Developing and assessing the measurement properties of an instrument to assess the impact of musculoskeletal pain in children aged 9 to 12-the pediatric musculoskeletal pain impact summary score

BACKGROUND

Despite the high prevalence of musculoskeletal (MSK) pain in children, there is a lack of instruments to measure the impact of MSK pain on children's activity and participation.

OBJECTIVE

To assess the reliability and construct validity of the Pediatric MSK Pain Impact summary score in school children (aged 9 to 12) with MSK pain.

METHODS

We used a pragmatic approach in a reflective framework to assess internal consistency, structural validity, convergent validity, and discriminative validity in a sample of 615 children with MSK pain.

RESULTS

The confirmatory factor analysis results indicate that the summary score has limited internal consistency and construct validity. The estimated Cronbach's alpha was 0.63, and most goodness of fit indices met the recommended thresholds (SRMR = 0.030; GFI = 0.993, CFI = 0.955, RMSEA 0.073), although they were close to the lower bounds of the thresholds. The convergent validity showed appropriate correlation of the summary score with quality of life (r = -0.33), care-seeking (r = 0.45), and medication intake (r = 0.37). Discriminative validity showed that the instrument can discriminate between the impact of pain on children with frequent and infrequent (2.93; 95% CI: 2.36 - 3.50) MSK pain.

CONCLUSION

The Pediatric MSK Pain Impact summary showed limited internal consistency and construct validity; however, it can discriminate between children with frequent and infrequent pain. The results are promising for clinical and research practices as it is a short and convenient tool to be used in school-aged children.

Overview of the economic burden of musculoskeletal pain in children and adolescents: a systematic review with meta-analysis

ABSTRACT

Studies suggest a high economic burden among children and adolescents with musculoskeletal pain. There is no summary in the literature on the overall economic burden of musculoskeletal pain in children and adolescents. The aim of this systematic review of cost-of-illness studies was to synthesize the economic burden of musculoskeletal pain in children and adolescents. We conducted electronic searches on MEDLINE, EMBASE, CINAHL, EconLit, NHSEED, and HTA databases. We included cost-of-illness studies that estimated healthcare, patient/family, lost productivity, and/or societal costs in children and adolescents with musculoskeletal pain. The risk of bias was assessed with the Consolidated Health Economic Evaluation Reporting Standards checklist. All values were adjusted to the same reference year (2021) and converted to American Dollar. We included 45 cost-of-illness studies (n = 665,623). Twenty-two studies estimated the annual healthcare costs that ranged from $143 to $41,379 per patient. Nine studies estimated the annual patient/family costs that ranged from $287 to $27,972 per patient. Seven studies estimated the annual lost productivity costs that ranged from $124 to $4671 per patient. Nine studies estimated the annual societal costs that ranged from $1095 to $69,351 per patient. Children and adolescents with juvenile idiopathic arthritis and musculoskeletal pain had higher annual incremental healthcare costs than those without these conditions (mean difference: $3800 higher, 95% confidence interval [CI]: 50-7550; mean difference: $740 higher, 95% CI: 470-1,010, respectively). In conclusion, the estimated annual economic burden of children and adolescents with musculoskeletal pain ranged from $124 to $69,351.

Prevalence of disabling musculoskeletal pain in children and adolescents in Brazil: A cross-sectional study

BACKGROUND

Estimates of prevalence of musculoskeletal pain in children and adolescents vary considerably and the impact of pain on children's life is often not considered.

OBJECTIVE

To determine the one-month prevalence of disabling musculoskeletal pain in children and adolescents. The secondary aims are to: 1) determine the body region with the highest prevalence; 2) understand the characteristics of the children with disabling musculoskeletal pain; and 3) describe the parents' perception of the prevalence.

METHODS

This cross-sectional study was conducted in public and private schools in the states of São Paulo and Ceará, Brazil. Children self-reported presence and impact of pain, pain intensity, psychosomatic symptoms, and quality of life. Parents completed parent-proxy versions and perception of the child's sleep quality. Descriptive statistics were used to summarise the data.

RESULTS

A total of 2,688 children and adolescents were included in this study. The prevalence of disabling musculoskeletal pain in the previous month was 27.1%. The back was the region most often affected (51.8%). Children with disabling musculoskeletal pain were older, heavier, had worse relationships with their family, perceived their backpacks as heavy, carried their backpacks more with one shoulder, had more negative psychosomatic symptoms, had poorer quality of life, and had higher pain intensity. Parents tended to underestimate the presence of pain in their children.

CONCLUSION

The one-month prevalence of activity limiting musculoskeletal pain in children and adolescents was 27.1% with the back being the most often affected body region. Parents tended to underestimate the presence of pain in their children.

Individuals with musculoskeletal conditions awaiting orthopaedic surgery consultation: an untapped opportunity for patient health management?

OBJECTIVE

To describe the health characteristics, condition-specific measures, chronic disease risk factors, and healthcare and medication use over time of individuals with musculoskeletal conditions awaiting orthopaedic surgical consultation. Study importance: Musculoskeletal conditions are highly prevalent in the general population and often coexist with chronic diseases. However, little is documented about the overall health of this group. This study describes the health of these individuals, with particular emphasis on modifiable risk factors of chronic disease.

STUDY TYPE

A repeated measures longitudinal cohort study of individuals referred for orthopaedic consultation across three time points (2014, 2015 and 2016).

METHODS

This study was undertaken in the orthopaedic outpatient service of a public tertiary referral hospital in New South Wales, Australia. Participants were aged 18 years and older and were referred for and awaiting orthopaedic surgical consultation for a musculoskeletal condition (back, neck, hand or wrist pain, or hip or knee osteoarthritis). Measures included patient demographics, condition-specific indicators (e.g. pain, disability, quality of life [QoL]) and chronic disease risk factors (e.g., excess weight, smoking).

RESULTS

The mean age of participants was 57.7 years, and 7.3% identified as Aboriginal and/or Torres Strait Islander. Back (43.1%) and knee (35.0%) pain were the most prevalent conditions. At baseline (N = 1052), participants reported moderate pain (mean numerical pain rating scale score of 6.4, standard deviation [SD] 2.4) and QoL (Physical Component Score of 32.7, SD 10.7; Mental Component Score of 46.6, SD 13.3). Chronic disease risk factors were highly prevalent, with 74.6% of participants having three or more. For most measures, there were only small changes over time.

CONCLUSION

Individuals with musculoskeletal conditions who are awaiting orthopaedic surgical consultation have a complex clinical picture and numerous chronic disease risk factors. Given the modifiable nature of many of these risk factors, identifying and addressing them before or while awaiting consultation may improve the health of these individuals.

Physical activity and education about physical activity for chronic musculoskeletal pain in children and adolescents

BACKGROUND

Chronic pain is a major health and socioeconomic burden, which is prevalent in children and adolescents. Among the most widely used interventions in children and adolescents are physical activity (including exercises) and education about physical activity.

OBJECTIVES

To evaluate the effectiveness of physical activity, education about physical activity, or both, compared with usual care (including waiting-list, and minimal interventions, such as advice, relaxation classes, or social group meetings) or active medical care in children and adolescents with chronic musculoskeletal pain.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PEDro, and LILACS from the date of their inception to October 2022. We also searched the reference lists of eligible papers, ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared physical activity or education about physical activity, or both, with usual care (including waiting-list and minimal interventions) or active medical care, in children and adolescents with chronic musculoskeletal pain.

DATA COLLECTION AND ANALYSIS

Two review authors independently determined the eligibility of the included studies. Our primary outcomes were pain intensity, disability, and adverse events. Our secondary outcomes were depression, anxiety, fear avoidance, quality of life, physical activity level, and caregiver distress. We extracted data at postintervention assessment, and long-term follow-up. Two review authors independently assessed risk of bias for each study, using the RoB 1. We assessed the overall certainty of the evidence using the GRADE approach. We reported continuous outcomes as mean differences, and determined clinically important differences from the literature, or 10% of the scale.

