Activity-Based Therapy for Mobility, Function and Quality of Life after Spinal Cord Injuries-A Mixed-Methods Case Series

(1) Background: Despite inconclusive evidence on the benefits of activity-based therapies (ABTs) in people with spinal cord injuries, implementation has occurred in clinics worldwide in response to consumers' requests. We explored the clinical changes and participants' perceptions from engaging in an ABT program in the community. (2) Methods: This mixed-methods study involved a pragmatic observational multiple-baseline design and an evaluation of participants' perceptions. Fifteen participants were included. Outcome measures were balance in sitting using the Seated Reach Distance test, mobility using the Modified Rivermead Mobility Index and quality of life using the Quality of Life Index SCI version pre- and post-participation in an ABT community-based program. Linear mixed models and logistic regressions were used to analyse the effects of intervention. Semi-structured interviews explored participants' perceptions using inductive thematic analysis. (3) Results: There was an increase of 9% in the standardised reach distance (95% CI 2-16) for sitting balance, 1.33 points (95% CI: 0.81-1.85) in mobility and 1.9 points (0.17-2.1) in quality of life. Two themes emerged from the interviews: (1) reduced impact of disability and an increased sense of life as before, and (2) the program was superior to usual rehabilitation. No adverse events related to the intervention were observed. (4) Conclusion: ABT delivered in the community improved clinical outcomes in people with a chronic SCI. High levels of satisfaction with the program were reported.

Who crashes their car following wrist fracture?

BACKGROUND

Wrist fractures are common injuries associated with high disability in the early recovery period. The impact of wrist fractures on safe return to drive is not understood.

PURPOSE

(1) To compare the proportion of adults who were drivers in car crashes before and after wrist fracture; (2) To examine potential factors (demographic and/or clinical) associated with increased odds of being a driver in a car crash following wrist fracture.

STUDY DESIGN

Retrospective cohort study.

METHODS

Three state-wide government datasets (MainRoads Western Australia [WA], Hospital Morbidity Data Collection and the Emergency Department Data Collection) were used to obtain and link demographic, clinical and car crash information relating to adults with a wrist fracture sustained between 2008 and 2017. McNemar's tests were used to compare the proportion of drivers in a car crash within the 2 years prior to and following the fracture date. Multivariable logistic regressions were used to identify if any variables were associated with increased odds of crashing in the post-fracture period.

RESULTS

Data relating to 37,107 adults revealed a 3.3% (95% CI 3.0%-3.6%, p < 0.05) decrease in the proportion of drivers in a car crash following wrist fracture, persisting for the entire 2 years post-fracture, when compared to the proportion who crashed before their fracture. Those with more severe wrist fracture injury patterns had 79%(95% CI 1.07-3.0, p = 0.03) higher odds of having a crash in the first 3 months following their injury, compared to those with isolated wrist fracture injuries.

CONCLUSIONS

These results inform and update return to drive recommendations. The reduced proportion of drivers involved in crashes following wrist fracture persisted for 2 years; longer than the expected physical recovery timeframe. It is important that hand therapists actively educate the sub-group of adults with more severe wrist fracture injury patterns of the increased likelihood of car crash for the 3 months following their fracture.

Implementation of a risk-stratified, guideline-based clinical pathway of care to improve health outcomes following whiplash injury (Whiplash ImPaCT): a multicentre, randomized, controlled trial

ABSTRACT

Current pathways of care for whiplash follow a "stepped care model," result in modest treatment outcomes and fail to offer efficient management solutions. This study aimed to evaluate the effectiveness of a risk-stratified clinical pathway of care (CPC) compared with usual care (UC) in people with acute whiplash. We conducted a multicentre, 2-arm, parallel, randomised, controlled trial in primary care in Australia. Participants with acute whiplash (n = 216) were stratified for risk of a poor outcome (low vs medium/high risk) and randomised using concealed allocation to either the CPC or UC. In the CPC group, low-risk participants received guideline-based advice and exercise supported by an online resource, and medium-risk/high-risk participants were referred to a whiplash specialist who assessed modifiable risk factors and then determined further care. The UC group received care from their primary healthcare provider who had no knowledge of risk status. Primary outcomes were neck disability index (NDI) and Global Rating of Change (GRC) at 3 months. Analysis blinded to group used intention-to-treat and linear mixed models. There was no difference between the groups for the NDI (mean difference [MD] [95% confidence interval (CI)] -2.34 [-7.44 to 2.76]) or GRC (MD 95% CI 0.08 [-0.55 to 0.70]) at 3 months. Baseline risk category did not modify the effect of treatment. No adverse events were reported. Risk-stratified care for acute whiplash did not improve patient outcomes, and implementation of this CPC in its current form is not recommended.

The Natural Helper approach to culturally responsive disease management: protocol for a type 1 effectiveness-implementation cluster randomised controlled trial of a cultural mentor programme

INTRODUCTION

Chronic disease is a leading cause of death and disability that disproportionately burdens culturally and linguistically diverse (CALD) communities. Self-management is a cornerstone of effective chronic disease management. However, research suggests that patients from CALD communities may be less likely to engage with self-management approaches. The Natural Helper Programme aims to facilitate patient engagement with self-management approaches (ie, 'activation') by embedding cultural mentors with lived experience of chronic disease into chronic disease clinics/programmes. The Natural Helper Trial will explore the effect of cultural mentors on patient activation, health self-efficacy, coping efforts and health-related quality of life (HRQoL) while also evaluating the implementation strategy.

METHODS AND ANALYSIS

A hybrid type-1 effectiveness-implementation cluster-randomised controlled trial (phase one) and a mixed-method controlled before-and-after cohort extension of the trial (phase 2). Hospital clinics in highly multicultural regions in Australia that provide healthcare for patients with chronic and/or complex conditions, will participate. A minimum of 16 chronic disease clinics (clusters) will be randomised to immediate (active arm) or delayed implementation (control arm). In phase 1, the active arm will receive a multifaceted strategy supporting them to embed cultural mentors in their services while the control arm continues with usual care. Each cluster will recruit an average of 15 patients, assessed at baseline and 6 months (n=240). In phase 2, clusters in the control arm will receive the implementation strategy and evaluate the intervention on an additional 15 patients per cluster, while sustainability in active arm clusters will be assessed qualitatively. Change in activation over 6 months, measured using the Patient Activation Measure will be the primary effectiveness outcome, while secondary effectiveness outcomes will explore changes in chronic disease self-efficacy, coping strategies and HRQoL. Secondary implementation outcomes will be collected from patient-participants, mentors and healthcare providers using validated questionnaires, customised surveys and interviews aligning with the Reach, Effectiveness, Adoption, Implementation, Maintenance framework to evaluate acceptability, reach, dose delivered, sustainability, cost-utility and healthcare provider determinants.

ETHICS AND DISSEMINATION

This trial has full ethical approval (2021/ETH12279). The results from this hybrid trial will be presented at scientific meetings and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12622000697785.

Back pain beliefs among Indian migrants in Australia: a cross-sectional study

PURPOSE

One of the largest migrant communities in Australia is the Indian migrant community. Current back pain guidelines recommend assessment of patients' beliefs; however, little is known about these beliefs in Indian communities. We aimed to investigate beliefs about back pain among Indian migrants living in Sydney.

MATERIAL AND METHODS

An online questionnaire with demographic information, participant characteristics, the Back Beliefs Questionnaire (BBQ) and open-ended questions relating to beliefs about causes of back pain and treatment preferences was completed by 386 Indian migrants in Sydney.

RESULTS

The overall BBQ score was 25.1 ± 6.7. We found significant but slightly more positive beliefs among Indian females than Indian males (standardized regression coefficient, β = 0.134, p = 0.014). Presence and severity of pain did not affect back pain beliefs. There seemed to be a belief in physical and structural/anatomical causes of back pain, and a belief in the effectiveness of exercise, medications, and Indian traditional approaches for pain management.

