Development of a patient decision aid for children and adolescents following anterior cruciate ligament rupture: an international mixed-methods study

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.

Remotely delivered physiotherapy is as effective as face-to-face physiotherapy for musculoskeletal conditions (REFORM): a randomised trial

QUESTION

Is remotely delivered physiotherapy as good or better than face-to-face physiotherapy for the management of musculoskeletal conditions?

DESIGN

Randomised controlled, non-inferiority trial with concealed allocation, blinded assessors and intention-to-treat analysis.

PARTICIPANTS

A total of 210 adult participants with a musculoskeletal condition who presented for outpatient physiotherapy at five public hospitals in Sydney.

INTERVENTION

One group received a remotely delivered physiotherapy program for 6 weeks that consisted of one face-to-face physiotherapy session in conjunction with weekly text messages, phone calls at 2 and 4 weeks, and an individualised home exercise program delivered through an app. The other group received usual face-to-face physiotherapy care in an outpatient setting.

OUTCOME MEASURES

The primary outcome was the Patient Specific Functional Scale at 6 weeks with a pre-specified non-inferiority margin of -15 out of 100 points. Secondary outcomes included: the Patient Specific Functional Scale at 26 weeks; kinesiophobia, pain, function/disability, global impression of change and quality of life at 6 and 26 weeks; and satisfaction with service delivery at 6 weeks.

RESULTS

The mean between-group difference (95% CI) for the Patient Specific Functional Scale at 6 weeks was 2.7 out of 100 points (-3.5 to 8.8), where a positive score favoured remotely delivered physiotherapy. The lower end of the 95% CI was greater than the non-inferiority margin. Whilst non-inferiority margins were not set for the secondary outcomes, the 95% CI of the mean between-group difference ruled out clinically meaningful differences.

CONCLUSION

Remotely delivered physiotherapy with support via phone, text and an app is as good as face-to-face physiotherapy for the management of musculoskeletal conditions.

TRIAL REGISTRATION

ACTRN12619000065190.

Education can reassure people with rotator cuff-related shoulder pain: a 3-arm, randomised, online experiment

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.

RECITAL: a non-inferiority randomised control trial evaluating a virtual fracture clinic compared with in-person care for people with simple fractures (study protocol)

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.

Development of the Reporting Infographics and Visual Abstracts of Comparative studies (RIVA-C) checklist and guide

People often use infographics (also called visual or graphical abstracts) as a substitute for reading the full text of an article. This is a concern because most infographics do not present sufficient information to interpret the research appropriately and guide wise health decisions. The Reporting Infographics and Visual Abstracts of Comparative studies (RIVA-C) checklist and guide aims to improve the completeness with which research findings of comparative studies are communicated and avoid research findings being misinterpreted if readers do not refer to the full text. The primary audience for the RIVA-C checklist and guide is developers of infographics that summarise comparative studies of health and medical interventions. The need for the RIVA-C checklist and guide was identified by a survey of how people use infographics. Possible checklist items were informed by a systematic review of how infographics report research. We then conducted a two-round, modified Delphi survey of 92 infographic developers/designers, researchers, health professionals and other key stakeholders. The final checklist includes 10 items. Accompanying explanation and both text and graphical examples linked to the items were developed and pilot tested over a 6-month period. The RIVA-C checklist and guide was designed to facilitate the creation of clear, transparent and sufficiently detailed infographics which summarise comparative studies of health and medical interventions. Accurate infographics can ensure research findings are communicated appropriately and not misinterpreted. By capturing the perspectives of a wide range of end users (eg, authors, informatics editors, journal editors, consumers), we are hopeful of rapid endorsement and implementation of RIVA-C.

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

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.

Awareness and use of five imaging decision rules for musculoskeletal injuries: a systematic review

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.

Compared to what? An analysis of comparators in trials informing the National Institute of Clinical Excellence (NICE) low back pain guideline

BACKGROUND

Low back pain (LBP) is the leading cause of disability globally. Clinical practice guidelines (CPGs) have been developed in hopes of encouraging evidence-based care for LBP. However, poor quality of trials that underpin CPGs can lead to misleading recommendations for LBP.

OBJECTIVES

To categorize the comparator used in trials included in the National Institute of Clinical Excellence (NICE) LBP CPG and describe the proportion and association of suboptimal comparators with NICE recommendation.

METHODS

We conducted a cross-sectional analysis to describe the proportion of trials included in the NICE LBP CPG that used a suboptimal comparator. If comparators used an ineffective treatment, a treatment of unknown effectiveness, or no or minimal treatment then they were considered suboptimal.

RESULTS

We included 408 trials and analyzed 580 comparators used in the trials. 30.9% of the comparators used in the trials were suboptimal. Trials testing invasive treatments (32.4%) had the highest proportion of suboptimal comparators followed by non-surgical (32.3%) and pharmacological (19.0%) treatments. Trials using suboptimal treatments were less likely to have their treatment recommended (odds ratio: 0.68; 95% CI: 0.47, 0.98) for use by NICE.

CONCLUSION

There is a concerning proportion of suboptimal comparators used in LBP trials that may be misleading CPG recommendations, funding allocation decisions, and ultimately clinical practice. Efforts to increase the use of optimal comparators in LBP trials are urgently needed to better understand what treatments should be recommended.