MAIN RESULTS

We included four studies (243 participants with juvenile idiopathic arthritis). We judged all included studies to be at unclear risk of selection bias, performance bias, and detection bias, and at high risk of attrition bias. We downgraded the certainty of the evidence for each outcome to very low due to serious or very serious study limitations, inconsistency, and imprecision. Physical activity compared with usual care Physical activity may slightly reduce pain intensity (0 to 100 scale; 0 = no pain) compared with usual care at postintervention (standardised mean difference (SMD) -0.45, 95% confidence interval (CI) -0.82 to -0.08; 2 studies, 118 participants; recalculated as a mean difference (MD) -12.19, 95% CI -21.99 to -2.38; I² = 0%; very low-certainty evidence). Physical activity may slightly improve disability (0 to 3 scale; 0 = no disability) compared with usual care at postintervention assessment (MD -0.37, 95% CI -0.56 to -0.19; I² = 0%; 3 studies, 170 participants; very low-certainty evidence). We found no clear evidence of a difference in quality of life (QoL; 0 to 100 scale; lower scores = better QoL) between physical activity and usual care at postintervention assessment (SMD -0.46, 95% CI -1.27 to 0.35; 4 studies, 201 participants; very low-certainty evidence; recalculated as MD -6.30, 95% CI -18.23 to 5.64; I² = 91%). None of the included studies measured adverse events, depression, or anxiety for this comparison. Physical activity compared with active medical care We found no studies that could be analysed in this comparison. Education about physical activity compared with usual care or active medical care We found no studies that could be analysed in this comparison. Physical activity and education about physical activity compared with usual care or active medical care We found no studies that could be analysed in this comparison.

AUTHORS' CONCLUSIONS

We are unable to confidently state whether interventions based on physical activity and education about physical activity are more effective than usual care for children and adolescents with chronic musculoskeletal pain. We found very low-certainty evidence that physical activity may reduce pain intensity and improve disability postintervention compared with usual care, for children and adolescents with juvenile idiopathic arthritis. We did not find any studies reporting educational interventions; it remains unknown how these interventions influence the outcomes in children and adolescents with chronic musculoskeletal pain. Treatment decisions should consider the current best evidence, the professional's experience, and the young person's preferences. Further randomised controlled trials in other common chronic musculoskeletal pain conditions, with high methodological quality, large sample size, and long-term follow-up are urgently needed.

What does high value care for musculoskeletal conditions mean and how do you apply it in practice? A consensus statement from a research network of physiotherapists in New South Wales, Australia

OBJECTIVES

To develop a physiotherapist-led consensus statement on the definition and provision of high-value care for people with musculoskeletal conditions.

DESIGN

We performed a three-stage study using Research And Development/University of California Los Angeles Appropriateness Method methodology. We reviewed evidence about current definitions through a rapid literature review and then performed a survey and interviews with network members to gather consensus. Consensus was finalised in a face-to-face meeting.

SETTING

Australian primary care.

PARTICIPANTS

Registered physiotherapists who are members of a practice-based research network (n=31).

RESULTS

The rapid review revealed two definitions, four domains of high value care and seven themes of high-quality care. Online survey responses (n=26) and interviews (n=9) generated two additional high-quality care themes, a definition of low-value care, and 21 statements on the application of high value care. Consensus was reached for three working definitions (high value, high-quality and low value care), a final model of four high value care domains (high-quality care, patient values, cost-effectiveness, reducing waste), nine high-quality care themes and 15 statements on application.

CONCLUSION

High value care for musculoskeletal conditions delivers most value for the patient, and the clinical benefits outweigh the costs to the individual or system providing the care. High-quality care is evidence based, effective and safe care that is patient-centred, consistent, accountable, timely, equitable and allows easy interaction with healthcare providers and healthcare systems.

Meaningful coproduction with clinicians: establishing a practice-based research network with physiotherapists in regional Australia

BACKGROUND

The disconnect between research and clinical practice leads to research evidence that is often not useful for clinical practice. Practice-based research networks are collaborations between researchers and clinicians aimed at coproducing more useful research. Such networks are rare in the physiotherapy field. We aimed to describe (i) clinicians' motivations behind, and enablers to, participating in a network, (ii) the process of network establishment and (iii) research priorities for a practice-based network of physiotherapists in the Hunter Region of New South Wales (NSW), Australia that supports research coproduction.

METHODS

We describe the methods and outcomes of the three steps we used to establish the network. Step 1 involved consultation with local opinion leaders and a formative evaluation to understand clinicians' motivations behind, and enablers to, participating in a network. Step 2 involved establishment activities to generate a founding membership group and codesign a governance model. Step 3 involved mapping clinical problems through a workshop guided by systems thinking theory with local stakeholders and prioritizing research areas.

RESULTS

Through formative evaluation focus groups, we generated five key motivating themes and three key enablers for physiotherapists' involvement in the network. Establishment activities led to a founding membership group (n = 29, 67% from private practice clinics), a network vision and mission statement, and a joint governance group (9/13 [70%] are private practice clinicians). Our problem-mapping and prioritization process led to three clinically relevant priority research areas with the potential for significant change in practice and patient outcomes.

CONCLUSIONS

Clinicians are motivated to break down traditional siloed research generation and collaborate with researchers to solve a wide array of issues with the delivery of care. Practice-based research networks have promise for both researchers and clinicians in the common goal of improving patient outcomes.

A new version of a measurement for presence and impact of pain in children and adolescents - Presence and impact of pain in Kids (PIP-KIDS) questionnaire: Translation, cross-cultural adaptation and measurement properties into Brazilian-Portuguese

BACKGROUND

Musculoskeletal pain in children and adolescents is prevalent and responsible for high levels of disability. Instruments to measure the presence and impact of pain in this population are needed.

OBJECTIVE

To translate, cross-culturally adapt, then test the measurement properties (structural validity, reliability and construct validity) of a questionnaire (Presence and Impact of Pain in Kids (PIP-Kids) questionnaire) to measure the presence and impact of pain in children and adolescents.

DESIGN

Measurement properties study.

METHODS

We conducted a measurement properties study. We translated and culturally adapted the PIP-Kids questionnaire into Brazilian Portuguese. The structural validity was measured by Confirmatory Factor Analysis. Reliability was measured by Kappa Coefficient. Measurement error was measured by the percentage of agreement. Construct validity was measured by Spearman Correlation.

RESULTS/FINDINGS

We included 656 children and adolescents from public and private schools. During the translation and cross-cultural adaptation no changes to wording were necessary. Structural validity confirmed two domains. Reliability by Kappa Coefficient ranges from 0.20 to 0.68. Measurement error by the percentage of agreement ranged from 60.2 to 92%. Construct validity was confirmed with 80.5% in accordance with prior hypotheses.

CONCLUSION

The PIP-Kids questionnaire translation and cross-cultural adaptation were adequate. The PIP-Kids questionnaire also has adequate structural validity with two dimensions (presence and impact), fair reliability, good agreement, and adequate construct validity.

Motor skills at 7 years of age and spinal pain at 11 years of age: a cohort study of 26,000 preadolescents

This study aims to investigate the relationship between motor skills at age 7 and spinal pain at age 11. The study included participants from the Danish National Birth Cohort. Data on motor skills were obtained from the Developmental Coordination Disorder Questionnaire, completed by the mothers when the children were 7 years old, and spinal pain was self-reported at age 11 for frequency and intensity of neck, mid back, and low back pain. This was categorized into "no," "moderate," or "severe" pain, based on frequency and pain intensity. Associations were estimated using multinomial logistic regression models. Data on both motor skills and spinal pain was available for 25,000 children. There was a consistent pattern of reporting more neck or mid back pain at age 11 for those with lower levels of fine motor skills and coordination scores at age 11. The relationship was significant for severe pain (the highest relative risk ratio being 1.87 and the lowest 1.18), but not for moderate pain (the highest relative risk ratio being 1.22 and the lowest 1.07). Gross motor skills were not associated with spinal pain, and there was no relationship between low back pain and motor skills.  Conclusion: Our results indicate a link between motor development at 7 years of age and neck and mid back pain, but not low back pain, at 11 years of age. Improvement of motor skills in young children might reduce the future burden of neck and mid back pain and should be a target of future research. What is Known: • Spinal pain in preadolescence and adolescence is common and predisposes to spinal pain in adulthood. • Motor skills influence the biomechanics of movement and therefore has a potential impact on musculoskeletal health. What is New: • Poor fine motor- and coordination skills in childhood were associated with increased risk of severe neck- or mid back pain, but not low back pain, four 4 years later. • Poor gross motor skills were not associated with higher risk of later spinal pain.

Do health education initiatives assist socioeconomically disadvantaged populations? A systematic review and meta-analyses

BACKGROUND

Health education interventions are considered critical for the prevention and management of conditions of public health concern. Although the burden of these conditions is often greatest in socio-economically disadvantaged populations, the effectiveness of interventions that target these groups is unknown. We aimed to identify and synthesize evidence of the effectiveness of health-related educational interventions in adult disadvantaged populations.