CONCLUSIONS

Beliefs of Indian migrants aligned with a "western traditional" biomedical model for the cause of pain, but with a belief in the effectiveness of both Indian traditional and western treatment approaches. Awareness of these beliefs could enable an effective therapeutic alliance between clinicians and Indian patients.IMPLICATIONS FOR REHABILITATIONBack pain beliefs of Australian Indian migrants are similar to their western counterparts, so the current guidelines for back pain can potentially be implemented without too much adjustment for this migrant community.Awareness of these beliefs is likely to improve the therapeutic alliance between clinician and an Indian migrant patient.

Cross-cultural adaptation, reliability and validity of the Marathi versions of the Back Beliefs Questionnaire and Pain Self-Efficacy Questionnaire in people living with chronic low back pain

PURPOSE

To translate and cross-culturally adapt the Back Beliefs Questionnaire (BBQ) and Pain Self-Efficacy Questionnaire (PSEQ) into Marathi, and to evaluate their clinimetric properties in a native Marathi speaking population with chronic low back pain.

MATERIAL AND METHODS

The BBQ and PSEQ were translated into Marathi using international published guidelines. Fifty native Marathi speakers were recruited. Reliability (n = 43) was evaluated in terms of internal consistency (Cronbach α) and test-retest reliability [intra class correlation coefficient, ICC (2, 1)] and 95% confidence interval (CI). Convergent validity (n = 50) was assessed by correlating the Marathi versions of BBQ and PSEQ with the Marathi version of Roland Morris Disability Questionnaire (RMDQ).

RESULTS

Internal consistency of BBQ (Cronbach α  =  0.67) was good and that for PSEQ (Cronbach α  =  0.93) was high. Test-retest reliability for BBQ (ICC =  0.80; 95% CI: 0.66 to 0.89) was good and PSEQ (ICC = 0.85; 95% CI: 0.74 to 0.92) was excellent. A significant, low negative correlation was found between RMDQ and BBQ scores (r = -0.298; p = 0.036) and PSEQ (r = -0.28; p = 0.049).

CONCLUSIONS

The BBQ and PSEQ were successfully cross-culturally adapted into Marathi. Clinimetric evaluation of these questionnaires in a sample of native Marathi speaking populations with chronic low back pain demonstrated good acceptability, acceptable internal consistency, and high test-retest reliability.Implications for rehabilitationThe Back Beliefs Questionnaire (BBQ) and Pain Self Efficacy Questionnaire (PSEQ) were successfully cross-culturally adapted into Marathi.The Marathi versions of BBQ and PSEQ have good acceptability, acceptable internal consistency, and high test-retest reliability.They can be used by clinicians and researchers to evaluate beliefs about back pain and pain self-efficacy in Marathi speaking patients with chronic low back pain.

Increase in ACC GABA+ levels correlate with decrease in migraine frequency, intensity and disability over time

Background

An imbalance between inhibitory and excitatory neurometabolites has been implicated in chronic pain. Prior work identified elevated levels of Gamma-aminobutyric acid + macromolecules (“GABA+”) using magnetic resonance spectroscopy (MRS) in people with migraine. What is not understood is whether this increase in GABA+ is a cause, or consequence of living with, chronic migraine. Therefore, to further elucidate the nature of the elevated GABA+ levels reported in migraine, this study aimed to observe how GABA+ levels change in response to changes in the clinical characteristics of migraine over time.

Methods

We observed people with chronic migraine (ICHD-3) over 3-months as their treatment was escalated in line with the Australian Pharmaceutical Benefits Scheme (PBS). Participants underwent an MRS scan and completed questionnaires regarding migraine frequency, intensity (HIT-6) and disability (WHODAS) at baseline and following the routine 3 months treatment escalation to provide the potential for some participants to recover. We were therefore able to monitor changes in brain neurochemistry as clinical characteristics potentially changed over time.

Results

The results, from 18 participants who completed both baseline and follow-up measures, demonstrated that improvements in migraine frequency, intensity and disability were associated with an increase in GABA+ levels in the anterior cingulate cortex (ACC); migraine frequency (r = − 0.51, p = 0.03), intensity (r = − 0.51, p = 0.03) and disability (r = − 0.53, p = 0.02). However, this was not seen in the posterior cingulate gyrus (PCG). An incidental observation found those who happened to have their treatment escalated with CGRP-monoclonal antibodies (CGRP-mAbs) (n = 10) had a greater increase in ACC GABA+ levels (mean difference 0.54 IU IQR [0.02 to 1.05], p = 0.05) and reduction in migraine frequency (mean difference 10.3 IQR [2.52 to 18.07], p = 0.01) compared to those who did not (n = 8).

Conclusion

The correlation between an increase in ACC GABA+ levels with improvement in clinical characteristics of migraine, suggest previously reported elevated GABA+ levels may not be a cause of migraine, but a protective mechanism attempting to suppress further migraine attacks.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10194-021-01352-1.

Implementation of a novel stratified PAthway of CarE for common musculoskeletal (MSK) conditions in primary care: protocol for a multicentre pragmatic randomised controlled trial (the PACE MSK trial)

Introduction

Musculoskeletal (MSK) conditions constitute the highest burden of disease globally, with healthcare services often utilised inappropriately and overburdened. The aim of this trial is to evaluate the effectiveness of a novel clinical PAthway of CarE programme (PACE programme), where care is provided based on people’s risk of poor outcome.

Methods and analysis

Multicentre randomised controlled trial. 716 people with MSK conditions (low back pain, neck pain or knee osteoarthritis) will be recruited in primary care. They will be stratified for risk of a poor outcome (low risk/high risk) using the Short Form Örebro Musculoskeletal Pain Screening Questionnaire (SF-ÖMSPQ) then randomised to usual care (n=358) or the PACE programme (n=358). Participants at low risk in the PACE programme will receive up to 3 sessions of guideline based care from their primary healthcare professional (HCP) supported by a custom designed website (mypainhub.com). Those at high risk will be referred to an allied health MSK specialist who will conduct a comprehensive patient-centred assessment then liaise with the primary HCP to determine further care. Primary outcome (SF 12-item PCS) and secondary outcomes (eg, pain self-efficacy, psychological health) will be collected at baseline, 3, 6 and 12 months. Cost-effectiveness will be measured as cost per quality-adjusted life-year gained. Health economic analysis will include direct and indirect costs. Analyses will be conducted on an intention-to-treat basis. Primary and secondary outcomes will be analysed independently, using generalised linear models. Qualitative and mixed-methods studies embedded within the trial will evaluate patient experience, health professional practice and interprofessional collaboration.

Ethics and dissemination

Ethics approval has been received from the following Human Research Ethics Committees: The University of Sydney (2018/926), The University of Queensland (2019000700/2018/926), University of Melbourne (1954239), Curtin University (HRE2019-0263) and Northern Sydney Local Health District (2019/ETH03632). Dissemination of findings will occur via peer-reviewed publications, conference presentations and social media.

Trial registration number

ACTRN12619000871145.

Allied health are key to improving health for people with chronic disease: but where are the outcomes and where is the strategy?

The global burden of chronic disease has forced health systems to focus on improved care. This has led to improved health outcomes for some populations, but not for all people or for all conditions. The rising prevalence of chronic disease has also significantly increased demands on healthcare systems, with unsustainable costs to funders. To improve health and social outcomes for all people with chronic disease, it is critical to embrace allied health professionals as key members of primary healthcare teams. The recognised efficacy and cost-effectiveness of many allied health interventions suggest that implementation into usual care would result in enhanced outcomes for people accessing healthcare, their families and communities, and for health systems. Our aim is to highlight the current unacceptable lack of allied health integration into primary healthcare teams, and illustrate the potential value of improved and equitable access to allied health professionals for managing chronic conditions and multimorbidity.