Can language enhance physical therapists' willingness to follow Choosing Wisely recommendations? A best-worst scaling study

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.

Developing a patient decision aid for Achilles tendon rupture management: a mixed-methods study

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.

How do people perceive different advice for rotator cuff disease? A content analysis of qualitative data collected in a randomised experiment

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.

Efficacy, safety, and tolerability of antidepressants for pain in adults: overview of systematic reviews

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.

Public and patient perceptions of diagnostic labels for non-specific low back pain: a content analysis

PURPOSE

An online randomised experiment found that the labels lumbar sprain, non-specific low back pain (LBP), and episode of back pain reduced perceived need for imaging, surgery and second opinions compared to disc bulge, degeneration, and arthritis among 1447 participants with and without LBP. They also reduced perceived seriousness of LBP and increased recovery expectations.

METHODS

In this study we report the results of a content analysis of free-text data collected in our experiment. We used two questions: 1. When you hear the term [one of the six labels], what words or feelings does this make you think of? and 2. What treatment (s) (if any) do you think a person with [one of the six labels] needs? Two independent reviewers analysed 2546 responses.

RESULTS

Ten themes emerged for Question1. Poor prognosis emerged for disc bulge, degeneration, and arthritis, while good prognosis emerged for lumbar sprain, non-specific LBP, and episode of back pain. Thoughts of tissue damage were less common for non-specific LBP and episode of back pain. Feelings of uncertainty frequently emerged for non-specific LBP. Twenty-eight treatments emerged for Question2. Surgery emerged for disc bulge, degeneration, and arthritis compared to lumbar sprain, non-specific LBP, and episode of back pain. Surgery did not emerge for non-specific LBP and episode of back pain.

CONCLUSION

Our results suggest that clinicians should consider avoiding the labels disc bulge, degeneration and arthritis and opt for labels that are associated with positive beliefs and less preference for surgery, when communicating with patients with LBP.

The effect of almond intake on cardiometabolic risk factors, inflammatory markers, and liver enzymes: A systematic review and meta-analysis

Almond intake may be correlated with improvements in several cardiometabolic parameters, but its effects are controversial in the published literature, and it needs to be comprehensively summarized. We conducted a systematic search in several international electronic databases, including MEDLINE, EMBASE, Scopus, Web of Science, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov until April 2021 to identify randomized controlled trials that examined the effects of almond consumption on cardiometabolic risk factors, inflammatory markers, and liver enzymes. Data were pooled using the random-effects model method and presented as standardized mean differences (SMDs) with 95% confidence intervals (CIs). Twenty-six eligible trials were analyzed (n = 1750 participants). Almond intake significantly decreased diastolic blood pressure, total cholesterol, triglyceride, low-density lipoprotein (LDL), non-high-density lipoprotein (HDL), and very LDL (p < 0.05). The effects of almond intake on systolic blood pressure, fasting blood glucose, insulin, hemoglobin A1c, homeostatic model assessment of insulin resistance, C-peptide, alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transferase, C-reactive protein (CRP), hs-CRP (high sensitivity C-reactive protein), interleukin 6, tumor necrosis factor-α, ICAM (Intercellular Adhesion Molecule), VCAM (Vascular Cell Adhesion Molecule), homocysteine, HDL, ox-LDL, ApoA1, ApoB, and lipoprotien-a were not statistically significant (p > .05). The current body of evidence supports the ingestion of almonds for their beneficial lipid-lowering and antihypertensive effects. However, the effects of almonds on antiinflammatory markers, glycemic control, and hepatic enzymes should be further evaluated via performing more extensive randomized trials.

Physiotherapists' attitudes, views, and beliefs about Choosing Wisely recommendations: A qualitative study

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.

Diagnostic labels and advice for rotator cuff disease influence perceived need for shoulder surgery: an online randomised experiment

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.

How do people use and view infographics that summarise health and medical research? A cross-sectional survey

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.

The impact of a patient decision aid on intention to undergo surgery for subacromial pain syndrome: An online randomised controlled trial

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).

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"

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.

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

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.

Online information about the management of anterior cruciate ligament ruptures in Australia: A content analysis

BACKGROUND

Most people who suffer an anterior cruciate ligament (ACL) injury search for information online.

OBJECTIVES

Summarise the proportion of webpages on ACL rupture management that present evidence-based information.

DESIGN

Content analysis.

METHODS

We examined webpage information on ACL ruptures identified through (1) Google searches using terms synonymous with 'anterior cruciate ligament rupture' and searching 'knee surgeon' linked to each Australian capital city, and (2) websites of professional associations. The primary outcome was the proportion of webpages that suggest people can return to at least some form of sport with non-surgical management. Secondary outcomes included webpage information on return to sport with ACL reconstruction (ACLR) and non-surgical management, benefits, harms, and risk of osteoarthritis related to these options, and activity modification.

RESULTS

Out of 115 webpages analysed, 48% suggested people can return to at least some form of sport with non-surgical management. Almost half of webpages suggested most people will return to some form of sport following ACLR (41%) and mentioned benefits of ACLR (43%). Fewer webpages mentioned benefits of non-surgical management (14%), approximately two in three people return to pre-injury level of sport following ACLR (4%), risk of re-injury following ACLR (23%), most people return to sport within 9 months of ACLR (27%), activity modification as a management approach (20%), and ACLR will reduce the risk of osteoarthritis (23%).