METHODS

We pre-registered the study on Open Science Framework https://osf.io/ek5yg/ . We searched Medline, Embase, Emcare, and the Cochrane Register from inception to 5/04/2022 to identify studies evaluating the effectiveness of health-related educational interventions delivered to adults in socio-economically disadvantaged populations. Our primary outcome was health related behaviour and our secondary outcome was a relevant biomarker. Two reviewers screened studies, extracted data and evaluated risk of bias. Our synthesis strategy involved random-effects meta-analyses and vote-counting.

RESULTS

We identified 8618 unique records, 96 met our criteria for inclusion - involving more than 57,000 participants from 22 countries. All studies had high or unclear risk of bias. For our primary outcome of behaviour, meta-analyses found a standardised mean effect of education on physical activity of 0.05 (95% confidence interval (CI) = -0.09-0.19), (5 studies, n = 1330) and on cancer screening of 0.29 (95% CI = 0.05-0.52), (5 studies, n = 2388). Considerable statistical heterogeneity was present. Sixty-seven of 81 studies with behavioural outcomes had point estimates favouring the intervention (83% (95% CI = 73%-90%), p < 0.001); 21 of 28 studies with biomarker outcomes showed benefit (75% (95%CI = 56%-88%), p = 0.002). When effectiveness was determined based on conclusions in the included studies, 47% of interventions were effective on behavioural outcomes, and 27% on biomarkers.

CONCLUSIONS

Evidence does not demonstrate consistent, positive impacts of educational interventions on health behaviours or biomarkers in socio-economically disadvantaged populations. Continued investment in targeted approaches, coinciding with development of greater understanding of factors determining successful implementation and evaluation, are important to reduce inequalities in health.

Mixed messages: most spinal pain and osteoarthritis observational research is unclear or misaligned

OBJECTIVES

We assessed authors' language and methods to determine alignment between reported aims, methods, intent, and interpretations in observational studies in spinal pain or osteoarthritis.

STUDY DESIGN AND SETTING

We searched five databases for observational studies that included people with spinal pain or osteoarthritis published in the last 5 years. We randomized 100 eligible studies, and classified study intent (aims and methods) and interpretations as causal, non-causal, unclear, or misaligned.

RESULTS

Overall, 38% of studies were aligned regarding their intent and interpretation (either causally (22%) or non-causally (16%)). 29% of studies' aims and 29% of study methods were unclear. Intent was misaligned in 16% of studies (where aim differed to method) and 23% of studies had misaligned interpretations (where there were multiple conflicting claims). The most common kind of aim was non-causal (38%), and the most common type of method (39%), intent (38%), and interpretations (35%) was causal.

CONCLUSIONS

Misalignment and mixed messages are common in observational research of spinal pain and osteoarthritis. More than 6 in 10 observational studies may be uninterpretable, because study intent and interpretations do not align. While causal methods and intent are most common in observational research, authors commonly shroud causal intent in non-causal terminology.

Rescaling pain intensity measures for meta-analyses of analgesic medicines for low back pain appears justified: an empirical examination from randomised trials

Objective

Meta-analyses of analgesic medicines for low back pain often rescale measures of pain intensity to use mean difference (MD) instead of standardised mean difference for pooled estimates. Although this improves clinical interpretability, it is not clear whether this method is justified. Our study evaluated the justification for this method.

Methods

We identified randomised clinical trials of analgesic medicines for adults with low back pain that used two scales with different ranges to measure the same construct of pain intensity. We transformed all data to a 0–100 scale, then compared between-group estimates across pairs of scales with different ranges.

Results

Twelve trials were included. Overall, differences in means between pain intensity measures that were rescaled to a common 0–100 scale appeared to be small and randomly distributed. For one study that measured pain intensity on a 0–100 scale and a 0–10 scale; when rescaled to 0–100, the difference in MD between the scales was 0.8 points out of 100. For three studies that measured pain intensity on a 0–10 scale and 0–3 scale; when rescaled to 0–100, the average difference in MD between the scales was 0.2 points out of 100 (range 5.5 points lower to 2.7 points higher). For two studies that measured pain intensity on a 0–100 scale and a 0–3 scale; when rescaled to 0–100, the average difference in MD between the scales was 0.7 points out of 100 (range 6.2 points lower to 12.1 points higher). Finally, for six studies that measured pain intensity on a 0–100 scale and a 0–4 scale; when rescaled to 0–100, the average difference in MD between the scales was 0.7 points (range 5.4 points lower to 8.3 points higher).

Conclusion

Rescaling pain intensity measures may be justified in meta-analyses of analgesic medicines for low back pain. Systematic reviewers may consider this method to improve clinical interpretability and enable more data to be included.

Study registration/data availability

Open Science Framework (osf.io/8rq7f).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-022-01763-x.

Low-value care in musculoskeletal health care: Is there a way forward?

BACKGROUND

Low-value care that wastes resources and harms patients is prevalent in health systems everywhere.

METHODS

As part of an invited keynote presentation at the Pain in Motion IV conference held in Maastricht, Holland, in May 2022, we reviewed evidence for low-value care in musculoskeletal conditions and discussed possible solutions.

RESULTS

Drivers of low-value care are diverse and affect patients, clinicians, and health systems everywhere. We show that low-value care for back pian, neck pain, and osteoarthritis is prevalent in all professional groups involved in caring for people who seek care for these conditions. Implementation efforts that aim to reverse low-value care seem to work better if designed using established conceptual and theoretical frameworks.

CONCLUSION

Low-value care is prevalent in the care of people with musculoskeletal conditions. Reducing low-value care requires behaviour change among patients and clinicians as well as in health systems. There is evidence that behaviour change can be facilitated through good conceptual and theoretical frameworks but not convincing evidence that it changes patient outcomes.

Defining Growing Pains: A Scoping Review

BACKGROUND AND OBJECTIVES

Up to one third of children may be diagnosed with growing pains, but considerable uncertainty surrounds how to make this diagnosis. The objective of this study was to detail the definitions of growing pains in the medical literature.

METHODS

Scoping review with 8 electronic databases and 6 diagnostic classification systems searched from their inception to January 2021. The study selection included peer-reviewed articles or theses referring to "growing pain(s)" or "growth pain(s)" in relation to children or adolescents. Data extraction was performed independently by 2 reviewers.

RESULTS

We included 145 studies and 2 diagnostic systems (ICD-10 and SNOMED). Definition characteristics were grouped into 8 categories: pain location, age of onset, pain pattern, pain trajectory, pain types and risk factors, relationship to activity, severity and functional impact, and physical examination and investigations. There was extremely poor consensus between studies as to the basis for a diagnosis of growing pains. The most consistent component was lower limb pain, which was mentioned in 50% of sources. Pain in the evening or night (48%), episodic or recurrent course (42%), normal physical assessment (35%), and bilateral pain (31%) were the only other components to be mentioned in more than 30% of articles. Notably, more than 80% of studies made no reference to age of onset in their definition, and 93% did not refer to growth. Limitations of this study are that the included studies were not specifically designed to define growing pains.

CONCLUSIONS

There is no clarity in the medical research literature regarding what defines growing pain. Clinicians should be wary of relying on the diagnosis to direct treatment decisions.

Compliance with telephone-based lifestyle weight loss programs improves low back pain but not knee pain outcomes: complier average causal effects analyses of 2 randomised trials

ABSTRACT

We conducted a complier average causal effect (CACE) analyses for 2 pragmatic randomised controlled trials. We aimed to assess the effectiveness of telephone-based lifestyle weight loss interventions compared with usual care among compliers. Participants from 2 trials with low back pain (n = 160) and knee osteoarthritis (n = 120) with a body mass index ≥27 kg/m2 were included. We defined adherence to the telephone-based lifestyle weight loss program as completing 60% (6 from 10) of telephone health coaching calls. The primary outcomes for CACE analyses were pain intensity (0-10 Numerical Rating Scale) and disability (Roland Morris Disability Questionnaire for low back pain and Western Ontario and McMaster Universities Osteoarthritis Index for knee osteoarthritis). Secondary outcomes were weight, physical activity, and diet. We used an instrumental variable approach to estimate CACE in compliers. From the intervention groups of the trials, 29% of those with low back pain (n = 23/80) and 34% of those with knee osteoarthritis (n = 20/60) complied. Complier average causal effect estimates showed potentially clinically meaningful effects, but with low certainty because of wide confidence intervals, for pain intensity (-1.4; 95% confidence interval, -3.1, 0.4) and small but also uncertain effects for disability (-2.1; 95% confidence interval, -8.6, 4.5) among compliers in the low back pain trial intervention compared with control but not in the knee osteoarthritis trial. Our findings showed that compliers of a telephone-based weight loss intervention in the low back pain trial generally had improved outcomes; however, there were inconsistent effects in compliers from the knee osteoarthritis trial. Complier average causal effect estimates were larger than intention-to-treat results but must be considered with caution.