Community-based interventions for chronic musculoskeletal health conditions in rural and remote populations: A systematic review

Chronic musculoskeletal health conditions are highly prevalent in rural and remote areas, globally. It is unknown, however, whether interventions shown to be effective for urban populations are also effective for rural and remote populations. The purpose of the review was to evaluate the effectiveness of community-based interventions for management of chronic musculoskeletal health conditions in rural and remote populations. A systematic review was undertaken of the major databases: Medline, Scopus, Web of Science, Rural and Remote Health, Embase and PEDro to April 2020 with no restrictions on language or publication date. Odds Ratios were calculated to report differences between intervention and control groups. Risk of bias was assessed using the PEDro scale. Meta-analysis was not conducted, given the high heterogeneity among studies. From a total of 3,219 articles identified from the title search, five studies were eligible, with a total of 2,831 participants. Interventions evaluated included education alone, exercise with education and ergonomic modifications. Community-based education and exercise led to significantly reduced chronic musculoskeletal pain [OR = 1.85 (95% CI 1.22, 2.82)] compared with controls. Ergonomic stove installation significantly reduced average prevalence of back pain (0.25% reduction in pain prevalence; p < .05); however, no significant effect [OR = 1.02 (0.63, 1.65)] was found when transformed to Odds Ratio. There were divergent findings for education programmes alone: one study reported a positive effect [OR = 1.78 (1.27, 2.49)], while another reported no significant effect [delivered either in home [OR: 1.21 (0.78, 1.86)] or in small groups [OR = 0.95 (0.60, 1.51)]. A significant improvement in knowledge was found with community-based education delivered in participants' homes [SMD: 1.27 (1.01, 1.54)], in small groups [SMD: 0.79 (0.53, 1.06)], using traditional puppetry [SMD: 4.79 (4.51, 5.06)], and with education and exercise [SMD: 0.29 (0.06, 0.52)]. There is low quality evidence that education and/or exercise improves knowledge of arthritis, and the effectiveness of ergonomic interventions on pain was unclear.

Sagittal spine shape literacy in the general adult population, assessed by a novel, simple graphical tool

[Purpose] The sagittal shape of the spine is associated with back-pain, balance and quality of life. We developed, evaluated and report the responses of a graphical tool to assess sagittal spine shape knowledge (literacy). [Participants and Methods] Two hundred and fifty adults were randomly assigned, in a cross-sectional crossover study, to free-hand draw and select the “ideal” sagittal spine shape. We evaluated the inter and intra-rater reliability and agreement between tests and the sagittal and lordotic spine literacy between the drawing and selection test versions. [Results] Drawing test inter- and intra-rater agreement was 79% and 80% respectively. Drawing vs. selection agreement was 43%. More participants drew than selected the correct spine (30% vs. 21%) (p<0.001) and lumbar lordosis shape (56% vs. 42%) (p<0.001). Test order did not affect spine shape literacy scores. A significantly poorer literacy trend was observed with spine pain presence (p=0.02). [Conclusion] We developed a reliable method to evaluate spine shape literacy and established that only 21% and 42% of our sample demonstrated correct sagittal spine and lordotic spine shape literacy, respectively. The low literacy scores suggests that consideration of including spine shape literacy in health literacy and self-management programs may be warranted, especially in ageing populations.

Increased GABA+ in People With Migraine, Headache, and Pain Conditions- A Potential Marker of Pain

Treatment outcomes for migraine and other chronic headache and pain conditions typically demonstrate modest results. A greater understanding of underlying pain mechanisms may better inform treatments and improve outcomes. Increased GABA+ has been identified in recent studies of migraine, however, it is unclear if this is present in other headache, and pain conditions. We primarily investigated GABA+ levels in the posterior cingulate gyrus (PCG) of people with migraine, whiplash-headache and low back pain compared to age- and sex-matched controls, GABA+ levels in the anterior cingulate cortex (ACC) and thalamus formed secondary aims. Using a cross-sectional design, we studied people with migraine, whiplash-headache or low back pain (n = 56) and compared them with a pool of age- and sex-matched controls (n = 22). We used spectral-edited magnetic resonance spectroscopy at 3T (MEGA-PRESS) to determine levels of GABA+ in the PCG, ACC and thalamus. PCG GABA+ levels were significantly higher in people with migraine and low back pain compared with controls (eg, migraine 4.89 IU ± 0.62 vs controls 4.62 IU ± 0.38; P = .02). Higher GABA+ levels in the PCG were not unique to migraine and could reflect a mechanism of chronic pain in general. A better understanding of pain at a neurochemical level informs the development of treatments that target aberrant brain neurochemistry to improve patient outcomes. PERSPECTIVE: This study provides insights into the underlying mechanisms of chronic pain. Higher levels of GABA+ in the PCG may reflect an underlying mechanism of chronic headache and pain conditions. This knowledge may help improve patient outcomes through developing treatments that specifically address this aberrant brain neurochemistry.

Progressive Resistance and Balance Training for Falls Prevention in Long-Term Residential Aged Care: A Cluster Randomized Trial of the Sunbeam Program

BACKGROUND

Falls prevention is an international priority, and residents of long-term aged care fall approximately 3 times more often than community dwellers. There is a relative scarcity of published trials in this setting.

OBJECTIVES

Our objective was to undertake a randomized controlled trial to test the effect of published best practice exercise in long-term residential aged care. The trial was designed to determine if combined high level balance and moderate intensity progressive resistance training (the Sunbeam Program) is effective in reducing the rate of falls in residents of aged care facilities.

METHOD

A cluster randomized controlled trial of 16 residential aged care facilities and 221 participants was conducted. The broad inclusion criterion was permanent residents of aged care. Exclusions were diagnosed terminal illness, no medical clearance, permanent bed- or wheelchair-bound status, advanced Parkinson's disease, or insufficient cognition to participate in group exercise. Assessments were taken at baseline, after intervention, and at 12 months. Randomization was performed by computer-generated sequence to receive either the Sunbeam program or usual care. A cluster refers to an aged care facility.

INTERVENTION

The program consisted of individually prescribed progressive resistance training plus balance exercise performed in a group setting for 50 hours over a 25-week period, followed by a maintenance period for 6 months.

OUTCOME MEASURES

The primary outcome measure was the rate of falls (number of falls and days followed up). Secondary outcomes included physical performance (Short Physical Performance Battery), quality of life (36-item Short-Form Health Survey), functional mobility (University of Alabama Life Space Assessment), fear of falling (Falls Efficacy Scale International), and cognition (Addenbrooke's Cognitive Evaluation-revised).

RESULTS

The rate of falls was reduced by 55% in the exercise group (incidence rate ratio = 0.45, 95% confidence interval 0.17-0.74); an improvement was also seen in physical performance (P = .02). There were no serious adverse events.

CONCLUSION

The Sunbeam Program significantly reduced the rate of falls and improved physical performance in residents of aged care. This finding is important as prior work in this setting has returned inconsistent outcomes, resulting in best practice guidelines being cautious about recommending exercise in this setting. This work provides an opportunity to improve clinical practice and health outcomes for long-term care residents.