CONCLUSION

Most online information on ACL rupture management isn't aligned with the best available evidence. Inaccurate information could mislead patients' treatment choices and create unrealistic expectations for return to sport.

Effect of diagnostic labelling on management intentions for non-specific low back pain: a randomised scenario-based experiment

Background

Diagnostic labels may influence treatment intentions. We examined the effect of labelling low back pain (LBP) on beliefs about imaging, surgery, second opinion, seriousness, recovery, work, and physical activities.

Methods

Six‐arm online randomized experiment with blinded participants with and without LBP. Participants received one of six labels: ‘disc bulge’,‘degeneration’,‘arthritis’,‘lumbar sprain’,‘non‐specific LBP’, ‘episode of back pain’. The primary outcome was the belief about the need for imaging.

Results

A total of 1375 participants (mean [SD] age, 41.7 years [18.4 years]; 748 women [54.4%]) were included. The need for imaging was rated lower with the labels ‘episode of back pain’ (4.2 [2.9]), ‘lumbar sprain’ (4.2 [2.9]) and ‘non‐specific LBP’ (4.4 [3.0]) compared to the labels ‘arthritis’ (6.0 [2.9]), ‘degeneration’ (5.7 [3.2]) and ‘disc bulge’ (5.7 [3.1]). The same labels led to higher recovery expectations and lower ratings of need for a second opinion, surgery and perceived seriousness compared to ‘disc bulge’,‘degeneration’ and ‘arthritis’. Differences were larger amongst participants with current LBP who had a history of seeking care. No differences were found in beliefs about physical activity and work between the six labels.

Conclusions

‘Episode of back pain’,‘lumbar sprain’ and ‘non‐specific LBP’ reduced need for imaging, surgery and second opinion compared to ‘arthritis’,‘degeneration’ and ‘disc bulge’ amongst public and patients with LBP as well as reducing the perceived seriousness of LBP and enhancing recovery expectations. The impact of labels appears most relevant amongst those at risk of poor outcomes (participants with current LBP who had a history of seeking care).

Healthcare students' attitudes towards patient centred care: a systematic review with meta-analysis

BACKGROUND

Patient centred care is commonly recommended in clinical practice guidelines to improve patient outcomes and reduce healthcare costs. Identifying measurement tools used to assess healthcare students' attitudes towards patient centered care and determining their attitudes is the first step to ensuring patient centred care is provided in the future. The primary aim of this review was to describe the measurement tools used to assess healthcare students' attitudes towards patient centred care. The secondary aim was to quantify healthcare students' attitudes towards patient centred care.

METHODS

An electronic database search was conducted in MEDLINE, EMBASE, CINAHL from inception until March 1, 2021, with combined terms relating to 'patient centred care', 'attitudes', and 'healthcare students'. Studies that quantitatively assessed healthcare students' attitudes towards patient centred care were included. Measurement tools used in the included studies were qualitatively described. Meta-analysis was conducted to quantify healthcare students' attitudes towards patient centred care and assess the respective influence of gender, profession, and study geographical location on healthcare students' attitudes towards patient centred care.

RESULTS

The electronic search identified 3948 total studies. One hundred twenty-nine full texts were screened, and 49 studies were included. There were 16 measurement tools used to assess healthcare students' attitudes towards patient centered care. Most studies (53%, n = 26) used the Patient-Practitioner Orientation Scale (PPOS) to assess patient centered care. Meta-analyses of 20 studies with 26 total groups resulted in a pooled mean PPOS score of 4.16 on a 0-6 scale (95% Confidence Interval [CI]: 3.95, 4.37), indicating low attitudes towards patient centered care. Additional analyses found that women have significantly higher attitudes towards patients centred care than men (pooled effect 0.14 [95% CI: 0.05, 0.23], n = 8 studies) and mean PPOS scores appear similar among sub-groups of only medical students (pooled mean 4.13, 95% CI: 3.85, 4.42, n = 13 studies) and only American healthcare students (pooled mean 4.49, 95% CI: 4.35, 4.64, n = 5 studies).

CONCLUSIONS

Several different measurement tools have been used to assess healthcare students' attitudes towards patient centred care, but the most commonly used is the PPOS. Our results indicate that healthcare students have low attitudes towards patient centred care. Future studies should evaluate if attitudes towards patient centred care can be improved during healthcare education.

Reporting characteristics of journal infographics: a cross-sectional study

BACKGROUND

Infographics have become an increasingly popular method to present research findings and increase the attention research receives. As many scientific journals now use infographics to boost the visibility and uptake of the research they publish, infographics have become an important tool for medical education. It is unknown whether such infographics convey the key characteristics that are needed to make useful interpretations of the data such as an adequate description of the study population, interventions, comparators and outcomes; methodological limitations; and numerical estimates of benefits and harms. This study described whether infographics published in peer-reviewed health and medical research journals contain key characteristics that are needed to make useful interpretations of clinical research.

METHODS

In this cross-sectional study, we identified peer-reviewed journals listed in the top quintile of 35 unique fields of medicine and health research listed in the Journal Citation Reports database. Two researchers screened journals for the presence of infographics. We defined an infographic as a graphical visual representation of research findings. We extracted data from a sample of two of the most recent infographics from each journal. Outcomes were the proportion of infographics that reported key characteristics such as study population, interventions, comparators and outcomes, benefits, harms, effect estimates with measures of precision, between-group differences and conflicts of interest; acknowledged risk of bias, certainty of evidence and study limitations; and based their conclusions on the study's primary outcome.