Adolescent perspectives on participating in a feasibility trial investigating shoe inserts for patellofemoral pain

BACKGROUND

Patellofemoral pain (PFP) affects one-quarter of adolescents, yet there are few evidence-informed recommendations to treat PFP in this population. HAPPi Kneecaps! is a randomised, controlled, participant- and assessor-blind, parallel-group feasibility trial of shoe inserts for adolescents with PFP. The aim of this qualitative study was to explore adolescents' perspectives of participating in HAPPi Kneecaps!.

METHODS

All 36 adolescents with PFP from the HAPPi Kneecaps! study were invited to participate in semi-structured interviews. We used a descriptive qualitative methodology underpinned by a relativist framework to investigate adolescents' perspectives on participating in the trial. Inductive thematic analysis was used to examine patterns regarding how each adolescent experienced the HAPPi Kneecaps! study within their social, cultural, and historical contexts.

RESULTS

14 out of 36 HAPPi Kneecaps! participants provided consent and participated in interviews (12 females; mean [SD] age 14.9 [2.4] years). Overall, most adolescents responded positively when discussing their experience, such as improvements in their knee pain and satisfaction with how the study was run. Major themes that were generated from the analysis and feedback were: (1) shoe inserts require little effort to use; (2) perceptions of the program were generally positive; (3) participation in the trial could be made easier; (4) warm weather matters; and (5) life happens.

CONCLUSION

Adolescents with PFP who participated in the HAPPi Kneecaps! study found that shoe inserts were easy to wear. Most adolescents experienced an improvement in their symptoms and enhanced participation in sport and exercise. Adolescents with PFP prefer an option for warmer climates (e.g. flip flops or sandals), access to online logbooks, and clinicians who are easily accessible.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12619000957190 . Date registered: 8/07/2019.

Low back pain presentations to rural, regional, and metropolitan emergency departments

Objective

To describe the context of low back pain (LBP) presentations to emergency departments (EDs) by remoteness areas, hospital delineation level and staffing portfolios.

Design

A retrospective observational study using routinely captured ED and admission data over a 5‐year period (July 2014–June 2019).

Settings

Thirty seven EDs across a large health district in NSW, Australia, covering major cities, inner regional areas and outer regional areas.

Participants

Emergency department (ED) presentations with a principal or secondary diagnosis of LBP based on ICD‐10 code (M54.5).

Main outcome measures

ED presentation and associated admission measures, including presentation rate, referral source, time in ED, re‐presentation rate, admission details and cost to the health system.

Results

There were 26 509 ED presentations for LBP across the 5 years. Time spent in ED was 206 min for EDs in major cities, 146 min for inner regional EDs and 89 min for outer regional EDs. Re‐presentation rates were 6% in major cities, 8.8% in inner regional EDs and 11.8% in outer regional EDs. Admission rates were 20.4%, 15.8% and 18.8%, respectively.

Conclusions

This study describes LBP presentations across 37 EDs, highlighting the potential burden these presentations place on hospitals. LBP presentations appear to follow different pathways depending on the ED remoteness area, delineation level and staff portfolio.

Exceeding 2-h sedentary time per day is not associated with moderate to severe spinal pain in 11- to 13-year-olds: a cross-sectional analysis

Neck, mid-back and low back pain, collectively known as spinal pain, become more common with increasing age across childhood and adolescence. A common belief among the general community is that sedentary time, including screen time, in adolescents is associated with spinal pain. We aimed to investigate whether exceeding 2-h of sedentary time per day is associated with moderate to severe spinal pain in a sample of Danish adolescents aged 11-13 years. We performed a cross-sectional analysis of the SPACE study baseline data (2010). Adolescents self-reported their spinal pain (outcome) via the Young Spine Questionnaire and duration of engagement in sedentary behaviours (exposure). We provide estimates of associations as odds ratios with 95% confidence intervals, stratified by age and sex. The sample comprised 1,303 adolescents (48.7% female, mean age 12.5 years, range 10.9-14.3 years). Approximately 9 out of 10 adolescents exceeded 2-h sedentary time on weekdays outside of school (88.9%) and weekend days (89.9%). Close to one-quarter, 23.3% (95%CI: 21.0-25.6), of participants experienced moderate to severe spinal pain. We found no association between exceeding 2-h sedentary time per day and experiencing moderate to severe spinal pain; odds ratios ranged from 0.34 (95%CI: 0.04-3.20) to 4.65 (95%CI: 0.26-82.44).Conclusion: We found no association between exceeding 2- or 5-h of sedentary time per day and moderate to severe spinal pain in this sample of 11-13-year-old Danish adolescents. Our cross-sectional analysis does not consider the longitudinal or complex sequences of events necessary to address predictive or causal questions. What is Known: • Up to a third of adolescents experience moderate to severe spinal pain, predisposing them to chronic spinal pain in adulthood. • Frequent and excessive sedentary time is associated with poor overall health in adolescents; there is conflicting evidence to suggest whether it is also related to spinal pain. What is New: • We found no association between sedentary time and moderate to severe spinal pain in 11- to 13-year-old Danes.

At my own pace, space, and place: a systematic review of qualitative studies of enablers and barriers to telehealth interventions for people with chronic pain

ABSTRACT

Telehealth is a promising approach to support self-management with the potential to overcome geographical barriers. Understanding patient perspectives will identify practical challenges to delivering self-management strategies by telehealth. The aim of this study was to synthesize the perceptions of people with chronic musculoskeletal pain for engaging in interventions delivered using telehealth. We searched MEDLINE, Embase, CINAHL, LILACS, and PsycINFO databases. We included qualitative studies that explored perceptions or experiences or attitudes of people with chronic musculoskeletal pain engaging with telehealth. We assessed the methodological quality using the Critical Appraisal Skills Programme checklist. Meta-synthesis was guided by a thematic synthesis approach. The level of confidence of review findings was assessed using the Confidence in the Evidence from Reviews of Qualitative Studies (GRADE-CERQual). Twenty-one studies were included (n = 429). Telehealth comprised web-based, videoconference-based, telephone-based, video-based, and smartphone app-based programs delivered solely or combined. Chronic musculoskeletal conditions included people with knee or hip osteoarthritis, chronic low back pain, persistent pain (chronic joint pain or nonspecific chronic musculoskeletal pain), rheumatoid arthritis, and functional fatigue syndrome. The enablers for engaging in telehealth interventions were as follows: (1) "at my own pace, space, and place" and (2) empowered patient. Barriers to engaging in telehealth interventions were as follows: (1) impersonal, (2) technological challenges, (3) irrelevant content, and (4) limited digital (health) literacy. Telehealth interventions with well-designed interactive platforms, flexibility to fit patients' routine, and the broad availability of material may favor better engagement. Encouragement of self-efficacy is linked to successful telehealth-delivered self-management programs.

HAPPi Kneecaps! A double-blind, randomised, parallel group superiority trial investigating the effects of sHoe inserts for adolescents with patellofemoral PaIn: phase II feasibility study

Background

Patellofemoral pain (PFP) affects one-third of adolescents and can persist into adulthood, negatively impacting health and quality of life. Foot orthoses are a recommended treatment for adults with PFP, but have not been evaluated in adolescents. The primary objective was to determine the feasibility of conducting a full-scale randomised controlled trial (RCT) evaluating effects of contoured, prefabricated foot orthoses on knee pain severity and patient-perceived global change, compared to flat insoles. The secondary objective was to describe outcomes on a range of patient-reported outcome measures.

Methods

We recruited adolescents aged 12–18 years with PFP of ≥2 months duration into a double-blind, randomised, parallel-group feasibility trial. Participants were randomised to receive prefabricated contoured foot orthoses or flat shoe insoles, and followed for 3 months. Participants and outcome assessors were blinded to group allocation. Primary outcomes were feasibility of a full-scale RCT (number of eligible/enrolled volunteers; recruitment rate; adherence with the intervention and logbook completion; adverse effects; success of blinding; drop-out rate), and credibility and expectancy of interventions. Secondary outcomes were patient-reported measures of pain, symptoms, function, quality of life, global rating of change, patient acceptable symptom state, and use of co-interventions.

Results

36 out of 279 (12.9%) volunteers (27 female, mean (SD) age 15 (2) years, body mass 60 (13) kg) were eligible and enrolled, at a recruitment rate of 1.2 participants/week. 17 participants were randomised to receive foot orthoses, and 19 to flat insoles. 15 participants returned logbooks; 7/15 (47%) adhered to the intervention. No serious adverse events were reported. 28% (10/36, 4 pandemic-related) of participants dropped out before 3 months. Blinding was successful. Both groups found the inserts to be credible.

