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Hamilton M, Mathieson S, Gnjidic D, Jansen J, Weir K, Shaheed CA, Blyth F, Lin CWC. Barriers, facilitators, and resources to opioid deprescribing in primary care: experiences of general practitioners in Australia. Pain 2022; 163:e518-e526. [PMID: 33990105 DOI: 10.1097/j.pain.0000000000002340] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 05/07/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Deprescribing is the systematic process of discontinuing drugs when harms outweigh the benefits. We conducted semistructured telephone interviews with 22 general practitioners (GPs) who had prescribed or deprescribed opioids in patients with chronic noncancer pain within the past 6 months to investigate the barriers and facilitators to deprescribing opioid analgesics in patients with chronic noncancer pain. We also explored GPs' perspectives on the available resources to assist them with opioid deprescribing. Interviews were audio-recorded, transcribed verbatim, and then coded using an iterative process until data saturation reached. The thematic analysis process identified themes, first as concepts, and then refined to overarching themes after the merging of similar subthemes. Themes exploring barriers to deprescribing highlighted the difficulties GPs face while considering patient factors and varying prescribing practices within the confines of the health system. Patient motivation and doctor-patient rapport were central factors to facilitate deprescribing and GPs considered the most important deprescribing resource to be a multidisciplinary network of clinicians to support themselves and their patients. Therefore, although GPs emphasised the importance of deprescribing opioid analgesics, they also expressed many barriers relating to managing complex pain conditions, patient factors, and varying prescribing practices between clinicians. Some of these barriers could be mitigated by GPs having time and resources to educate and build rapport with their patients. This suggests the need for further development of multimodal resources and improved support through the public health system to enable GPs to prioritise patient-centred care.
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Affiliation(s)
- Melanie Hamilton
- Institute for Musculoskeletal Health, Sydney, NSW, Australia
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | - Stephanie Mathieson
- Institute for Musculoskeletal Health, Sydney, NSW, Australia
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | - Danijela Gnjidic
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | - Jesse Jansen
- ASK-GP Centre of Research Excellence, The University of Sydney, Sydney, NSW, Australia
| | - Kristie Weir
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | - Christina A Shaheed
- Institute for Musculoskeletal Health, Sydney, NSW, Australia
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | - Fiona Blyth
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | - Chung-Wei C Lin
- Institute for Musculoskeletal Health, Sydney, NSW, Australia
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
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Pocovi NC, Lin CWC, Latimer J, Merom D, Tiedemann A, Maher C, van Tulder MW, Macaskill P, Clavisi O, Tong SYK, Hancock MJ. Effectiveness and cost-effectiveness of a progressive, individualised walking and education programme for prevention of low back pain recurrence in adults: study protocol for the WalkBack randomised controlled trial. BMJ Open 2020; 10:e037149. [PMID: 33033088 PMCID: PMC7545638 DOI: 10.1136/bmjopen-2020-037149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Low back pain (LBP) is recognised globally as a prevalent, costly and disabling condition. Recurrences are common and contribute to much of the burden of LBP. Current evidence favours exercise and education for prevention of LBP recurrence, but an optimal intervention has not yet been established. Walking is a simple, widely accessible, low-cost intervention that has yet to be evaluated. This randomised controlled trial (RCT) aims to establish the effectiveness and cost-effectiveness of a progressive and individualised walking and education programme (intervention) for the prevention of LBP recurrences in adults compared with no treatment (control). METHODS AND ANALYSIS A pragmatic, two-armed RCT comparing walking and education (n=349) with a no treatment control group (n=349). Inclusion criteria are adults recovered from an episode of non-specific LBP within the last 6 months. Those allocated to the intervention group will receive six sessions (three face to face and three telephone delivered) with a trained physiotherapist to facilitate a progressive walking programme and education over a 6-month period. The primary outcome will be days to first recurrence of an episode of activity-limiting LBP. The secondary outcomes include days to recurrence of an episode of LBP, days to recurrence of an episode of LBP leading to care seeking, disability and quality of life measured at 3, 6, 9 and 12 months and costs associated with LBP recurrence. All participants will be followed up monthly for a minimum of 12 months. The primary intention-to-treat analysis will assess difference in survival curves (days to recurrence) using the log-rank statistic. The cost-effectiveness analysis will be conducted from the societal perspective. ETHICS AND DISSEMINATION Approved by Macquarie University Human Research Ethics Committee (Reference: 5201949218164, May 2019). Findings will be disseminated through publication in peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER ACTRN12619001134112.