RESULTS

We included 129 infographics from 69 journals. Most infographics described the population (81%), intervention (96%), comparator (91%) and outcomes (94%), but fewer contained enough information on the population (26%), intervention (45%), comparator (20%) and outcomes (55%) for those components of the study to be understood without referring to the main paper. Risk of bias was acknowledged in only 2% of infographics, and none of the 69 studies that had declared a conflict of interest disclosed it in the infographics.

CONCLUSIONS

Most infographics do not report sufficient information to allow readers to interpret study findings, including the study characteristics, results, and sources of bias. Our results can inform initiatives to improve the quality of the information presented in infographics.

Feasibility of delivering and evaluating stratified care integrated with telehealth ('Rapid Stratified Telehealth') for patients with low back pain: protocol for a feasibility and pilot randomised controlled trial

INTRODUCTION

Long waiting time is an important barrier to accessing recommended care for low back pain (LBP) in Australia's public health system. This study describes the protocol for a randomised controlled trial (RCT) that aims to establish the feasibility of delivering and evaluating stratified care integrated with telehealth ('Rapid Stratified Telehealth'), which aims to reduce waiting times for LBP.

METHODS AND ANALYSIS

We will conduct a single-centre feasibility and pilot RCT with nested qualitative interviews. Sixty participants with LBP newly referred to a hospital outpatient clinic will be randomised to receive Rapid Stratified Telehealth or usual care. Rapid Stratified Telehealth involves matching the mode and type of care to participants' risk of persistent disabling pain (using the Keele STarT MSK Tool) and presence of potential radiculopathy. 'Low risk' patients are matched to one session of advice over the telephone, 'medium risk' to telehealth physiotherapy plus App-based exercises, 'high risk' to telehealth physiotherapy, App-based exercises, and an online pain education programme, and 'potential radiculopathy' fast tracked to usual in-person care. Primary outcomes include the feasibility of delivering Rapid Stratified Telehealth (ie, acceptability assessed through interviews with clinicians and patients, intervention fidelity, appointment duration, App useability and online pain education programme usage) and evaluating Rapid Stratified Telehealth in a future trial (ie, recruitment rates, consent rates, lost to follow-up and missing data). Secondary outcomes include waiting times, number of appointments, intervention and healthcare costs, clinical outcomes (pain, function, quality of life, satisfaction), healthcare use and adverse events (AEs). Quantitative analyses will be descriptive and inform a future adequately-powered RCT. Interview data will be analysed using thematic analysis.

ETHICS AND DISSEMINATION

This study has received approval from the Ethics Review Committee (RPAH Zone: X21-0221). Results will be published in peer-reviewed journals and presented at conferences.

TRIAL REGISTRATION NUMBER

ACTRN12621001104842.

How do people perceive different labels for rotator cuff disease? A content analysis of data collected in a randomised controlled experiment

OBJECTIVES

Explore how people perceive different labels for rotator cuff disease in terms of words or feelings evoked by the label and treatments they feel are needed.

SETTING

We performed a content analysis of qualitative data collected in a six-arm, online randomised controlled experiment.

PARTICIPANTS

1308 people with and without shoulder pain read a vignette describing a patient with rotator cuff disease and were randomised to one of six labels: subacromial impingement syndrome, rotator cuff tear, bursitis, rotator-cuff-related shoulder pain, shoulder sprain and episode of shoulder pain.

PRIMARY AND SECONDARY OUTCOMES

Participants answered two questions (free-text response) about: (1) words or feelings evoked by the label; (2) what treatments they feel are needed. Two researchers iteratively developed coding frameworks to analyse responses.Results1308/1626 (80%) complete responses for each question were analysed. Psychological distress (21%), uncertainty (22%), serious condition (15%) and poor prognosis (9%) were most often expressed by those labelled with subacromial impingement syndrome. For those labelled with a rotator cuff tear, psychological distress (13%), serious condition (9%) and poor prognosis (8%) were relatively common, while minor issue was expressed least often compared with the other labels (5%). Treatment/investigation and surgery were common among those labelled with a rotator cuff tear (11% and 19%, respectively) and subacromial impingement syndrome (9% and 10%) compared with bursitis (7% and 5%).

CONCLUSIONS

Words or feelings evoked by certain labels for rotator cuff disease and perceived treatment needs may explain why some labels drive management preferences towards surgery and imaging more than others.

Online Information About the Effectiveness of Shoulder Surgery Is Not Based on the Best Available Evidence: A Content Analysis

OBJECTIVE

To summarize the proportion of consumer webpages on subacromial decompression and rotator cuff repair surgery that make an accurate portrayal of the evidence for these operations (primary outcome), mention the benefits and harms of surgery, outline alternatives to surgery, and make various surgical recommendations.

DESIGN

Content analysis.

SETTING

Online consumer information about subacromial decompression and rotator cuff repair surgery. Webpages were identified through (1) Google searches using terms synonymous with "shoulder pain" and "shoulder surgery" and searching "orthopedic surgeon" linked to each Australian capital city and (2) websites of relevant professional associations (eg, Australian Orthopaedic Association). Two reviewers independently identified webpages and extracted data.