Conclusions

Based on a priori criteria for feasibility, findings suggest that a full-scale RCT comparing contoured foot orthoses to flat insoles in adolescents with PFP would not be feasible using the current protocol. Prior to conducting a full-scale RCT, feasibility issues should be addressed, with protocol modifications to facilitate participant retention, logbook completion and shoe insert wear.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12619000957190. Date registered: 8/07/2019.

Effectiveness of a Healthy Lifestyle Program (HeLP) for low back pain: statistical analysis plan for a randomised controlled trial

BACKGROUND

This paper describes the statistical analysis plan for a randomised controlled trial of a Healthy Lifestyle Program (HeLP) for low back pain targeting multiple health risks and behaviours, weight, physical activity, diet and smoking, to improve disability. We describe the methods for the main analyses and economic analysis of the trial.

METHODS AND DESIGN

The trial is a two-arm pragmatic randomised controlled trial comparing the effect of the HeLP intervention to usual care on low back pain disability at 26 weeks. A total of 346 adults with low back pain were recruited from the Newcastle and Hunter region between September 2017 and November 2019 and randomised to either HeLP or usual care. HeLP is a 6-month intervention with participant outcomes measured at weeks 6, 12, 26 and 52 post randomisation. This statistical analysis plan describes data integrity, handling and preparation of data for analyses and methods for analyses. The primary endpoint for the trial is disability at 26 weeks using the 24-item self-report Roland Morris Disability Questionnaire. The primary analysis will follow the intention-to-treat principle using linear mixed regression models.

DISCUSSION

The statistical analysis plan for this trial was produced to reduce outcome reporting bias arising from knowledge of the study findings. Any deviations will be described and justified in the final report.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12617001288314 . Registered on 6 September 2017.

Perspectives of emergency department clinicians on the challenges of addressing low back pain in the emergency setting: A qualitative study

OBJECTIVE

To identify and explore ED clinician perspectives on: (i) why patients with low back pain (LBP) present to the ED and are admitted into hospital from ED; (ii) barriers and enablers they face when providing care to patients with LBP; and (iii) strategies to improve the care of patients with LBP, and associated care processes, in the ED.

METHODS

We undertook a qualitative exploratory study with ED clinicians (medical officers, nurses and physiotherapists) at a tertiary-level public hospital in New South Wales, Australia, using focus groups and individual interviews. We used thematic analysis to synthesise participant responses to answer the predefined research questions.

RESULTS

Twenty-one clinicians participated (two individual interviews, 19 focus groups). Perceptions about better access to the ED and advanced care within ED were thought to drive presentations to the ED for LBP. Barriers and enablers to optimal patient care included patient-, clinician- and service-level factors. The main strategies to improve care included a department LBP pathway, modernised patient and clinician resources, better follow-up options post-discharge and improved communication between ED and primary care.

CONCLUSION

We identified a range of targets to improve LBP management in ED. Clinicians perceived internal and external factors to the ED as influences of ED presentation and hospital admission. Clinicians also reported that patient-, clinician- and service-level barriers and enablers influenced patient management in ED. Strategies suggested by clinicians included improved follow-up options, access to resources and an 'LBP pathway' to support decision making.

A Guideline for Reporting Mediation Analyses of Randomized Trials and Observational Studies: The AGReMA Statement

Importance

Mediation analyses of randomized trials and observational studies can generate evidence about the mechanisms by which interventions and exposures may influence health outcomes. Publications of mediation analyses are increasing, but the quality of their reporting is suboptimal.

Objective

To develop international, consensus-based guidance for the reporting of mediation analyses of randomized trials and observational studies (A Guideline for Reporting Mediation Analyses; AGReMA).

Design, Setting, and Participants

The AGReMA statement was developed using the Enhancing Quality and Transparency of Health Research (EQUATOR) methodological framework for developing reporting guidelines. The guideline development process included (1) an overview of systematic reviews to assess the need for a reporting guideline; (2) review of systematic reviews of relevant evidence on reporting mediation analyses; (3) conducting a Delphi survey with panel members that included methodologists, statisticians, clinical trialists, epidemiologists, psychologists, applied clinical researchers, clinicians, implementation scientists, evidence synthesis experts, representatives from the EQUATOR Network, and journal editors (n = 19; June-November 2019); (4) having a consensus meeting (n = 15; April 28-29, 2020); and (5) conducting a 4-week external review and pilot test that included methodologists and potential users of AGReMA (n = 21; November 2020).

Results

A previously reported overview of 54 systematic reviews of mediation studies demonstrated the need for a reporting guideline. Thirty-three potential reporting items were identified from 3 systematic reviews of mediation studies. Over 3 rounds, the Delphi panelists ranked the importance of these items, provided 60 qualitative comments for item refinement and prioritization, and suggested new items for consideration. All items were reviewed during a 2-day consensus meeting and participants agreed on a 25-item AGReMA statement for studies in which mediation analyses are the primary focus and a 9-item short-form AGReMA statement for studies in which mediation analyses are a secondary focus. These checklists were externally reviewed and pilot tested by 21 expert methodologists and potential users, which led to minor adjustments and consolidation of the checklists.

Conclusions and Relevance

The AGReMA statement provides recommendations for reporting primary and secondary mediation analyses of randomized trials and observational studies. Improved reporting of studies that use mediation analyses could facilitate peer review and help produce publications that are complete, accurate, transparent, and reproducible.

Producing Clinically Meaningful Reductions in Disability: A Causal Mediation Analysis of a Patient Education Intervention

Patient education is recommended as first-line care for low back pain (LBP), although its efficacy for providing clinically meaningful reductions in disability has been questioned. One way to improve treatment effects is to identify and improve targeting of treatment mechanisms. We conducted a pre-planned causal mediation analysis of a randomized, placebo-controlled trial investigating the effectiveness of patient education for patients with acute LBP. 202 patients who had fewer than six-weeks' duration of LBP and were at high-risk of developing chronic LBP completed two, one-hour treatment sessions of either intensive patient education, or placebo patient education. 189 participants provided data for the outcome self-reported disability at three-months and the mediators, pain self-efficacy, pain catastrophizing, and back beliefs at one-week post treatment. This causal mediation analysis found that pain catastrophizing (mediated effect, -0.64; 95% Confidence Interval [CI], -1.31 to -0.15) and back beliefs (mediated effect, -0.51; 95% CI, -1.15 to -0.02) partly explained the effect of patient education on disability but pain self-efficacy did not (mediated effect, -0.40; 95% CI -1.13 to 0.28). Considering the mediator-outcome relationship, patient education would need to induce an 8 point difference on the pain self-efficacy questionnaire (0-60); an 11 point difference on the back beliefs questionnaire (9-45); and a 21 point difference on the pain catastrophizing scale (0-52) to achieve a minimally clinically important difference of 2 points on the Roland Morris Disability Questionnaire (0-24). PERSPECTIVE: Understanding the mechanisms of patient education can inform how this treatment can be adapted to provide clinically meaningful reductions in disability. Our findings suggest that adapting patient education to better target back beliefs and pain self-efficacy could result in clinically meaningful reductions in disability whereas the role of pain catastrophizing in acute LBP is less clear.

Exercise interventions for low back pain are poorly reported: a systematic review

OBJECTIVE

To assess the reporting quality of exercise interventions from clinical trials of low back pain (LBP).

STUDY DESIGN AND SETTING

We conducted a systematic review to assess the reporting quality of randomised controlled trials (RCTs) that investigated the effectiveness of exercise interventions for patients with LBP. Five online databases and Clinical Trial Registries were searched (October 2018). We included RCTs that reported interventions for LBP, containing at least 50% exercise. The Template for Intervention Description and Replication (TIDieR) and the Consensus on Exercise Reporting Template (CERT) reporting checklists were then used to assess quality of reporting.

RESULTS

582 trials were eligible for inclusion. Due to the large number of eligible studies, 100 studies were randomly selected for data extraction and coding with the TIDieR and CERT checklists. The random sample was representative of the 582 eligible trials. The overall completeness of reporting (median (IQR)) of TIDieR items was 59.2% (45.5%-72.7%) and CERT was 33.3% (22.2%-52.6%).

CONCLUSIONS

We found poor overall reporting with both checklists, which has not improved over time or since the introduction of the checklists. More dedicated work is required to address poor reporting of exercise interventions in clinical trials.