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Affiliation(s)
- Natasha Celeste Pocovi
- Department of Health Professions, Macquarie University, Sydney, New South Wales, Australia
| | - Chung-Wei C Lin
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Jane Latimer
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Dafna Merom
- Department of Physical Activity and Health, Western Sydney University, Sydney, New South Wales, Australia
| | - Anne Tiedemann
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Christopher Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | | | - Petra Macaskill
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | | | - Shuk Yin Kate Tong
- Department of Health Professions, Macquarie University, Sydney, New South Wales, Australia
| | - Mark J Hancock
- Department of Health Professions, Macquarie University, Sydney, New South Wales, Australia
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Cross AJ, Buchbinder R, Bourne A, Maher C, Mathieson S, Lin CWC, O'Connor DA. Barriers and enablers to monitoring and deprescribing opioid analgesics for chronic non-cancer pain: protocol for a qualitative evidence synthesis using the Theoretical Domains Framework. BMJ Open 2019; 9:e034039. [PMID: 31722956 PMCID: PMC6858188 DOI: 10.1136/bmjopen-2019-034039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/22/2019] [Accepted: 10/25/2019] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION The over-prescription and overuse of opioid analgesics for chronic non-cancer pain (CNCP) is a growing issue. Synthesis of evidence about the barriers and enablers to reducing long-term opioid prescribing and use will enable the development of tailored interventions to address both problems. OBJECTIVE To synthesise the barriers and enablers to monitoring the ongoing appropriateness of opioid treatment and deprescribing opioids for CNCP from the clinician, patient and general public point of view, and to map the findings to the Theoretical Domains Framework (TDF). METHODS AND ANALYSIS We will perform a qualitative evidence synthesis using the TDF. We will include qualitative research that has explored clinician, patient and the general public's perceptions regarding barriers and enablers to monitoring and deprescribing opioids for CNCP. Studies will be identified via searches in MEDLINE, EMBASE, CINAHL, AMED and PsycINFO. Databases will be searched from inception to July 2019, and the studies must be published in English. Article selection and data extraction will be completed independently by two review authors. Methodological quality of included studies will be independently assessed by two review authors using the Critical Appraisal Skills Programme quality assessment tool. We will conduct thematic synthesis and then map identified themes and sub-themes to TDF domains. Confidence in synthesis findings will be evaluated using the Grading of Recommendations Assessment, Development, and Evaluation Confidence in the Evidence from Reviews of Qualitative Research tool. ETHICS AND DISSEMINATION Ethical approval is not required to conduct this review. We will publish the results in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42019140784.
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Affiliation(s)
- Amanda J Cross
- Monash Department of Clinical Epidemiology, Cabrini Institute, Malvern, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University Faculty of Medicine Nursing and Health Sciences, Melbourne, Victoria, Australia
| | - Rachelle Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Institute, Malvern, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University Faculty of Medicine Nursing and Health Sciences, Melbourne, Victoria, Australia
| | - Allison Bourne
- Monash Department of Clinical Epidemiology, Cabrini Institute, Malvern, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University Faculty of Medicine Nursing and Health Sciences, Melbourne, Victoria, Australia
| | - Christopher Maher
- Institute for Musculoskeletal Health, Sydney, New South Wales, Australia
- Sydney School of Public Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Stephanie Mathieson
- Institute for Musculoskeletal Health, Sydney, New South Wales, Australia
- Sydney School of Public Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Chung-Wei C Lin
- Institute for Musculoskeletal Health, Sydney, New South Wales, Australia
- Sydney School of Public Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Denise A O'Connor
- Monash Department of Clinical Epidemiology, Cabrini Institute, Malvern, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University Faculty of Medicine Nursing and Health Sciences, Melbourne, Victoria, Australia
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Stevens ML, Lin CWC, van der Ploeg HP, De Sousa M, Castle J, Nicholas MK, Maher CG. Feasibility, Validity, and Responsiveness of Self-Report and Objective Measures of Physical Activity in Patients With Chronic Pain. PM R 2019; 11:858-867. [PMID: 30609195 DOI: 10.1002/pmrj.12058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 11/22/2018] [Indexed: 11/08/2022]