PARTICIPANTS

Not applicable.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Whether the webpage made an accurate portrayal of the evidence for subacromial decompression or rotator cuff repair surgery (primary outcome), mentioned benefits and harms of surgery, outlined alternatives to surgery, and made various surgical recommendations (eg, delay surgery). Outcome data were summarized using counts and percentages.

RESULTS

A total of 155 webpages were analyzed (n=89 on subacromial decompression, n=90 on rotator cuff repair, n=24 on both). Only 18% (n=16) and 4% (n=4) of webpages made an accurate portrayal of the evidence for subacromial decompression and rotator cuff repair surgery, respectively. For subacromial decompression and rotator cuff repair, respectively, 85% (n=76) and 80% (n=72) of webpages mentioned benefits, 38% (n=34) and 47% (n=42) mentioned harms, 94% (n=84) and 92% (n=83) provided alternatives to surgery, and 63% (n=56) and 62% (n=56) recommended delayed surgery (the most common recommendation).

CONCLUSIONS

Most online information about subacromial decompression and rotator cuff repair surgery does not accurately portray the best available evidence for surgery and may be inadequate to inform patient decision making.

Global Media Coverage of the Benefits and Harms of Early Detection Tests

This cross-sectional study examines global media coverage of the benefits and harms of early detection tests for asymptomatic individuals.

The effectiveness of biofeedback for improving pain, disability and work ability in adults with neck pain: A systematic review and meta-analysis

BACKGROUND

Biofeedback is used to optimise muscle activation patterns in people with neck pain.

OBJECTIVES

To evaluate the safety and efficacy of electromyographic and pressure biofeedback on pain, disability and work ability in adults with neck pain.

DESIGN

Systematic review and meta-analysis.

METHODS

We searched key databases and trial registries to September 2020, using terms synonymous with 'neck pain' and 'biofeedback'. We included randomised controlled trials (RCTs) evaluating biofeedback (against any comparison) for adults with neck pain. Outcomes included pain, disability, work ability and adverse events. Two authors independently selected the studies, extracted data, and evaluated risk of bias. GRADE was applied to each meta-analysis. Data were pooled using random-effects models to determine the standardised mean change (SMC).

RESULTS

We included 15 RCTs (n = 990). Moderate-quality evidence suggests biofeedback has a moderate effect on reducing short-term disability (SMC = -0.42, 95%CI: 0.59 to -0.26, nine trials, n = 627), and a small effect on reducing intermediate-term disability (SMC = -0.30, 95%CI: 0.53 to -0.06, five trials, n = 458). Biofeedback had no effect on pain or work ability in the short- and intermediate-term (low-to moderate-quality evidence). One study reported headaches in 6.7% of participants, but headache frequency was not reported by group.

LIMITATIONS

There were a variety of control interventions across studies. Few studies compared biofeedback with no treatment or placebo.

CONCLUSION

Biofeedback appears to have a small-to-moderate effect on reducing neck pain disability in the short- and intermediate-term, but no effect on pain or work ability. More trials reporting adverse events and comparing biofeedback to placebo are needed.

Intensive supervised rehabilitation versus less supervised rehabilitation following anterior cruciate ligament reconstruction? A systematic review and meta-analysis

OBJECTIVES

To investigate whether intensive supervised rehabilitation following ACL reconstruction leads to superior self-reported function and sports participation compared to less supervised rehabilitation.

DESIGN

Systematic review and meta-analysis.

METHODS

We included randomised controlled trials (RCTs) comparing supervised rehabilitation to rehabilitation with a similar protocol that used less supervised sessions for athletes following ACL reconstruction. Two reviewers independently screened studies and extracted data. The Physiotherapy Evidence Database (PEDro) scale was used to evaluate methodological quality and GRADE to evaluate overall quality of evidence. Self-reported function and sports participation were the primary outcomes. Data were pooled using random effects meta-analyses.

RESULTS

Our search retrieved 4075 articles. Seven articles reporting on six RCTs were included (n=353). Very-low to low-certainty evidence suggests intensive supervised rehabilitation is not superior to less supervised rehabilitation following ACL reconstruction for improving self-reported function, sports participation, knee flexor and extensor strength, range of motion, sagittal plane knee laxity, single leg hop performance, or quality of life.

CONCLUSION

Based on uncertain evidence, intensive supervised rehabilitation is not superior to less supervised rehabilitation for athletes following ACL reconstruction. Although high-quality RCTs are needed to provide more certain evidence, clinicians should engage athletes in shared decision making to ensure athletes' rehabilitation decisions align with current evidence on supervised rehabilitation as well as their preferences and values.

Physiotherapy utilisation and costs before lumbar spine surgery: a retrospective analysis of workers compensation claims in Australia

Background

Understanding how much physiotherapy people receive before lumbar spine surgery could give insight into what people and clinicians consider an adequate trial of non-operative management. The aim of this study was to investigate physiotherapy utilisation and costs before lumbar spine surgery under a workers’ compensation claim in New South Wales (NSW), Australia.

Methods

Using data from the NSW State Insurance Regulatory Authority, we audited physiotherapy billing codes used before surgery for people who received lumbar spine surgery from 2010 to 2018. We summarised, separately for fusion and decompression, the time from initiation of physiotherapy to surgery, number of physiotherapy sessions people received before surgery, total cost of physiotherapy before surgery, and time from injury date to initiation of physiotherapy. All analyses were descriptive.