Items for consideration in a reporting guideline for mediation analyses: a Delphi study

OBJECTIVES

Mediation analysis is a widely used quantitative method for investigating how interventions and exposures in randomised controlled trials and observational studies have an effect on healthcare outcomes. This study aimed to assess the importance of items that should be considered in a consensus meeting aimed at developing a guideline for reporting mediation analyses.

DESIGN

International online Delphi study.

PARTICIPANTS

International experts in the development and application of mediation analysis.

MAIN OUTCOME MEASURES

The Delphi panel were asked to rate the importance of a list of items for inclusion in a guideline for reporting mediation analyses. Thresholds for disagreement and consensus on importance for inclusion were specified a priori. We used the Research ANd Development/University of California Los Angeles appropriateness method to quantitatively assess the importance for inclusion and panel agreement.

RESULTS

Nineteen expert panellists (10 female) from seven countries agreed to participate. All panellists contributed to all three rounds conducted between 10 June 2019 and 6 November 2019. The panel reached consensus on 34 unique reporting items for study design, analytic procedures and effect estimates, with three items rated 'optional'. Panellists added one extra item and provided 60 qualitative comments for item refinement and prioritisation.

CONCLUSION

This Delphi study used a rigorous consensus process to reach consensus on 34 reporting items for studies that use mediation analysis. These results will inform a consensus meeting that will consolidate a core set of recommended items for reporting mediation analyses.

Reporting of social deprivation in musculoskeletal trials: An analysis of 402 randomised controlled trials

BACKGROUND

Social deprivation is broadly defined as the restriction of access an individual has to social or cultural interactions due to poverty, discrimination or other disadvantages. While social deprivation is a widely acknowledged determinant of outcome in musculoskeletal conditions, it remains unclear how this is considered in the conduct and interpretation of musculoskeletal trials.

AIM

To determine the frequently to which measures of social deprivation are reported in trials recruiting people with musculoskeletal diseases.

MATERIALS AND METHODS

We conducted a Pubmed search of randomised controlled trials published between 01 January 2019 and 01 June 2020. We included full-text papers of trials recruiting people with musculoskeletal diseases, irrespective of intervention type or origin. We extracted data relating to trial characteristics, setting, trial design, funding source and musculoskeletal disease. We extracted data on any reported social deprivation index or measure of social deprivation based on internationally adopted indicators. We analysed data descriptively to summarise the reporting of each social deprivation index and measure of social deprivation within trials.

RESULTS

From 2133 potentially eligible citations, 402 were eligible. Mean age of participants was 51.7 years; 63% were female. Trials most frequently recruited people with spinal pain (24.6%) or osteoarthritis (10.0%). Two trials (0.5%) reported social deprivation indices/scores. When assessed by discrete measures of social deprivation, 164 trials (40.8%) reported one or more social deprivation measures. The most commonly reported measures were morbidity (20.2%), employment status (17.7%) and educational attainment (15.5%). Race (6.7%), ethnicity (6.2%) and annual salary (1.3%) were infrequently reported. One trial (0.3%) presented subgroup results by social deprivation measures.

DISCUSSION AND CONCLUSION

Social deprivation is inconsistently reported in musculoskeletal trials. Trialists should report baseline measures of social deprivation in trial reports and aid generalisability to target population, and to examine whether social deprivation might modify treatment effects of interventions for musculoskeletal conditions.

HAPPi Kneecaps! Protocol for a participant- and assessor-blinded, randomised, parallel group feasibility trial of foot orthoses for adolescents with patellofemoral pain

Background

Patellofemoral pain (PFP) is a common cause of knee pain in adolescents, but there are limited evidence-based treatment options for this population. Foot orthoses can improve pain and function in adults with PFP, and may be effective for adolescents. The primary aim of this study is to determine the feasibility of conducting a full-scale randomised controlled trial (RCT) evaluating the effects of contoured foot orthoses on knee pain severity and patient-perceived global change, compared to flat shoe insoles, in adolescents with PFP. The secondary aim is to provide an estimate of treatment effects for foot orthoses, compared to flat insoles, in adolescents with PFP.

Methods

This randomised, controlled, participant- and assessor-blinded, feasibility trial has two parallel groups. Forty adolescents (aged 12–18 years) with clinical symptoms of PFP will be recruited from Queensland, Australia. Participants will be randomised to receive either prefabricated contoured foot orthoses or flat shoe insoles. Both interventions will be fit by a physiotherapist, and worn for 3 months. Feasibility will be evaluated through assessing willingness of volunteers to enrol, number of eligible participants, recruitment rate, adherence with the study protocol, adverse effects, success of blinding, and drop-out rate. Secondary outcomes will evaluate knee-related pain, symptoms, function, quality of life, global rating of change, patient acceptable symptom state, and use of co-interventions, at 6 weeks and 3 months. Primary outcomes will be reported descriptively, while estimates of standard deviation and between-group differences (with 95% confidence intervals) will be reported for secondary outcomes.

Discussion

Findings of this study will inform the feasibility of a full-scale RCT investigating the efficacy of contoured foot orthoses in adolescents with PFP. This full-scale study is necessary to improve the evidence base for management of adolescent PFP, and enhance outcomes for this population.

Trial registration

ACTRN12619000957190.

Enablers and barriers of people with chronic musculoskeletal pain for engaging in telehealth interventions: protocol for a qualitative systematic review and meta-synthesis

BACKGROUND

Chronic musculoskeletal pain represents an enormous burden in society. Best-practice care for chronic musculoskeletal pain suggests adoption of self-management strategies. Telehealth interventions (e.g., videoconferencing) are a promising approach to promote self-management and have the potential to overcome geographical barriers between patient and care providers. Understanding patient perspectives will inform and identify practical challenges towards applying the self-management strategies delivered via telehealth to everyday lives. The aim of this study is to synthesize the perceptions of individuals with musculoskeletal pain with regards to enablers and barriers to engaging in telehealth interventions for chronic musculoskeletal pain self-management.

METHODS

A systematic review of qualitative studies will be performed based on searches of MEDLINE, EMBASE, CINAHL, LILACS, and PsycINFO databases. Screening of identified titles will be conducted by two independent investigators. Data extraction will retrieve detailed qualitative information from selected articles. The critical appraisal skills program (CASP) checklist will be used for critical appraisal of included studies, and the level of confidence in the findings will be assessed using the confidence in the evidence from reviews of qualitative research (GRADE-CERQual). A thematic synthesis approach will be used to derive analytical themes.

DISCUSSION

This review will systematically identify, synthesize, and present enablers and barriers reported by people with musculoskeletal pain to engage in telehealth interventions. The review will provide information required to support the design and improvement of telehealth services.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019136148.

Development of A Guideline for Reporting Mediation Analyses (AGReMA)

BACKGROUND

There are a growing number of studies using mediation analysis to understand the mechanisms of health interventions and exposures. Recent work has shown that the reporting of these studies is heterogenous and incomplete. This problem stifles clinical application, reproducibility, and evidence synthesis. This paper describes the processes and methods that will be used to develop a guideline for reporting studies of mediation analyses (AGReMA).

METHODS/DESIGN

AGReMA will be developed over five overlapping stages. Stage one will comprise a systematic review to examine relevant evidence on the quality of reporting in published studies that use mediation analysis. In the second stage we will consult a group of methodologists and applied researchers by using a Delphi process to identify items that should be considered for inclusion in AGReMA. The third stage will involve a consensus meeting to consolidate and prioritise key items to be included in AGReMA. The fourth stage will involve the production of AGReMA and an accompanying explanation and elaboration document. In the final stage we will disseminate the AGReMA statement via journals, conferences, and professional meetings across multiple disciplines.

DISCUSSION

The development and implementation of AGReMA will improve the standardization, transparency, and completeness in the reporting of studies that use mediation analysis to understand the mechanisms of health interventions and exposures.

Interventions Targeting Smoking Cessation for Patients With Chronic Pain: An Evidence Synthesis

INTRODUCTION

Smoking is a risk factor for chronic pain conditions. Epidemiological evidence suggests that smoking cessation may be an important treatment target in people with chronic pain. The aim of this study was to examine the effectiveness of smoking cessation interventions in people with chronic pain.

METHODS

We systematically searched for clinical trials investigating the effectiveness of smoking cessation interventions for people with chronic pain, compared with any control comparator. Primary outcomes were pain and physical function. Secondary outcomes were smoking status, quality of life, psychological and cognitive function, and adverse events. We assessed risk of bias using the Cochrane Risk of Bias criteria and the quality of evidence with GRADE.

RESULTS

Searches retrieved 3845 records and identified two trials for inclusion (total n = 99 participants). There was low-quality evidence of no effect of smoking cessation programs on pain and very low-quality evidence of no effect on function at short-term follow-up. There was conflicting evidence on the effect of smoking cessation interventions for changing the smoking status and number of cigarettes consumed per day. There was no effect on depression and anxiety.