Development and validation of the Charcot-Marie-Tooth Disease Infant Scale

Many genetic subtypes of Charcot-Marie-Tooth disease (CMT) show signs of symptomatic disease during the earliest years of life. This might be the ideal time to intervene before progression of clinical sequelae due to demyelination and axonal loss. In the absence of disease-specific clinical trial outcome measures for CMT during infancy and early childhood the aim of this study was to develop and validate a functional measure of disease severity, known as the Charcot-Marie-Tooth disease Infant Scale (CMTInfS). Development projects involved identification of a preliminary pool of 31 items representing the range of disability in affected patients aged 0-4 years from a systematic review of the literature, peer review by 12 expert clinicians and researchers in the field, design of a scoring algorithm and pilot testing in 22 participants. Subsequently, a series of validation projects were conducted based on 128 assessments of: 26 confirmed cases of inherited neuropathy (17 CMT1A, one CMT1B, one CMT1D, one CMT2C, one CMT2S, two CMT4C, one CMTX3, one Riboflavin Transporter Deficiency Type 2, and one unidentified mutation); seven 'at risk' cases and 95 unaffected healthy controls recruited through the NIH-funded Inherited Neuropathies Consortium. Validation projects included: Item, Factor and Rasch analysis, intra- and inter-rater reliability, discriminant ability and convergent validity with the CMT Pediatric Scale (CMTPedS) for children aged 3-4 years. Development and validation projects produced a psychometrically robust 15-item scale. Rasch analysis supported the viability of the CMTInfS as a unidimensional measure of disease severity and showed good overall model fit, no evidence of misfitting items or persons and was well targeted for affected children. The CMTInfS demonstrated high intra-rater reliability [intraclass correlation coefficient (ICC)3,1 0.999, 95% confidence interval 0.996-1.000) and inter-rater reliability (ICC2,1 0.997, 95% confidence interval 0.992-0.999). The CMTInfS was able to discriminate between the CMT group and controls (P = 0.006), and convergent validity demonstrated good agreement between CMTInfS and CMTPedS scores (r = 0.76, P = 0.01). The final version of the CMTInfS requires 20 min to administer and is a reliable and sensitive functional outcome measure for early onset CMT and related neuropathies.10.1093/brain/awy280_video1awy280media15970672819001.

Activity-Based Therapy in a Community Setting for Independence, Mobility, and Sitting Balance for People With Spinal Cord Injuries

INTRODUCTION

Activity-based therapy (ABT) aims to activate the neuromuscular system below the level of the spinal cord lesion and promote recovery of motor tasks through spinal reorganisation, motor learning and changes to muscles and sensory system. We investigated the effects of a multimodal ABT program on mobility, independence and sitting balance in individuals with spinal cord injury (SCI).

METHODS

Retrospective clinical data from 91 adults who independently enrolled in four community-based ABT centres in Australia were analysed. The multimodal ABT program was delivered for 3 to 12 months, one to four times per week. Assessments were undertaken every 3 months and included the Modified Rivermead Mobility Index (MRMI), Spinal Cord Independence Measure (SCIM) and seated reach distance (SRD). A linear mixed model analysis was used to determine time-based and other predictors of change.

RESULTS

There was a significant improvement after 12 months for all outcome measures, with a mean change score of 4 points in the SCIM (95% confidence interval [CI]: 2.7-5.3, d = 0.19), 2 points in the MRMI (95% CI: 1-2.3, d = 0.19) and 0.2 in the SRD (95% CI: 0.1-2.2, d = 0.52). Greater improvements occurred in the first 3 months of intervention. There were no interaction effects between time and the neurological level of injury, American Spinal Injury Association Impairment Scale classification, or duration post-injury for most outcomes.

CONCLUSIONS

A community-based ABT exercise program for people with SCI can lead to small improvements in mobility, independence and balance in sitting, with greater improvements occurring early during intervention.

Combined education and patient-led goal setting intervention reduced chronic low back pain disability and intensity at 12 months: a randomised controlled trial

BACKGROUND

One model of care that has not been tested for chronic low back pain (LBP) is patient-led goal setting. We aimed to compare the clinical effectiveness and healthcare use of a patient-led goal setting approach (intervention) with simple advice to exercise (control) over 12 months.

METHODS

An assessor-blinded randomised controlled trial. Intervention was education combined with patient-led goal setting compared with a control group receiving a standardised exercise programme. The primary outcomes were back pain disability and pain intensity. Secondary outcomes were quality of life, kinesiophobia, self-efficacy, depression, anxiety and stress. Outcomes and healthcare use were assessed immediately post-treatment (2 months) and after 4 and 12 months. Analysis was by intention to treat.

RESULTS

Seventy-five patients were randomly assigned to either the intervention (n=37) or the control (n=38) group. Using linear mixed model analyses, adjusted mean changes in primary outcomes of disability and pain intensity were greater in the intervention group than in the control group (disability post-treatment: p<0.05). These differences were clinically meaningful. Mean differences in all secondary measures were greater in the intervention group than in the control group (p<0.05). There was no difference in healthcare use between groups over 12 months.

CONCLUSION

A patient-led goal setting intervention was significantly more effective than advice to exercise for improving outcomes in disability, pain intensity, quality of life, self-efficacy and kinesiophobia in chronic LBP. These improvements were maintained at 12 months. Smaller effects were seen in measures of depression, anxiety and stress.

TRIAL REGISTRATION NUMBER

ACTRN12614000830695.

An economic evaluation of the SUNBEAM programme: a falls-prevention randomized controlled trial in residential aged care

OBJECTIVE:

To estimate the cost-effectiveness of a strength and balance exercise programme (SUNBEAM) which has been shown to be clinically effective in reducing the rate of falls in residents of aged care facilities.

DESIGN:

An economic evaluation was conducted alongside a pragmatic cluster randomized controlled trial that included 16 residential care facilities and 221 participants. Mean participant age was 86 years, 65% were female and 78% relied on a mobility aide. A cost-effectiveness analysis examined the costs of providing the exercise programme and costs of health service use arising from falls in each arm (intervention and usual care) over 12 months.

MAIN MEASURES:

Incremental cost-effectiveness ratios were calculated for the cost per fall avoided. Costs were bootstrapped to obtain adjusted confidence intervals for the incremental cost-effectiveness ratios.

RESULTS:

Of 63 facilities contacted, 16 met the eligibility criteria and were randomized to the intervention or usual care (1:1). There were 142 falls in the intervention group and 277 in the usual care group. 72 injurious falls occurred in the intervention group versus 157 with usual care. Delivery of the SUNBEAM programme cost $463 per participant. The mean total cost of each fall (regardless of group) was $400.09 and the mean cost of each injurious fall was $708.27. The incremental cost-effectiveness ratio was $22 per fall per person avoided with the mean bootstrapped incremental cost-effectiveness ratio $18 per fall avoided (95% CI: -$380.34 to $417.85).

CONCLUSION:

The SUNBEAM programme can be considered cost-effective, relative to other fall-prevention interventions in older adults.

Can we have an overall osteoarthritis severity score for the patellofemoral joint using magnetic resonance imaging? Reliability and validity

This work aimed to assess inter-rater reliability and agreement of a magnetic resonance imaging (MRI)-based Kellgren and Lawrence (K&L) grading for patellofemoral joint osteoarthritis (OA) and to validate it against the MRI Osteoarthritis Knee Score (MOAKS). MRI scans from people aged 45 to 75 years with chronic knee pain participating in a randomised clinical trial evaluating dietary supplements were utilised. Fifty participants were randomly selected and scored using the MRI-based K&L grading using axial and sagittal MRI scans. Raters conducted inter-rater reliability, blinded to clinical information, radiology reports and other rater results. Intra- and inter-rater reliability and agreement were evaluated using the intra-class correlation coefficient (ICC) and Cohen's weighted kappa. There was a 2-week interval between the first and second readings for intra-rater reliability. Validity was assessed using the MOAKS and evaluated using Spearman's correlation coefficient. Intra-rater reliability of the K&L system was excellent: ICC 0.91 (95% CI 0.82-0.95); weighted kappa (ĸ = 0.69). Inter-rater reliability was high (ICC 0.88; 95% CI 0.79-0.93), while agreement between raters was moderate (ĸ = 0.49-0.57). Validity analysis demonstrated a strong correlation between the total MOAKS features score and the K&L grading system (ρ = 0.62-0.67) but weak correlations when compared with individual MOAKS features (ρ = 0.19-0.61). The high reliability and good agreement show consistency in grading the severity of patellofemoral OA with the MRI-based K&L score. Our validity results suggest that the scale may be useful, particularly in the clinical environment. Future research should validate this method against clinical findings.