Results

We included 3070 people (800 had fusion, 2270 decompression). Mean age (standard deviation, SD) was similar between those who received fusion and decompression [42.9 (10.4) vs. 41.9 (11.6)]. Compared to people who had fusion, those who had decompression were more likely to not have any physiotherapy before surgery (28.4% vs. 15.4%), received physiotherapy for a shorter duration before surgery [median (interquartile range, IQR): 5 (3 to 11) vs. 15 (4–26) months], were less likely to have physiotherapy for ≥2 years before surgery (5.6% vs. 27.5%), had fewer physiotherapy sessions before surgery [mean (SD): 16 (21) vs. 28 (35) sessions], were less likely to have > 50 physiotherapy sessions before surgery (6.8% vs. 18.1%), and had lower total physiotherapy-related costs [mean (IQR): $1265 ($0–1808) vs. $2357 ($453–2947)]. Time from injury date to first physiotherapy session was similar between people who had fusion and decompression [median (IQR): 23 (9–66) vs.19 (7–53) days].

Conclusions

There is variation in physiotherapy utilisation and costs before lumbar spine surgery for people funded by NSW Workers’ Compensation. Some people may not be receiving an adequate trial of physiotherapy before surgery, particularly before decompression surgery. Others may be receiving an excessive amount of physiotherapy before surgery, particularly before fusion.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04129-4.

Low back pain presentations to New South Wales emergency departments: Trends over time and geographical variation

OBJECTIVE

To determine whether rates of ED presentations because of low back pain (LBP) have increased from 2016 to 2019 in New South Wales and map the geographical distribution of ED presentations because of LBP across New South Wales.

METHODS

We sourced data from the New South Wales Emergency Department Records for Epidemiology. We included all ED presentations aged 15 years and older with a diagnosis of LBP to the 178 public EDs across New South Wales from 1 January 2016 to 31 December 2019. We calculated the ratio (95% confidence interval) between the 2016 and 2019 age-standardised rates to determine whether an increase in the rate of ED LBP presentations has occurred. To assess geographical variation, we aggregated presentations by their home postcode. We calculated age-standardised rates per 100 000 person year for each of those areas using data from 2016 to 2019.

RESULTS

We included 188 275 LBP presentations for patients aged 15 years or older. Their mean (standard deviation) age was 51.3 (20.0) years. From 2016 to 2019, we observed a 5.3% increase in the age-adjusted LBP ED presentation rates (age-standardised ratio 1.05, 95% confidence interval 1.04-1.06). We found a 20-fold variation in LBP ED age-standardised presentation rates across the different local government areas of New South Wales. Higher rates were mostly observed in rural and regional areas.

CONCLUSIONS

The demand for ED services because of LBP has increased in New South Wales over time, and we observed a 20-fold variation in presentation rates across different regions.

Effect of Probiotic, Prebiotic, and Synbiotic Supplementation on Cardiometabolic and Oxidative Stress Parameters in Patients With Chronic Kidney Disease: A Systematic Review and Meta-analysis

PURPOSE

Chronic kidney disease (CKD) is a major health problem worldwide. Evidence supporting the use of probiotic, prebiotic, and synbiotic supplementation in the management of CKD is mixed, although some studies suggest they may be useful. A systematic review and meta-analysis was performed to evaluate the effectiveness of probiotic, prebiotic, and synbiotic supplementation for improving cardiometabolic and oxidative stress parameters in patients with CKD.

METHODS

A comprehensive key word search was performed in EMBASE, Medline, Scopus, Cochrane Central, and Web of Science until April 2020. Randomized controlled trials investigating the effectiveness of probiotic, synbiotic, and prebiotic supplementation for the management of adults with CKD were included. Primary outcomes were measures of cardiometabolic parameters such as cholesterol and fasting blood glucose. Secondary outcomes were measures of oxidative stress (eg, malondialdehyde levels) and body mass index. Random effects meta-analyses were used to estimate mean treatment effects. Results are reported as standardized mean differences (SMDs) and 95% CIs.

FINDINGS

Fourteen articles were included. In patients with CKD, probiotic, prebiotic, and synbiotic supplementation significantly reduced total cholesterol (SMD, -0.25; 95% CI, -0.46 to -0.04; I² = 00.0%), fasting blood glucose (SMD, -0.41; 95% CI, -0.65 to -0.17; I² = 00.0%), homeostatic model assessment of insulin resistance (SMD, -0.63; 95% CI, -0.95 to -0.30; I² = 43.3%), insulin levels (SMD, -0.49; 95% CI, -0.90 to -0.08; I² = 65.2%), high-sensitivity C-reactive protein levels (SMD, -0.52; 95% CI, -0.81 to -0.22; I² = 52.7%), and malondialdehyde levels (SMD, -0.79; 95% CI, -1.22 to -0.37; I² = 69.8%) compared with control interventions. Supplementation significantly increased the quantitative insulin sensitivity check index (SMD, 0.78; 95% CI, 0.51 to 1.05; I² = 00.0%), total antioxidant capacity (SMD, 0.42; 95% CI, 0.18 to 0.66; I² = 00.0%), and glutathione levels (SMD, 0.52; 95% CI, 0.19 to 0.86; I² = 37.0%).