Abstract
BACKGROUND Accurate tools for measuring physical activity are important for monitoring patients with chronic pain. However, these tools have not been properly validated in this population. OBJECTIVE To determine the suitability of two physical activity measures for use in chronic pain populations. DESIGN Longitudinal observational study. SETTING Pain Management and Research Centre. PARTICIPANTS Sixty-four patients presenting to the Pain Management and Research Centre with chronic pain. METHODS Participants underwent a 3-week pain management program that included cognitive behavioral strategies, education, and multiple exercises sessions per day. Physical activity was measured by the Active Australia Survey and the Actigraph GT3X at the start and end of the program. Feasibility of the physical activity measures was assessed. Criterion validity and responsiveness between the measures was compared. Correlation of physical activity with self-rated global rating of change (GROC) scales in health were calculated. MAIN OUTCOME MEASUREMENTS Minutes per day spent in low, moderate, and vigorous physical activity; global rating of change. RESULTS Fifty-two percent (n = 33) and 78% (n = 50) of participants had valid Actigraph and Active Australia data, respectively, for both time points. For criterion validity and responsiveness correlations varied (rho = -.12-.52). All correlations between physical activity measures and GROC were small or negligible (rho ≤ .18). CONCLUSION Feasibility of the Actigraph was poor compared to the Active Australia Survey. The criterion validity and responsiveness of the Active Australia Survey to the Actigraph was inconsistent and the relationship of both these measures to clinical outcomes was poor. However, limitations due to missing data mean that further research is required. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Matthew L Stevens
- Musculoskeletal Health Sydney, School of Public Health, University of Sydney, Sydney, Australia
| | - Chung-Wei C Lin
- Musculoskeletal Health Sydney, School of Public Health, University of Sydney, Sydney, Australia
| | - Hidde P van der Ploeg
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.,Sydney School of Public Health, University of Sydney, Sydney, Australia
| | - Maria De Sousa
- Pain Management Research Institute, University of Sydney at the Royal North Shore Hospital, Sydney, Australia
| | - Jessica Castle
- Pain Management Research Institute, University of Sydney at the Royal North Shore Hospital, Sydney, Australia
| | - Michael K Nicholas
- Pain Management Research Institute, University of Sydney at the Royal North Shore Hospital, Sydney, Australia
| | - Chris G Maher
- Musculoskeletal Health Sydney, School of Public Health, University of Sydney, Sydney, Australia
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Stevens ML, Lin CWC, Hancock MJ, Wisby-Roth T, Latimer J, Maher CG. A physiotherapist-led exercise and education program for preventing recurrence of low back pain: a randomised controlled pilot trial. Physiotherapy 2018; 104:217-223. [PMID: 29352578 DOI: 10.1016/j.physio.2017.08.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 08/21/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Before beginning a large and complex trial it is considered good practice to run a pilot study to assess the feasibility and acceptability so that quality is maintained and resources are not wasted. OBJECTIVE To assesses the feasibility and acceptability of procedures for TOPS: Trial Of Prevention Strategies for low back pain. DESIGN Randomised controlled pilot trial. METHODS This is a trial of an 8 week, physiotherapist-led group exercise and education program for preventing recurrence of low back pain (LBP) in those recently recovered from LBP. We assessed the feasibility of recruitment and data-collection procedures, acceptability of the trial interventions and loss-to-follow up. RESULTS The feasibility of recruitment, acceptability of the intervention and feasibility of physical activity data-collection procedures were all below anticipated levels. We enrolled 12 participants over 44 weeks, the adherence rate for the intervention group was 63% and valid physical activity data were obtained for 67% of the measurements. Follow-up methods for collection of LBP recurrence were successful with this information able to be collected for 100% of participants. CONCLUSION In response to the pilot, modifications were made to the main trial protocol. We will increase recruitment by relaxing inclusion criteria and expanding recruitment sites to include workplaces, community centres and via social media. We will facilitate compliance by expanding treatment sites to provide more options for participants to access the program and we will limit missing data by checking the validity of baseline physical activity measures prior to enrolment. TRIAL REGISTRATION The study was prospectively registered with the Australian and New Zealand Clinical Trials Registry (ref: ACTRN12614000706673).