CONCLUSION

Current evidence does not indicate clinically important effects of smoking cessation interventions in people with chronic pain. There is a need for high-quality trials in this area.

IMPLICATIONS

Our review highlights an important evidence gap. We found only two studies investigating smoking cessation programs for chronic pain conditions providing very low- to low-quality evidence.

How much of the effect of exercise and advice for subacute low back pain is mediated by depressive symptoms?

BACKGROUND

Exercise and advice can reduce pain and disability in patients with subacute low back pain. However, the mechanisms by which this combined intervention works are unclear. Our objective was to estimate how much of the effect of a physiotherapist-directed exercise and advice intervention on pain and disability is mediated via changes in depressive symptoms.

METHODS

Causal mediation analysis of a randomized controlled trial. We measured our hypothesized mediator - depressive symptoms (Depression, Anxiety, Stress Scale-21) at 6 weeks, and the outcomes - pain (numerical rating scale) and disability (Roland Morris Disability Questionnaire) at 3 months, estimating the average causal mediation effect (ACME), average direct effect (ADE), and total effect. We pre-specified a causal model to identify potential confounders of the mediator-outcome effect and conducted sensitivity analyses to assess the robustness of the ACME under varying levels of unknown confounding.

RESULTS

Data from 240 patients were analyzed (average age 50.5 (SD 15.6) years, 52% male, median depressive symptoms score 4). The effect of exercise combined with advice was not mediated via depressive symptoms: ACME on pain (0.05, 95%CI -0.24 to 0.15), ACME on disability (-0.10, 95%CI -0.59 to 0.38). However depressive symptoms were associated with pain (regression coefficient 0.06; SE 0.03)) and disability (regression coefficient 0.17; SE 0.05).) CONCLUSIONS: Depressive symptoms did not mediate the effect of exercise and/or advice in this sample. However, depressive symptoms were associated with pain and disability.

Talking to Teens about Pain: A Modified Delphi Study of Adolescent Pain Science Education

Background: Persistent pain is a prevalent condition that negatively influences physical, emotional, social and family functioning in adolescents. Pain science education is a promising therapy for adults, yet to be thoroughly investigated for persistent pain in adolescents. There is a need to develop suitable curricula for adolescent pain science education.

Methods: An interdisciplinary meeting of 12 clinicians and researchers was held during March 2018 in Adelaide, South Australia. An a priori objective of the meeting was to identify and gain consensus on key learning objectives for adolescent pain science education using a modified-Delphi process.

Results and Conclusion: Consensus was reached via a modified Delphi process for seven learning objectives to form the foundation of a curriculum: 1) Pain is a protector; 2) The pain system can become overprotective; 3) Pain is a brain output; 4) Pain is not an accurate marker of tissue state; 5) There are many potential contributors to anyone’s pain; 6) We are all bioplastic and; 7) Pain education is treatment. Recommendations are made for promising areas for future research in adolescent pain science education.

Tackling the language barrier to implementing research into practice: A survey of usage of the Physiotherapy Evidence Database

BACKGROUND

Language is a barrier to implementing research evidence into practice. Whilst the majority of the world's population speak languages other than English, English has become the dominant language of publication for research in healthcare.

OBJECTIVE

The aim of this study was to quantify the usage of the Physiotherapy Evidence Database (PEDro) web-site (www.pedro.org.au) and training videos by language, including the use of online translation, and to calculate relative usage of the different sections of the web-site.

METHODS

Google Analytics was used to track usage of the PEDro web-site for July 2017 to June 2018. The number of views of each of the PEDro training videos was downloaded from YouTube for January 2015 to August 2018. The pageviews and videos were categorized by language and, for pageviews, web-site section.

RESULTS

2,828,422 pageviews were included in the analyses. The English-language sections had the largest number of pageviews (58.61%), followed by Portuguese (15.57%), and Spanish (12.02%). Users applied online translation tools to translate selected content of the PEDro web-site into 41 languages. The PEDro training videos had been viewed 78,150 times. The three most commonly viewed languages were English (58.80%), Portuguese (19.83%), and Spanish (6.13%).

CONCLUSIONS

There was substantial use of some of the translated versions of the resources offered by PEDro. Future efforts could focus on region-specific promotion of the language resources that are underutilized in PEDro. The developers of PEDro and PEDro users can work collaboratively to facilitate uptake and translate resources into languages other than English to reduce the language barrier in using research to guide practice.

Co-occurrence of Chronic Musculoskeletal Pain and Cardiovascular Diseases: A Systematic Review with Meta-analysis

Objective

To determine the magnitude of the association between cardiovascular disease and chronic musculoskeletal pain.

Design

Systematic review with meta-analysis.

Methods

A comprehensive search was performed in five electronic databases. Population-based studies reporting the prevalence of cardiovascular diseases in adults stratified by chronic musculoskeletal pain status were considered eligible. Two independent reviewers performed the screening of the records following the inclusion criteria, extracted data, and evaluated the risk of bias of the included studies using an assessment tool of risk of bias for observational studies. In addition, we assessed the overall quality of evidence using an adaptation of the GRADE approach for prognosis.

Results

Twenty studies were included in this review. There was high-quality evidence that people with chronic musculoskeletal pain are 1.91 times more likely to report having a cardiovascular disease compared with those without chronic musculoskeletal pain (risk ratio = 1.91, 95% confidence interval = 1.64–2.21).

Conclusions

Our findings demonstrated associations between chronic musculoskeletal pain and any cardiovascular diseases. Future studies are still warranted to better understand the association between chronic musculoskeletal pain and the specific types of cardiovascular diseases.

Back pain, mental health and substance use are associated in adolescents

BACKGROUND

During adolescence, prevalence of pain and health risk factors such as smoking, alcohol use and poor mental health all rise sharply. The aim of this study was to describe the relationship between back pain and health risk factors in adolescents.

METHODS

Cross-sectional data from the Healthy Schools Healthy Futures study, and the Australian Child Wellbeing Project was used, mean age: 14-15 years. Children were stratified according to back pain frequency. Within each strata, the proportion of children that reported drinking alcohol or smoking or that experienced feelings of anxiety or depression was reported. Test-for-trend analyses assessed whether increasing frequency of pain was associated with health risk factors.

RESULTS

Data was collected from ~2500 and 3900 children. Larger proportions of children smoked or drank alcohol within each strata of increasing pain frequency. The trend with anxiety and depression was less clear, although there was a marked difference between the children that reported no pain, and pain more frequently.

CONCLUSION

Two large, independent samples show adolescents that experience back pain more frequently are also more likely to smoke, drink alcohol and report feelings of anxiety and depression. Pain appears to be part of the picture of general health risk in adolescents.

Healthy Lifestyle Program (HeLP) for low back pain: protocol for a randomised controlled trial

INTRODUCTION

Low back pain is one of the most common and burdensome chronic conditions worldwide. Lifestyle factors, such as excess weight, physical inactivity, poor diet and smoking, are linked to low back pain chronicity and disability. There are few high-quality randomised controlled trials that investigate the effects of targeting lifestyle risk factors in people with chronic low back pain.

METHODS AND ANALYSIS

The aim of this study is to determine the effectiveness of a Healthy Lifestyle Program (HeLP) for low back pain targeting weight, physical activity, diet and smoking to reduce disability in patients with chronic low back pain compared with usual care. This is a randomised controlled trial, with participants stratified by body mass index, allocated 1:1 to the HeLP intervention or usual physiotherapy care. HeLP involves three main components: (1) clinical consultations with a physiotherapist and dietitian; (2) educational resources; and (3) telephone-based health coaching support for lifestyle risk factors. The primary outcome is disability (Roland Morris Disability Questionnaire) at 26 weeks. Secondary outcomes include pain intensity, weight, quality of life and smoking status. Data will be collected at baseline, and at weeks 6, 12, 26 and 52. Patients with chronic low back pain who have at least one health risk factor (are overweight or obese, are smokers and have inadequate physical activity or fruit and vegetable consumption) will be recruited from primary or secondary care, or the community. Primary outcome data will be analysed by intention to treat using linear mixed-effects regression models. We will conduct three supplementary analyses: causal mediation analysis, complier average causal effects analysis and economic analysis.

ETHICS AND DISSEMINATION

This study was approved by the Hunter New England Research Ethics Committee (Approval No 17/02/15/4.05), and the University of Newcastle Human Research Ethics Committee (Ref No H-2017-0222). Outcomes of this trial and supplementary analyses will be disseminated through publications in peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

ACTRN12617001288314.