Non-radiographic methods of measuring global sagittal balance: a systematic review

Background

Global sagittal balance, describing the vertical alignment of the spine, is an important factor in the non-operative and operative management of back pain. However, the typical gold standard method of assessment, radiography, requires exposure to radiation and increased cost, making it unsuitable for repeated use. Non-radiologic methods of assessment are available, but their reliability and validity in the current literature have not been systematically assessed. Therefore, the aim of this systematic review was to synthesise and evaluate the reliability and validity of non-radiographic methods of assessing global sagittal balance.

Methods

Five electronic databases were searched and methodology evaluated by two independent reviewers using the13-item, reliability and validity, Brink and Louw critical appraisal tool.

Results

Fourteen articles describing six methodologies were identified from 3940 records. The six non-radiographic methodologies were biophotogrammetry, plumbline, surface topography, infra-red motion analysis, spinal mouse and ultrasound. Construct validity was evaluated for surface topography (R = 0.49 and R = 0.68, p < 0.001), infra-red motion-analysis (ICC = 0.81) and plumbline testing (ICC = 0.83). Reliability ranged from moderate (ICC = 0.67) for spinal mouse to very high for surface topography (Cronbach α = 0.985). Measures of agreement ranged from 0.9 mm (plumbline) to 22.94 mm (infra-red motion-analysis). Variability in study populations, reporting parameters and statistics prevented a meta-analysis.

Conclusions

The reliability and validity of the non-radiographic methods of measuring global sagittal balance was reported within 14 identified articles. Based on this limited evidence, non-radiographic methods appear to have moderate to very high reliability and limited to three methodologies, moderate to high validity. The overall quality and methodological approaches of the included articles were highly variable. Further research should focus on the validity of non-radiographic methods with a greater adherence to reporting actual and clinically relevant measures of agreement.

Effectiveness of telehealth-based interventions in the management of non-specific low back pain: a systematic review with meta-analysis

BACKGROUND

Telehealth has emerged as a potential alternative to deliver interventions for low back pain (LBP); however, its effectiveness has not been investigated.

PURPOSE

The aim of this review was to evaluate whether interventions delivered by telehealth improve pain, disability, function, and quality of life in non-specific LBP.

STUDY DESIGN

This is a systematic review with meta-analysis.

METHODS

Seven databases were searched from the earliest records to August 2015. Eligible studies were randomized controlled trials that investigated the effectiveness of telehealth-based interventions, solo or in combination with other interventions, for non-specific LBP compared with a control group. Trials deemed clinically homogeneous were grouped in meta-analyses.

RESULTS

Eleven studies were included (n=2,280). In chronic LBP, telehealth interventions had no significant effect on pain at short-term follow-up (four trials: 1,089 participants, weighted mean difference [WMD]: -2.61 points, 95% confidence interval [CI]: -5.23 to 0.01) or medium-term follow-up (two trials: 441 participants, WMD: -0.94 points, 95% CI: -6.71 to 4.84) compared with a control group. Similarly, there was no significant effect for disability. Results from three individual trials showed that telehealth was superior to a control intervention for improving quality of life. Interventions combining telehealth and usual care were more beneficial than usual care alone in people with recent onset of LBP symptoms.

CONCLUSION

There is moderate-quality evidence that current telehealth interventions, alone, are not more effective than minimal interventions for reducing pain and disability in chronic LBP. To date, modern telehealth media (eg, apps) and telehealth as an adjunct to usual care remain understudied.

Self-reported knee pain and disability among healthy individuals: reference data and factors associated with the Knee injury and Osteoarthritis Outcome Score (KOOS) and KOOS-Child

OBJECTIVE

To develop normative reference data for the Knee injury and Osteoarthritis Outcome Score (KOOS) and KOOS-Child, as well as investigate socio-demographic, psychological and physical factors associated with knee pain and disability among healthy adults.

METHOD

The KOOS or KOOS-Child (each containing five subscales) was administered to participants aged 8-101 years within the 1000 Norms Project, an observational study of 1000 self-reported healthy individuals. Self-efficacy, physical activity, body mass index (BMI), lower limb alignment, knee frontal plane projection angle (FPPA), knee range of motion (ROM), knee and hip strength, six-minute walk, 30-second chair stand and timed up and down stairs tests were collected. KOOS data were dichotomised using established cut-off scores and logistic regression analyses were conducted for each subscale.

RESULTS

Socio-demographic characteristics were similar to the Australian population. Normative reference data were generated for children (8-17 years) and adults (18-101 years). Female adults were up to twice as likely to report knee pain, symptoms and sport/recreation (Sport/Rec) limitations compared to males (P < .05). Older age, lower self-efficacy, greater BMI, varus lower limb alignment, lower knee flexion ROM and lower hip external rotation (ER) strength were independently associated with knee pain and disability among adults.

CONCLUSIONS

Age- and gender-stratified reference data for the KOOS and KOOS-Child have been developed to guide interpretation of results in practice and research for individuals with knee disorders. Psychological and physical factors are linked with self-reported knee pain/disability among adults, and longitudinal studies to investigate causation are required.

Physiotherapists' beliefs and attitudes influence clinical practice in chronic low back pain: a systematic review of quantitative and qualitative studies

QUESTION

What influence do physiotherapists' beliefs and attitudes about chronic low back pain have on their clinical management of people with chronic low back pain?

DESIGN

Systematic review with data from quantitative and qualitative studies. Quantitative and qualitative studies were included if they investigated an association between physiotherapists' attitudes and beliefs about chronic low back pain and their clinical management of people with chronic low back pain.

RESULTS

Five quantitative and five qualitative studies were included. Quantitative studies used measures of treatment orientation and fear avoidance to indicate physiotherapists' beliefs and attitudes about chronic low back pain. Quantitative studies showed that a higher biomedical orientation score (indicating a belief that pain and disability result from a specific structural impairment, and treatment is selected to address that impairment) was associated with: advice to delay return to work, advice to delay return to activity, and a belief that return to work or activity is a threat to the patient. Physiotherapists' fear avoidance scores were positively correlated with: increased certification of sick leave, advice to avoid return to work, and advice to avoid return to normal activity. Qualitative studies revealed two main themes attributed to beliefs and attitudes of physiotherapists who have a relationship to their management of chronic low back pain: treatment orientation and patient factors.

CONCLUSION

Both quantitative and qualitative studies showed a relationship between treatment orientation and clinical practice. The inclusion of qualitative studies captured the influence of patient factors in clinical practice in chronic low back pain. There is a need to recognise that both beliefs and attitudes regarding treatment orientation of physiotherapists, and therapist-patient factors need to be considered when introducing new clinical practice models, so that the adoption of new clinical practice is maximised. [Gardner T, Refshauge K, Smith L, McAuley J, Hübscher M, Goodall S (2017) Physiotherapists' beliefs and attitudes influence clinical practice in chronic low back pain: a systematic review of quantitative and qualitative studies. Journal of Physiotherapy 63: 132-143].

Gait patterns of children and adolescents with Charcot-Marie-Tooth disease

Gait abnormalities reported in childhood Charcot-Marie-Tooth disease (CMT) include foot-drop, reduced ankle power at push-off and increased knee and hip flexion for swing clearance ('steppage-gait'). The purpose of this study was to describe the gait patterns of 60 children aged 6-17 years with CMT (CMT_all) and distinguish differences based on functional weakness using the CMT Pediatric Scale (CMTPedS). Data were captured using Vicon Nexus system and compared to 50 healthy norms. Data were subdivided into three groups denoting increasing severity of dorsiflexion and plantarflexion weakness from the CMTPedS: no difficulty heel or toe walking (CMT_ND), difficulty heel walking (CMT_DH), difficulty toe and heel walking (CMT_DTH). Compared to healthy norms, CMT_all demonstrated significantly worse gait profile score, reduced ankle dorsiflexion during swing (foot-drop), reduced ankle dorsiflexor moment in loading response and reduced external thigh-foot angle. Contrary to previous studies there were no signs of reduced ankle power or compensation through 'steppage gait' in this mild-moderately affected population. Instead, CMT_all demonstrated reduced internal hip rotation and reduced hip abductor moment. When data were sub-grouped and compared to healthy norms, three different gait patterns at the ankle emerged: CMT_ND had a near-normal gait pattern, CMT_DH presented with foot-drop, and CMT_DTH had increased peak dorsiflexion and reduced ankle power generation. Several distinct and abnormal gait patterns were identified in children with CMT, with increasing gait abnormalities in more functionally severe cases. Classifying gait patterns based on disease severity might be a valuable tool in clinical decision making, assessing disease progression and phenotype-genotype correlation studies.