IMPLICATIONS

Probiotic, prebiotic, and synbiotic supplementation seems to be a promising intervention for improving cardiometabolic and oxidative stress parameters in patients with CKD.

Are musculoskeletal conditions neglected in national health surveys?

OBJECTIVE

To describe the proportion of national health surveys that contained questions on the prevalence and consequences of musculoskeletal conditions.

METHODS

We used a comprehensive search strategy to obtain national health surveys from the 218 countries listed by the World Bank. Two authors independently extracted information from each national health survey. Outcomes were the proportion of surveys that: (i) contained questions on the prevalence of musculoskeletal conditions using the Global Burden of Disease categorisation of rheumatoid arthritis, osteoarthritis, low back pain, neck pain, gout and other; (ii) contained condition-specific questions about activity limitation, severity of pain, and work absence. We also measured how frequently prevalence of low back pain was measured using a consensus-based standard definition for low back pain prevalence studies.

RESULTS

We identified national health surveys from 170 countries. Sixty-two (36.4%), the majority from high-income countries (N = 43), measured prevalence of at least one musculoskeletal condition. Osteoarthritis (53, 85.4%), low back pain (39, 62.9%) and neck pain (37, 59.7%) were the most commonly measured, while rheumatoid arthritis and gout prevalence were only measured in 10 (5.9%) and 3 (1.8%) surveys, respectively. A minority of surveys assessed condition-specific activity limitation (6, 3.6%), pain severity (5, 2.9%) and work absence (1, 0.6%). Only one survey used the consensus-based standard definition for low back pain.

CONCLUSION

Musculoskeletal conditions are being neglected in the majority of national health surveys. Monitoring musculoskeletal conditions through ongoing surveys is crucial for the development and evaluation of health policies to reduce their burden.

Efficacy and safety of antidepressants for the treatment of back pain and osteoarthritis: systematic review and meta-analysis

OBJECTIVE

To investigate the efficacy and safety of antidepressants for back and osteoarthritis pain compared with placebo.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Medline, Embase, Cochrane Central Register of Controlled Trials, CINAHL, International Pharmaceutical Abstracts, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform from inception to 15 November and updated on 12 May 2020.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

Randomised controlled trials comparing the efficacy or safety, or both of any antidepressant drug with placebo (active or inert) in participants with low back or neck pain, sciatica, or hip or knee osteoarthritis.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data. Pain and disability were primary outcomes. Pain and disability scores were converted to a scale of 0 (no pain or disability) to 100 (worst pain or disability). A random effects model was used to calculate weighted mean differences and 95% confidence intervals. Safety (any adverse event, serious adverse events, and proportion of participants who withdrew from trials owing to adverse events) was a secondary outcome. Risk of bias was assessed with the Cochrane Collaboration's tool and certainty of evidence with the grading of recommendations assessment, development and evaluation (GRADE) framework.

RESULTS

33 trials (5318 participants) were included. Moderate certainty evidence showed that serotonin-noradrenaline reuptake inhibitors (SNRIs) reduced back pain (mean difference -5.30, 95% confidence interval -7.31 to -3.30) at 3-13 weeks and low certainty evidence that SNRIs reduced osteoarthritis pain (-9.72, -12.75 to -6.69) at 3-13 weeks. Very low certainty evidence showed that SNRIs reduced sciatica at two weeks or less (-18.60, -31.87 to -5.33) but not at 3-13 weeks (-17.50, -42.90 to 7.89). Low to very low certainty evidence showed that tricyclic antidepressants (TCAs) did not reduce sciatica at two weeks or less (-7.55, -18.25 to 3.15) but did at 3-13 weeks (-15.95, -31.52 to -0.39) and 3-12 months (-27.0, -36.11 to -17.89). Moderate certainty evidence showed that SNRIs reduced disability from back pain at 3-13 weeks (-3.55, -5.22 to -1.88) and disability due to osteoarthritis at two weeks or less (-5.10, -7.31 to -2.89), with low certainty evidence at 3-13 weeks (-6.07, -8.13 to -4.02). TCAs and other antidepressants did not reduce pain or disability from back pain.

CONCLUSION

Moderate certainty evidence shows that the effect of SNRIs on pain and disability scores is small and not clinically important for back pain, but a clinically important effect cannot be excluded for osteoarthritis. TCAs and SNRIs might be effective for sciatica, but the certainty of evidence ranged from low to very low.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020158521.

What makes a great clinical trial in physiotherapy?

Objective: To identify common characteristics of landmark physiotherapy clinical trials.Methods: The Physiotherapy Evidence Database (PEDro) top five trials were compared to 91 physiotherapy trials published in top medical journals and 99 trials randomly selected from PEDro on the following characteristics: PEDro score, sample size, number of trial sites, use of prospective registration, positive or negative trial, citations, citations in guidelines, Altmetric score, impact factor, publications and citations of first and last author, and PEDro codes (sub-discipline, topic, problem, therapy, and body part). Trials were published from 2014 to 2019. One-way independent ANOVA and Chi-squared test evaluated between-group differences.Results: Compared to a random sample of physiotherapy trials, the PEDro top five trials and trials in top medical journals have higher PEDro scores, larger sample sizes, more study sites, more citations (including in guidelines), higher Altmetric scores, more likely to be prospectively registered, less likely to be positive trials, and have first and last authors with more citations and publications. The problem was the only PEDro code was distributed differently across the trial groups.Conclusion: The PEDro top five trials and physiotherapy trials published in the top medical journals have characteristics that may inform the design, conduct, and reporting of future physiotherapy trials.