Interrater agreement and reliability of clinical tests for assessment of patients with shoulder pain in primary care

Background: There is limited information about the agreement and reliability of clinical shoulder tests. Objectives: To assess the interrater agreement and reliability of clinical shoulder tests in patients with shoulder pain treated in primary care. Methods: Patients with a primary report of shoulder pain underwent a set of 21 clinical shoulder tests twice on the same day, by pairs of independent physical therapists. The outcome parameters were observed and specific interrater agreement for positive and negative scores, and interrater reliability (Cohen's kappa (κ)). Positive and negative interrater agreement values of ≥0.75 were regarded as sufficient for clinical use. For Cohen's κ, the following classification was used: <0.20 poor, 0.21-0.40 fair, 0.41-0.60 moderate, 0.61-0.80 good, 0.81-1.00 very good reliability. Participating clinics were randomized in two groups; with or without a brief practical session on how to conduct the tests. Results: A total of 113 patients were assessed in 12 physical therapy practices by 36 physical therapists. Positive and negative interrater agreement values were both sufficient for 1 test (the Full Can Test), neither sufficient for 5 tests, and only sufficient for either positive or negative agreement for 15 tests. Interrater reliability was fair for 11 tests, moderate for 9 tests, and good for 1 test (the Full Can Test). An additional brief practical session did not result in better agreement or reliability. Conclusion: Clinicians should be aware that interrater agreement and reliability for most shoulder tests is questionable and their value in clinical practice limited.

Causal mechanisms of a healthy lifestyle intervention for patients with musculoskeletal pain who are overweight or obese

PURPOSE

To assess the causal mechanisms of a healthy lifestyle intervention for patients with chronic low back pain and knee osteoarthritis, who are overweight or obese.

METHODS

We conducted causal mediation analyses of aggregated data from two randomized controlled trials (RCTs); which included 160 patients with chronic low back pain, and 120 patients with knee osteoarthritis. The intervention consisted of brief advice and referral to a six-month telephone-based healthy lifestyle coaching service. We used causal mediation to estimate the indirect, direct and path-specific effects of hypothesized mediators including: self-reported weight, diet, physical activity, and pain beliefs. Outcomes were pain intensity, disability, and quality of life (QoL).

RESULTS

The intervention did not reduce weight, improve diet or physical activity or change pain beliefs, and these mediators were not associated with the outcomes. Sensitivity analyses showed that our estimates were robust to the possible effects of unknown and unmeasured confounding.

CONCLUSIONS

Our findings show that the intervention did not cause a meaningful change in the hypothesized mediators, and these mediators were not associated with patient-reported outcomes.

Economic evaluation of telephone-based weight loss support for patients with knee osteoarthritis: a randomised controlled trial

Background

The prevalence of knee osteoarthritis is increasing worldwide. Obesity is an important modifiable risk factor for both the incidence and progression of knee osteoarthritis. Consequently, international guidelines recommend all patients with knee osteoarthritis who are overweight receive support to lose weight. However, few overweight patients with this condition receive care to support weight loss. Telephone-based interventions are one potential solution to provide scalable care to the many patients with knee osteoarthritis. The objective of this study is to evaluate, from a societal perspective, the cost-utility and cost-effectiveness of a telephone-based weight management and healthy lifestyle service for patients with knee osteoarthritis, who are overweight or obese.

Methods

An economic evaluation was undertaken alongside a pragmatic randomised controlled trial. Between May 19 and June 30, 2015, 120 patients with knee osteoarthritis were randomly assigned to an intervention or usual care control group in a 1:1 ratio. Participants in the intervention group received a referral to an existing non-disease specific 6-month telephone-based weight management and healthy lifestyle service. Quality-adjusted life years (QALYs) was the utility measure and knee pain intensity, disability, weight, and body mass index (BMI) were the clinical measures of effect. Costs included intervention costs, healthcare utilisation costs (healthcare services and medication use) and absenteeism costs due to knee pain. Data was collected at baseline, 6 weeks and 26 weeks. The primary cost-effectiveness analysis was performed from the societal perspective.

Results

Mean cost differences between groups (intervention minus control) were $493 (95%CI: -3513 to 5363) for healthcare costs, $-32 (95%CI: -73 to 13) for medication costs, and $125 (95%CI: -151 to 486) for absenteeism costs. The total mean difference in societal costs was $1197 (95%CI: -2887 to 6106). For QALYs and all clinical measures of effect, the probability of the intervention being cost-effective compared with usual care was less than 0.36 at all willingness-to-pay values.

Conclusions

From a societal perspective, telephone-based weight loss support, provided using an existing non-disease specific 6-month weight management and healthy lifestyle service was not cost-effective in comparison with usual care for overweight and obese patients with knee osteoarthritis.

Trial registration number

ACTRN12615000490572, registered 18th May 2015

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6300-1) contains supplementary material, which is available to authorized users.

Scoping review of priority setting of research topics for musculoskeletal conditions

OBJECTIVE

Describe research methods used in priority-setting exercises for musculoskeletal conditions and synthesise the priorities identified.

DESIGN

Scoping review.

SETTING AND POPULATION

Studies that elicited the research priorities of patients/consumers, clinicians, researchers, policy-makers and/or funders for any musculoskeletal condition were included.

METHODS AND ANALYSIS

We searched MEDLINE and EMBASE from inception to November 2017 and the James Lind Alliance top 10 priorities, Cochrane Priority Setting Methods Group, and Cochrane Musculoskeletal and Back Groups review priority lists. The reported methods and research topics/questions identified were extracted, and a descriptive synthesis conducted.

RESULTS

Forty-nine articles fulfilled our inclusion criteria. Methodologies and stakeholders varied widely (26 included a mix of clinicians, consumers and others, 16 included only clinicians, 6 included only consumers or patients and in 1 participants were unclear). Only two (4%) reported any explicit inclusion criteria for priorities. We identified 294 broad research priorities from 37 articles and 246 specific research questions from 17 articles, although only four (24%) of the latter listed questions in an actionable format. Research priorities for osteoarthritis were identified most often (n=7), followed by rheumatoid arthritis (n=4), osteoporosis (n=4) and back pain (n=4). Nearly half of both broad and specific research priorities were focused on treatment interventions (n=116 and 111, respectively), while few were economic (n=8, 2.7% broad and n=1, 0.4% specific), implementation (n=6, 2% broad and n=4, 1.6% specific) or health services and systems research (n=15, 5.1% broad and n=9, 3.7% specific) priorities.

CONCLUSIONS

While many research priority-setting studies in the musculoskeletal field have been performed, methodological limitations and lack of actionable research questions limit their usefulness. Future studies should ensure they conform to good priority-setting practice to ensure that the generated priorities are of maximum value.

PROSPERO REGISTRATION NUMBER

CRD42017059250.

Economic evaluation of a healthy lifestyle intervention for chronic low back pain: A randomized controlled trial

BACKGROUND

Economic evaluations which estimate cost-effectiveness of potential treatments can guide decisions about real-world healthcare services. We performed an economic evaluation of a healthy lifestyle intervention targeting weight loss, physical activity and diet for patients with chronic low back pain, who are overweight or obese.

METHODS

Eligible patients with chronic low back pain (n = 160) were randomized to an intervention or usual care control group. The intervention included brief advice, a clinical consultation and referral to a 6-month telephone-based healthy lifestyle coaching service. The primary outcome was quality-adjusted life years (QALYs). Secondary outcomes were pain intensity, disability, weight and body mass index. Costs included intervention costs, healthcare utilization costs and work absenteeism costs. An economic analysis was performed from the societal perspective.

RESULTS

Mean total costs were lower in the intervention group than the control group (-$614; 95%CI: -3133 to 255). The intervention group had significantly lower healthcare costs (-$292; 95%CI: -872 to -33), medication costs (-$30; 95%CI: -65 to -4) and absenteeism costs (-$1,000; 95%CI: -3573 to -210). For all outcomes, the intervention was on average less expensive and more effective than usual care, and the probability of the intervention being cost-effective compared to usual care was relatively high (i.e., 0.81) at a willingness-to-pay of $0/unit of effect. However, the probability of cost-effectiveness was not as favourable among sensitivity analyses.

CONCLUSIONS

The healthy lifestyle intervention seems to be cost-effective from the societal perspective. However, variability in the sensitivity analyses indicates caution is needed when interpreting these findings.

SIGNIFICANCE

This is an economic evaluation of a randomized controlled trial of a healthy lifestyle intervention for chronic low back pain. The findings suggest that a healthy lifestyle intervention may be cost-effective relative to usual care.