Effects of Activity-Based Therapy Interventions on Mobility, Independence, and Quality of Life for People with Spinal Cord Injuries: A Systematic Review and Meta-Analysis

The aim of this study was to review the literature about the effects of activity-based therapy (ABT) interventions on mobility, functional independence, and quality of life for people with a spinal cord injury (SCI). A systematic review with meta-analysis of randomized and non-randomized trials was performed, including adults with a non-progressive SCI at any level. The intervention of interest was ABT, defined as any intervention that sought to improve muscle activation or sensory function below the level of injury in the spinal cord and does not rely on compensatory mechanisms for improving function. The comparison was either no intervention or conventional physical interventions targeted to regions above the level of injury. The outcome measures were quality-of-life questionnaires, mobility assessments, and functional independence scales. Nineteen trials were included in this systematic review. Three compared ABT to no intervention and 16 to conventional physical rehabilitation. The methodological quality of the trials was assessed using the PEDro scale as moderate. Six studies investigated the effects of ABT interventions for the upper limbs, 11 investigated gait-related interventions, and two applied multi-modal interventions. Compared with no intervention, the meta-analysis found that ABT was not more effective for improving independence or lower limb mobility, but conferred a large positive effect on upper limb function. Compared with conventional physical interventions, there was no significant effect of ABT on lower limb mobility, independence, or quality of life; however, it had positive effects on upper limbs. In conclusion, there is evidence that ABT can improve independence and functional ability when applied to the upper limbs in people with SCI. However, it is not superior to conventional physical interventions when applied to the lower limbs.

Mapping the association between back pain and type 2 diabetes: A cross-sectional and longitudinal study of adult Spanish twins

BACKGROUND

Back pain and type 2 diabetes often co-occur, resulting in greater impact on people's health and complexity in their care. Plausible causal mechanisms for this association have been proposed, yet the nature of the link remains unclear. We therefore explored the direction of the association between type 2 diabetes and chronic back pain in twins, controlling for genetics and early environmental confounding.

METHODS

2,096 and 1,098 twins were included in the cross-sectional and longitudinal analyses, respectively. Any or severe (≥ 9) low back pain (LBP), neck pain (NP), and spinal pain (concurrent LBP and NP) and type 2 diabetes were investigated. Sequential analyses were performed using logistic regression. Firstly, twins were analysed unpaired (adjusted age and gender): total sample analyses. Then, to control for genetic and shared environmental factors, a co-twin case-control analysis was performed including monozygotic and dizygotic twin pairs discordant for back pain (cross-sectional only).

RESULTS

In the cross-sectional total sample analyses, type 2 diabetes was associated with chronic spinal pain (OR 1.61; 95%CI 1.12 to 2.31), severe chronic spinal pain (OR 3.33; 95%CI 1.47 to 7.53), chronic NP (OR 1.37; 95%CI 1.01 to 1.85), severe chronic NP (OR 2.28; 95%CI 1.24 to 4.21), and severe chronic LBP (OR 1.63; 95%CI 1.00 to 2.64). After further adjustment for genetic and shared environmental factors, none of the associations remained significant. The longitudinal analyses indicated that the presence of type 2 diabetes did not increase the risk of future back pain, or vice-versa, after two to four years.

CONCLUSIONS

Chronic back pain (spinal pain, NP, or LBP) was associated with the prevalence of type 2 diabetes. Associations are stronger for severe cases of pain. Future research should investigate the temporal relationships between these conditions with longer follow up in twins.

Obesity does not increase the risk of chronic low back pain when genetics are considered. A prospective study of Spanish adult twins

BACKGROUND CONTEXT

Obesity is commonly investigated as a potential risk factor for low back pain (LBP); however, current evidence remains unclear. Limitations in previous studies may explain the inconsistent results in the field, such as the use of a cross sectional design, limitations in the measures used to assess obesity (eg, body mass index-BMI), and poor adjustment for confounders (eg, genetics and physical activity).

PURPOSE AND DESIGN

To better understand the effects of obesity on LBP, our aim was to investigate in a prospective cohort whether obesity-related measures increase the risk of chronic LBP outcomes using a longitudinal design. We assessed obesity through measures that consider the magnitude as well as the distribution of body fat mass. A within-pair twin case-control analysis was used to control for the possible effects of genetic and early shared environmental factors on the obesity-LBP relationship.

PATIENT SAMPLE AND OUTCOME MEASURES

Data were obtained from the Murcia Twin Registry in Spain. Participants were 1,098 twins, aged 43 to 71 years, who did not report chronic LBP at baseline. Follow-up data on chronic LBP (>6 months), activity-limiting LBP, and care-seeking for LBP were collected after 2 to 4 years.

RISK FACTORS

The risk factors were BMI, percentage of fat mass, waist circumference, and waist-to-hip ratio.

METHODS

Sequential analyses were performed using logistic regression controlling for familial confounding: (1) total sample analysis (twins analyzed as independent individuals); (2) within-pair twin case-control analyses (all complete twin pairs discordant for LBP at follow-up); and within-pair twin case-control analyses separated for (3) dizygotic and (4) monozygotic twins.

RESULTS

No increase in the risk of chronic LBP was found for any of the obesity-related measures: BMI (men/women, odds ratio [OR]: 0.99; 95 % confidence interval [CI]: 0.86-1.14), % fat mass (women, OR: 0.87; 95% CI: 0.66-1.14), waist circumference (women, OR: 0.98; 95% CI: 0.74-1.30), and waist-to-hip ratio (women, OR: 1.05; 95% CI: 0.81-1.36). Similar results were found for activity-limiting LBP and care-seeking due to LBP. After the adjustment for genetics and early environmental factors shared by twins, the non-significant results remained unchanged.

CONCLUSIONS

After 2 to 4 years, obesity-related measures did not increase the risk of developing chronic LBP or care-seeking for LBP with or without adjustment for familial factors such as genetics in Spanish adults.

Diagnosis of upper limb lymphedema: development of an evidence-based approach

BACKGROUND

The diagnosis of secondary upper limb lymphedema (LE) is complicated by the lack of an agreed-upon measurement tool and diagnostic threshold. The aim of this study was to determine which of the many commonly used and normatively determined clinical diagnostic thresholds has the best diagnostic accuracy of secondary upper limb LE, when compared to diagnosis by an appropriate reference standard, lymphoscintigraphy.

MATERIAL AND METHODS

The arms of women treated for breast cancer with and without a previous diagnosis of LE, as well as healthy controls, were assessed using lymphoscintigraphy, bioimpedance spectroscopy (BIS) and perometry. Dermal backflow score determined from lymphoscintigraphy imaging assessment (reference standard) was compared with diagnosis by both commonly used and normatively determined diagnostic thresholds for volume and circumference measurements as well as BIS.

RESULTS

For those with established dermal backflow, all commonly used and normatively determined diagnostic thresholds accurately identified presence of LE compared with lymphoscintigraphy diagnosis. In participants with mild to moderate changes in dermal backflow, only a normatively determined diagnostic threshold, set at two standard deviations above the norm, for arm circumference and full arm BIS were found to have both high sensitivity (81% and 76%, respectively) and specificity (96% and 93%, respectively). For this group, strong, and clinically useful, positive (23 and 10, respectively) and negative likelihood (0.2 and 0.3) ratios were found for both the circumference and bioimpedance diagnostic thresholds.

CONCLUSION

For the first time, evidence-based clinical diagnostic thresholds have been established for secondary LE. With mild LE, normatively determined circumference and BIS thresholds are superior to the commonly used thresholds.

