydney Local Health District; Sydney Australia
| |
Collapse
|
50
|
Withers HG, Liu H, Glinsky JV, Chu J, Jennings MD, Hayes AJ, Starkey IJ, Palmer BA, Szymanek L, Cruwys JJ, Wong D, Duong K, Barnett A, Tindall MJ, Lucas BR, Lambert TE, Taylor DA, Sherrington C, Ferreira ML, Maher CG, Zadro JR, Harvey LA. Protocol for a process evaluation: face-to-face physiotherapy compared with a supported home exercise programme for the management of musculoskeletal conditions: the REFORM trial. BMJ Open 2022; 12:e057790. [PMID: 35790326 PMCID: PMC9258511 DOI: 10.1136/bmjopen-2021-057790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION The REFORM (REhabilitation FOR Musculoskeletal conditions) trial is a non-inferiority randomised controlled trial (n=210) designed to determine whether a supported home exercise programme is as good or better than a course of face-to-face physiotherapy for the management of some musculoskeletal conditions. The trial is currently being conducted across Sydney government hospitals in Australia. This process evaluation will run alongside the REFORM trial. It combines qualitative and quantitative data to help explain the trial results and determine the feasibility of rolling out supported home exercise programmes in settings similar to the REFORM trial. METHODS AND ANALYSIS Two theoretical frameworks underpin our process evaluation methodology: the Realist framework (context, mechanism, outcomes) considers the causal assumptions as to why a supported home exercise programme may be as good or better than face-to-face physiotherapy in terms of the context, mechanisms and outcomes of the trial. The RE-AIM framework describes the Reach, Effectiveness, Adoption, Implementation and Maintenance of the intervention. These two frameworks will be broadly used to guide this process evaluation using a mixed-methods approach. For example, qualitative data will be derived from interviews with patients, healthcare professionals and stakeholders, and quantitative data will be collected to determine the cost and feasibility of providing supported home exercise programmes. These data will be analysed iteratively before the analysis of the trial results and will be triangulated with the results of the primary and secondary outcomes. ETHICS AND DISSEMINATION This trial will be conducted in accordance with the National Health and Medical Research Council National Statement on Ethical Conduct in Human Research (2018) and the Note for Good Clinical Practice (CPMP/ICH-135/95). Ethical approval was obtained on 17 March 2017 from the Northern Sydney Local Health District Human Research Ethics Committee (trial number: HREC/16HAWKE/431-RESP/16/287) with an amendment for the process evaluation approved on 4 February 2020. The results of the process evaluation will be disseminated through publications in peer-reviewed journals and presentations at scientific conferences. TRIAL REGISTRATION NUMBER ACTRN12619000065190.
Collapse
Affiliation(s)
- Hannah G Withers
- John Walsh Centre for Rehabilitation Research, Northern Sydney Local Health District, The University of Sydney, Kolling Institute, Sydney, NSW, Australia
| | - Hueiming Liu
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Joanne V Glinsky
- John Walsh Centre for Rehabilitation Research, Northern Sydney Local Health District, The University of Sydney, Kolling Institute, Sydney, NSW, Australia
| | - Jackie Chu
- John Walsh Centre for Rehabilitation Research, Northern Sydney Local Health District, The University of Sydney, Kolling Institute, Sydney, NSW, Australia
| | - Matthew D Jennings
- Physiotherapy Department, South Western Sydney Local Health District, Liverpool, New South Wales, Australia
| | - Alison J Hayes
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Ian J Starkey
- Physiotherapy Department, Blacktown and Mount Druitt Hospital, Blacktown, New South Wales, Australia
| | - Blake A Palmer
- Physiotherapy Department, Blacktown and Mount Druitt Hospital, Blacktown, New South Wales, Australia
| | - Lukas Szymanek
- Physiotherapy Department, Campbelltown Hospital, Campbelltown, New South Wales, Australia
| | - Jackson J Cruwys
- Physiotherapy Department, Campbelltown Hospital, Campbelltown, New South Wales, Australia
| | - David Wong
- Physiotherapy Department, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Kitty Duong
- Physiotherapy Department, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Anne Barnett
- Physiotherapy Department, Bankstown Hospital, Bankstown, New South Wales, Australia
| | - Matthew J Tindall
- Physiotherapy Department, Bankstown Hospital, Bankstown, New South Wales, Australia
| | - Barbara R Lucas
- Physiotherapy Department, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Tara E Lambert
- Physiotherapy Department, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Deborah A Taylor
- Physiotherapy Department, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Catherine Sherrington
- Institute for Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Manuela L Ferreira
- Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health, School of Public Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Joshua R Zadro
- Institute for Musculoskeletal Health, School of Public Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Lisa A Harvey
- John Walsh Centre for Rehabilitation Research, Northern Sydney Local Health District, The University of Sydney, Kolling Institute, Sydney, NSW, Australia
| |
Collapse
|