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Affiliation(s)
- Matthew L Stevens
- Musculoskeletal Health Sydney, School of Public Health, The University of Sydney, Sydney, Australia.
| | - Chung-Wei C Lin
- Musculoskeletal Health Sydney, School of Public Health, The University of Sydney, Sydney, Australia
| | - Mark J Hancock
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | | | - Jane Latimer
- Musculoskeletal Health Sydney, School of Public Health, The University of Sydney, Sydney, Australia
| | - Chris G Maher
- Musculoskeletal Health Sydney, School of Public Health, The University of Sydney, Sydney, Australia
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Stevens ML, Lin CWC, de Carvalho FA, Phan K, Koes B, Maher CG. Advice for acute low back pain: a comparison of what research supports and what guidelines recommend. Spine J 2017; 17:1537-1546. [PMID: 28713052 DOI: 10.1016/j.spinee.2017.05.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 05/02/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND Advice is widely considered an effective treatment for acute low back pain (LBP); however, details on what and how to deliver this intervention is less clear. PURPOSE We assessed and compared clinical trials that test advice for acute LBP with practice guidelines for their completeness of reporting and concordance on the content, method of delivery, and treatment regimen of advice interventions. DESIGN/SETTING Systematic review. METHODS Advice randomized controlled trials were identified through a systematic search. Guidelines were taken from recent overviews of guidelines for LBP. Completeness of reporting was assessed using the Template for Intervention Description and Replication checklist. Thematic analysis was used to characterize advice interventions into topics across the aspects of content, method of delivery, and regimen. Concordance between clinical trials and guidelines was assessed by comparing the number of trials that found a statistically significant treatment effect for an intervention that included a specific advice topic with the number of guidelines recommending that topic. RESULTS The median (interquartile range) completeness of reporting for clinical trials and guidelines was 8 (7-9) and 3 (2-4) out of nine items on the Template for Intervention Description and Replication checklist, respectively. Guideline recommendations were discordant with clinical trials for 50% of the advice topics identified. CONCLUSION Completeness of reporting was less than ideal for randomized controlled trials and extremely poor for guidelines. The recommendations made in guidelines of advice for acute LBP were often not concordant with the results of clinical trials. Taken together, these findings mean that the potential clinical value of advice interventions for patients with acute LBP is probably not being realized.
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Affiliation(s)
- Matthew L Stevens
- Musculoskeletal Health Sydney, School of Public Health, University of Sydney, Sydney, NSW, Australia.
| | - Chung-Wei C Lin
- Musculoskeletal Health Sydney, School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Flavia A de Carvalho
- Department of Physiotherapy, University of Sao Paulo State, R. Roberto Símonsen, 305 - Centro Educacional, Presidente Prudente, SP 19060-900, Brazil
| | - Kevin Phan
- Westmead Clinical School, Sydney Medical School, University of Sydney, Hospital, Darcy Rd, Westmead, NSW 2145, Australia
| | - Bart Koes
- Department of General Practice, Erasmus MC, Postbus 2040, 3000 CA Rotterdam, The Netherlands
| | - Chris G Maher
- Musculoskeletal Health Sydney, School of Public Health, University of Sydney, Sydney, NSW, Australia
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Stevens ML, Moseley AM, Elkins MR, Lin CWC, Maher CG. Evidence-based physiotherapy and the use of PEDro: Re: Condon C, McGrane N, Mockler D, et al. Ability of physiotherapists to undertake evidence-based practice steps: a scoping review. Physiotherapy 2016; 103:337-338. [PMID: 27919408 DOI: 10.1016/j.physio.2016.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 07/22/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Matthew L Stevens
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Australia.