The prevalence of patellofemoral osteoarthritis: a systematic review and meta-analysis

OBJECTIVE

To determine the prevalence of radiographic patellofemoral osteoarthritis (OA) from population- and symptom-based cohorts and to evaluate if knee pain, physical function and quality of life (QOL) differ between people with isolated patellofemoral OA, isolated tibiofemoral OA and combined patellofemoral and tibiofemoral OA.

METHOD

Terms associated with "patellofemoral OA", "prevalence" and "clinical features" were used to search Medline, EMBASE, CINAHL, SCOPUS, AMED and Web of Science databases with no language restriction' from inception to August 2014. Two independent reviewers screened papers for eligibility. Studies were included if they reported prevalence of compartmental patterns of radiographic knee OA in population- or symptom-based cohorts. Studies were excluded if they evaluated a targeted sample (e.g., occupation-specific participants) or repeated already reported data from the same cohorts. Point prevalence estimates of patellofemoral OA were extracted from eligible studies, pooled and quantitatively analysed. A critical appraisal tool was used to evaluate methodological quality.

RESULTS

The search yielded 1891 records. The inclusion criteria were met by 32 studies. The crude prevalence of patellofemoral OA was 25% in the population-based cohorts (aged >20 years) and 39% in the symptom-based cohorts (aged >30 years). Eight studies reported knee pain, physical function and QOL in people with different compartmental disease; however no significant differences were found.

CONCLUSION

These findings confirm the substantial prevalence of patellofemoral OA, demonstrating the need to specifically consider the patellofemoral joint in knee OA research and clinical settings.

Implementation of a guideline-based clinical pathway of care to improve health outcomes following whiplash injury (Whiplash ImPaCT): protocol of a randomised, controlled trial

INTRODUCTION

Whiplash-associated disorders (WAD) are a huge worldwide health and economic burden. The propensity towards developing into chronic, disabling conditions drives the rise in health and economic costs associated with treatment, productivity loss and compulsory third party insurance claims. Current treatments fail to address the well-documented heterogeneity of WAD and often result in poor outcomes. A novel approach is to evaluate whether the care provided according to the estimated risk of poor prognosis improves health outcomes while remaining cost-effective.

RESEARCH QUESTIONS

(1) Does a guideline-based clinical pathway of care improve health outcomes after whiplash injury compared to usual care? (2) Does risk of recovery have a differential effect on health outcomes for the clinical pathway of care? (3) Is the clinical pathway of care intervention cost-effective? (4) What are the variations in professional practice between usual care and the clinical pathway of care?

DESIGN

Multi-centre, randomised, controlled trial conducted over two Australian states: Queensland and New South Wales.

PARTICIPANTS AND SETTING

236 people with WAD (grade I-III, within 6 weeks of injury) and their primary healthcare providers.

INTERVENTION

A clinical pathway of care, with care matched to the predicted risk of poor recovery. Participants at low risk of ongoing pain and disability (hence, predicted to fully recover) will receive up to three sessions of guideline-based advice and exercise with their primary healthcare provider. Participants at medium/high risk of developing ongoing pain and disability will be referred to a specialist (defined as a practitioner with expertise in whiplash) who will conduct a more in-depth physical and psychological assessment. As a result, the specialist will liaise with the original primary healthcare provider and determine one of three further pathways of care.

CONTROL

Usual care provided by the primary healthcare provider that is based on clinical judgment.

MEASUREMENTS

Primary (global rating of change and neck-related disability) and secondary (self-efficacy, pain intensity, general health and disability and psychological health) outcomes will be collected using validated scales. Direct (eg, professional care, transportation costs, time spent for care, co-payments) and indirect (eg, lost economic productivity) costs will be obtained through an electronic cost diary. Health and cost outcomes will be assessed at baseline, 3, 6 and 12 months after randomisation. Professional practice outcomes will be evaluated through questionnaires completed by healthcare providers and their patients at 3 months.

PROCEDURE

Potential participants (patients) will be identified through emergency departments, primary health clinics and advertisements. Eligible participants will complete baseline assessments and will be categorised into low or medium/high risk of poor recovery using a clinical prediction rule. After this assessment, participants will be randomly allocated to either a control group (n=118) or intervention group (n=118), stratified by risk subgroup and treatment site. The participants' nominated primary healthcare providers will be informed of their involvement in the trial. Consent will be obtained from the primary healthcare providers to participate and to obtain information about professional practice. Participants in the intervention group will additionally have access to an interactive website that provides information about whiplash and recovery relative to their risk category.

ANALYSIS

Analysis will be conducted on an intention-to-treat basis. Outcomes will be analysed independently through cross-sectional analyses using generalised linear models methods, with an appropriate link function, to test for an intervention effect, adjusted for the baseline values. The risk category will be tested for its association with treatment effect by adding risk group to the regression equation. Cost-effectiveness will be calculated using utility weights and the resulting measure will be cost per quality-adjusted life year (QALY) saved. Professional practice outcomes will be analysed using descriptive statistics.

DISCUSSION

This research is significant as it will be the first study to address the heterogeneity of whiplash by implementing a clinical pathway of care that matches evidence-based interventions to projected risk of poor recovery. The results of this trial have the potential to change clinical practice for WAD, thereby maximising treatment effects, improving patient outcomes, reducing costs and maintaining the compulsory third party system.

Using Balance Tests to Discriminate Between Participants With a Recent Index Lateral Ankle Sprain and Healthy Control Participants: A Cross-Sectional Study

CONTEXT

The first step to identifying factors that increase the risk of recurrent ankle sprains is to identify impairments after a first sprain and compare performance with individuals who have never sustained a sprain. Few researchers have restricted recruitment to a homogeneous group of patients with first sprains, thereby introducing the potential for confounding.

OBJECTIVE

To identify impairments that differ in participants with a recent index lateral ankle sprain versus participants with no history of ankle sprain.

DESIGN

Cross-sectional study.

PATIENTS OR OTHER PARTICIPANTS

We recruited a sample of convenience from May 2010 to April 2013 that included 70 volunteers (age = 27.4 ± 8.3 years, height = 168.7 ± 9.5 cm, mass = 65.0 ± 12.5 kg) serving as controls and 30 volunteers (age = 31.1 ± 13.3 years, height = 168.3 ± 9.1 cm, mass = 67.3 ± 13.7 kg) with index ankle sprains.

MAIN OUTCOME MEASURE(S)

We collected demographic and physical performance variables, including ankle-joint range of motion, balance (time to balance after perturbation, Star Excursion Balance Test, foot lifts during single-legged stance, demi-pointe balance test), proprioception, motor planning, inversion-eversion peak power, and timed stair tests. Discriminant analysis was conducted to determine the relationship between explanatory variables and sprain status. Sequential discriminant analysis was performed to identify the most relevant variables that explained the greatest variance.

RESULTS

The average time since the sprain was 3.5 ± 1.5 months. The model, including all variables, correctly predicted a sprain status of 77% (n = 23) of the sprain group and 80% (n = 56) of the control group and explained 40% of the variance between groups ([Formula: see text] = 42.16, P = .03). Backward stepwise discriminant analysis revealed associations between sprain status and only 2 tests: Star Excursion Balance Test in the anterior direction and foot lifts during single-legged stance ([Formula: see text] = 15.2, P = .001). These 2 tests explained 15% of the between-groups variance and correctly predicted group membership of 63% (n = 19) of the sprain group and 69% (n = 48) of the control group.

CONCLUSIONS

Balance impairments were associated with a recent first ankle sprain, but proprioception, motor control, power, and function were not.

Symptoms of Depression and Risk of New Episodes of Low Back Pain: A Systematic Review and Meta-Analysis

OBJECTIVE

To investigate the contribution of symptoms of depression to future episodes of low back pain (LBP).