People considering exercise to prevent low back pain recurrence prefer exercise programs that differ from programs known to be effective: a discrete choice experiment

QUESTION

Do program and participant characteristics influence people's willingness to undertake exercise programs to prevent recurrence of low back pain?

DESIGN

Discrete choice experiment.

PARTICIPANTS

Six hundred and forty-seven people with a recent history of low back pain.

DATA COLLECTION

Recruitment and participation occurred online. Participants were randomised to a block of 10 choice tasks, where the characteristics of the exercise program varied systematically. The characteristics that were presented for each exercise program were mode of exercise delivery, mode of supervision, setting, duration, weekly frequency, travel time, risk of recurrence, and costs. For each choice task, participants chose between no program or an exercise program with the characteristics as presented.

DATA ANALYSIS

Choices were analysed using mixed logit models. Latent class models examined preference heterogeneity and identified participant-level characteristics predictive of preferences.

RESULTS

There appeared to be an underlying preference for exercise compared with no exercise, all else being equal. Preferences for programs were significantly influenced by the characteristics of the programs. Participants were less likely to choose exercise when programs were of a longer duration (OR 0.92, 95% CI 0.89 to 0.96 per extra month), but more likely to prefer programs offering greater reduction in the risk of recurrence of low back pain (OR 3.91, 95% CI 3.20 to 4.79 per 10% reduction in risk of recurrence). Preferences for engaging in exercise programs to prevent recurrent of low back pain were influenced by the characteristics of the programs themselves. However, there was mismatch between the preferred characteristics of exercise programs and the characteristics of known effective programs.

CONCLUSION

People who have had low back pain should be advised explicitly about which exercise programs reduce recurrence. Understanding low back pain patients' preferences can help inform the implementation of existing prevention programs and guide the design of new prevention programs.

Effectiveness of Implementation Strategies to Improve Adherence of Physical Therapist Treatment Choices to Clinical Practice Guidelines for Musculoskeletal Conditions: Systematic Review

OBJECTIVE

The objective of this study was to evaluate the effectiveness of implementation strategies aimed at improving the adherence of physical therapists' treatment choices to clinical practice guidelines for a range of musculoskeletal conditions.

METHODS

For this review, searches were performed in several databases combining terms synonymous with "practice patterns" and "physical therapy" until August 2019. The review included randomized controlled trials that investigated any intervention to improve the adherence of physical therapists' treatment choices to clinical practice guidelines or research evidence. Treatment choices assessed by surveys, audits of clinical notes, and treatment recording forms were the primary measures of adherence. Self-reported guideline adherence was the secondary measure. Three reviewers independently assessed risk of bias. Because of heterogeneity across studies, only a narrative synthesis of the results was performed.

RESULTS

Nine studies were included. Four demonstrated a positive effect on at least 1 measure of treatment choices for low back pain and acute whiplash. One involved a comparison with no intervention, and 3 involved a comparison with another active intervention. The interventions that demonstrated a positive effect included dissemination of clinical practice guidelines, with additional elements including interactive educational meetings (3 studies), tailored interventions and monitoring of the performance of health care delivery (1 study), peer assessment (1 study), and local opinion leaders plus educational outreach visits (1 study).

CONCLUSIONS

Although this review revealed limited trials evaluating interventions to increase physical therapists' use of evidence-based treatments for musculoskeletal conditions compared with no intervention, it highlighted some interventions that may be effective.

IMPACT

Dissemination of clinical practice guidelines, interactive educational meetings, tailored interventions and monitoring the performance of health care delivery, peer assessment, and use of local opinion leaders plus educational outreach visits should be implemented to improve physical therapists' adherence to clinical practice guidelines for a range of musculoskeletal conditions.

Do different sit-stand workstations influence lumbar kinematics, lumbar muscle activity and musculoskeletal pain in office workers? A secondary analysis of a randomized controlled trial

Purpose. This study investigated the effect of different sit-stand workstations on lumbar spine kinematics, lumbar muscle activity and musculoskeletal pain. Methods. Thirty-two office workers were randomized to one of three sit-stand workstations (Group 1, ratio of minutes spent sitting to standing each hour at work 40:20, n = 8; Group 2, 30:30, n = 6; Group 3, 20:40, n = 7) and a control group (usual sitting, n = 11). Intervention groups (Groups 1, 2 and 3) were collapsed into one group for analysis (n = 21). Data on lumbar kinematics and muscle activity were only collected for 25 participants due to equipment availability. Results. Participants in the intervention group had lower overall lumbar spine flexion angles during the workday compared to the control group (mean difference 10.6°; 95% confidence interval [-18.1, -3.2]; p = 0.008; Cohen's d = 1.5). There were no between-group differences for the remaining kinematic measures (i.e., mean flexion angle in standing and sitting, mean side flexion angle in standing and sitting, and percentage of time in upright sitting), muscle activity or presence of musculoskeletal pain. Conclusions. Sit-stand workstations reduced overall lumbar spine flexion angles over the course of a workday but had no effect on other kinematic measures, lumbar spine muscle activity or musculoskeletal pain.Trial registration: Australian New Zealand Clinical Trials Registry identifier: ACTRN12615001018505..