METHODS

A search was conducted of AMED, CINAHL, Embase, Health and Society (H&S), LILACS, MEDLINE, PsycINFO, Scopus, and Web of Science databases. We included cohort studies investigating the effect of symptoms of depression on the development of new episodes of LBP, either lifetime incidence or a recurrent episode, in a population free of LBP at baseline. We accepted the original study's definition for a new episode of LBP, and for classifying patients as LBP-free at study entry. Two independent investigators extracted data and assessed methodological quality. Meta-analyses with random effects were used to pool risk estimates.

RESULTS

We included 19 studies, with 11 incorporated in the meta-analyses. Overall pooled results showed that symptoms of depression increased the risk of developing LBP (odds ratio [OR] 1.59, 95% confidence interval [95% CI] 1.26-2.01). The risk was similar in studies that used the diagnostic interview method (OR 1.66, 95% CI 1.14-2.42) and in studies using self-report screening questionnaires (OR 1.68, 95% CI 1.05-2.70). No statistically significant relationship was observed when we pooled studies that employed nonspecific screening questionnaires (OR 1.17, 95% CI 0.48-2.87). Three studies provided results in incremental categories of symptoms of depression and the pooled OR for the most severe level of depression (OR 2.51, 95% CI 1.58-3.99) was higher than for the lowest level (OR 1.51, 95% CI 0.89-2.56).

CONCLUSION

Individuals with symptoms of depression have an increased risk of developing an episode of LBP in the future, with the risk being higher in patients with more severe levels of depression.

Symptoms of depression as a prognostic factor for low back pain: a systematic review

BACKGROUND CONTEXT

It has been proposed that depression plays an important role in the course of low back pain; however, there is considerable uncertainty on its predictive value.

PURPOSE

This systematic review aims to investigate the effect of depression on the course of acute and subacute low back pain.

STUDY DESIGN

This is a systematic review.

METHODS

We searched the following databases using optimized search strategies: AMED, CINAHL, EMBASE, Health & Society Database, LILACS, MEDLINE, PsycINFO, Scopus, and Web of Science. We only included prospective studies that investigated a cohort of participants with acute or subacute non-specific low back pain (pain of less than 12 weeks' duration). The prognostic factor of interest was depression or symptoms of depression assessed at baseline. The outcomes of interest included pain intensity, chronicity (non-recovery from low back pain), disability, return to work, health-related quality of life, and overall patient satisfaction. Two independent reviewers selected the studies, extracted the data, and assessed the methodological quality of the studies that were included.

FUNDING

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors declare no conflicts of interest-associated biases.

RESULTS

Seventeen articles reporting 13 cohort studies were included in this review. There was considerable variability between studies in terms of the method of assessment of depression and low back pain, statistical methods, and follow-up length, which precluded the quantitative synthesis of the results. Definition of outcomes varied across studies, but overall they could be divided into work-related outcome measures, followed by disability, pain, self-perceived recovery, and mixed outcomes. Eleven out of 17 articles (or 8 out of 13 cohorts) reported that symptoms of depression at baseline are related to worse low back pain outcomes (measured in various ways) at follow-up, and the effect sizes (odds ratio [OR]) ranged from 1.04 to 2.47. Only two studies that did not find a statistically significant association reported quantitative results: OR=1.03, 95% confidence interval (CI) 0.98-1.08; and OR=1.02, 95% CI 0.99-1.06. All included studies, regardless of statistical significance, showed an effect in the direction of harm.

CONCLUSIONS

Although a definitive answer on the effect of depression on the course of low back pain is not available, the findings of this systematic review suggest that depression might have an adverse effect on the prognosis of low back pain. Future large studies that enroll an inception cohort and that employ a standardized method for assessing depression and low back pain are needed.

Correlates of functional ankle instability in children and adolescents with Charcot-Marie-Tooth disease

BACKGROUND

Functional ankle instability (FAI) is commonly reported by children and adolescents with Charcot-Marie-Tooth disease (CMT), however,, the specific variables associated with FAI remain unknown. An improved understanding of these variables may suggest interventions to improve ankle stability and possibly prevent the long-term complications associated with ankle instability in this population. The aim of this study was to therefore investigate the relationship between FAI and other functional, structural, anthropometric and demographic characteristics in a cross sectional sample of children and adolescents with CMT.

METHODS

Thirty children and adolescents with CMT aged 7-18 years were recruited from the Peripheral Neuropathy Clinics of a large tertiary paediatric hospital. Measures of FAI were obtained using the Cumberland Ankle Instability Tool (CAIT). Demographic and anthropometric data was also collected. Other variables collected included foot structure (Foot Posture Index), ankle range of motion (weight bearing lunge) and functional parameters (balance, timed motor function and falls). Descriptive statistics were calculated to characterise the participants. Pearson's correlation coefficients were calculated to investigate the correlates of right and left FAI and demographic (age), anthropometric (height, weight, BMI), foot/ankle (foot structure and ankle flexibility) and functional parameters (balance task, timed motor function and falls frequency). Point biserial correlation was employed to correlate gender with right and left FAI.

RESULTS

All but one study participant (n = 29) reported moderate to severe bilateral FAI with females reporting significantly greater ankle instability than males. FAI was significantly associated with cavus foot structure (r = .69, P < .001), female gender (r = -.47, P < .001) and impaired balance (r = .50, P < .001).

CONCLUSIONS

This study confirms FAI is common in children and adolescents with CMT. An examination of the correlates of FAI suggests interventions, which target balance, and normalise foot structure should be explored to evaluate whether they might help to improve ankle stability in this population.

Patient led goal setting in chronic low back pain-What goals are important to the patient and are they aligned to what we measure?

OBJECTIVE

To determine the extent of alignment between clinical outcome measures and patient-derived goals for the management of chronic low back pain (cLBP).

METHODS

A customised, patient-led goal setting intervention was implemented facilitated by a physiotherapist, in which participants identified problem areas and developed strategies to address them. Patient goals were compared to the most commonly used outcome measures in cLBP as well as research outcomes recommended by the IMMPACT consortium.

RESULTS

From 20 participants, a total of 27 unique goals were identified, the most common goal related to physical activity (49%). Comparison of participant goals to the most common measures used by physiotherapists found none of the goals could be aligned. Comparison of goals and domains with IMPACCT outcome domains found 76% of the goals were aligned with physical functioning and 16% with emotional functioning.

CONCLUSION

This study has identified goals important to patients in cLBP, these were varied, and most did not correspond with current clinical measures.

PRACTICE IMPLICATIONS

Clinical outcome measures may not be providing accurate information about the success of treatments that are meaningful to the patient. Clinicians should consider a collaborative approach with cLBP patients to determine treatment interventions that are driven by patient preference.

When can I drive? Return to driving following a wrist fracture: A critical review

Introduction

The primary aim of this review was to identify literature that examined factors which influence driving performance following a wrist fracture. Given the known scarcity of research in this area, secondary aims were to detail current practices including the driving habits of patients following a wrist fracture and health professionals’ opinions on safe return to driving.

Methods

We performed a search in April 2015 using three electronic databases to obtain relevant literature in the English language. Relevant studies including clinical trials, surveys and case reports were reviewed.

Results

The search identified 12 relevant studies. Five of these were clinical studies with a crossover design that investigated the driving ability of uninjured individuals with the wrist immobilised in a cast. The remaining were survey-based studies. The clinical trials showed that the presence of a wrist cast reduced driving performance in uninjured individuals. No studies investigated driving performance in individuals with a wrist fracture. The surveys showed that this patient group returns to driving despite perceived safety risks. Inconsistency in expert opinions on whether individuals with a wrist fracture are safe to drive was highlighted.

Conclusions

There is evidence to suggest that driving performance is reduced in uninjured individuals when wearing a cast immobilising the wrist; however, the influence of wrist fracture is unknown. This, along with safety implications resulting from current driving behaviours and inconsistent information provided to patients regarding return to driving, highlights the need for further studies to ascertain which factors influence driving performance following wrist fracture.