| | - Anne M Moseley
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Australia
| | - Mark R Elkins
- Central Clinical School, Sydney Medical School, University of Sydney, Australia
| | - Chung-Wei C Lin
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Australia
| | - Chris G Maher
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Australia
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Stevens ML, Lin CWC, Hancock MJ, Latimer J, Buchbinder R, Grotle M, van Tulder M, New CH, Wisby-Roth T, Maher CG. TOPS: Trial Of Prevention Strategies for low back pain in patients recently recovered from low back pain-study rationale and protocol. BMJ Open 2016; 6:e011492. [PMID: 27217287 PMCID: PMC4885430 DOI: 10.1136/bmjopen-2016-011492] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 03/31/2016] [Accepted: 04/19/2016] [Indexed: 01/16/2023] Open
Abstract
INTRODUCTION Low back pain (LBP) is the health condition that carries the greatest disability burden worldwide; however, there is only modest support for interventions to prevent LBP. The aim of this trial is to establish the effectiveness and cost-effectiveness of group-based exercise and educational classes compared with a minimal intervention control in preventing recurrence of LBP in people who have recently recovered from an episode of LBP. METHODS AND ANALYSIS TOPS will be a pragmatic comparative effectiveness randomised clinical trial with a parallel economic evaluation combining three separate cohorts (TOPS Workers, TOPS Primary Care, TOPS Defence) with the same methodology. 1482 participants who have recently recovered from LBP will be randomised to either a comprehensive exercise and education programme or a minimal intervention control. Participants will be followed up for a minimum of 1 year. The primary outcome will be days till recurrence of LBP. Effectiveness will be assessed using survival analysis. Cost-effectiveness will be assessed from the societal perspective. ETHICS AND DISSEMINATION This trial has been approved by the University of Sydney Human Research Ethics Committee (HREC) (ref: 2015/728) and prospectively registered with the Australian and New Zealand Clinical Trials Registry (ref: 12615000939594). We will also obtain ethics approval from the Australian Defence Force HREC. The results of this study will be submitted for publication in a prominent journal and widely publicised in the general media. TRIAL REGISTRATION NUMBER Australian and New Zealand Clinical Trial Registry (ANZCTR) 12615000939594.
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Affiliation(s)
- Matthew L Stevens
- Musculoskeletal Division, The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Chung-Wei C Lin
- Musculoskeletal Division, The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Mark J Hancock
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Jane Latimer
- Musculoskeletal Division, The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Rachelle Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne, Victoria, Australia
| | - Margreth Grotle
- Oslo and Akershus University College of Applied Sciences, Oslo/FORMI, Oslo University Hospital Norway, Oslo, Norway
| | - Maurits van Tulder
- Department of Health Sciences, Faculty of Earth & Life Sciences, VU University, Amsterdam, The Netherlands
| | - Charles H New
- Nepean Clinical School, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | | | - Chris G Maher
- Musculoskeletal Division, The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
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Williams CM, Hancock MJ, Maher CG, McAuley JH, Lin CWC, Latimer J. Predicting rapid recovery from acute low back pain based on the intensity, duration and history of pain: a validation study. Eur J Pain 2014; 18:1182-9. [PMID: 24648103 DOI: 10.1002/j.1532-2149.2014.00467.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND Clinical prediction rules can assist clinicians to identify patients with low back pain (LBP) who are likely to recover quickly with minimal treatment; however, there is a paucity of validated instruments to assist with this task. METHOD We performed a pre-planned external validation study to assess the generalizability of a simple 3-item clinical prediction rule developed to estimate the probability of recovery from acute LBP at certain time points. The accuracy of the rule (calibration and discrimination) was determined in a sample of 956 participants enrolled in a randomized controlled trial. RESULTS The calibration of the rule was reasonable in the new sample with predictions of recovery typically within 5-10% of observed recovery. Discriminative performance of the rule was poor to moderate and similar to that found in the development sample. CONCLUSIONS The results suggest that the rule can be used to provide accurate information about expected recovery from acute LBP, within the first few weeks of patients presenting to primary care. Impact analysis to determine if the rule influences clinical behaviours and patient outcomes is required.
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Affiliation(s)
- C M Williams
- The George Institute for Global Health, University of Sydney, NSW, Australia; Hunter Medical Research Institute and School of Medicine and Public Health, University of Newcastle, NSW, Australia
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Verwoerd AJH, Luijsterburg PAJ, Lin CWC, Jacobs WCH, Koes BW, Verhagen AP. Systematic review of prognostic factors predicting outcome in non-surgically treated patients with sciatica. Eur J Pain 2013; 17:1126-37. [PMID: 23494852 DOI: 10.1002/j.1532-2149.2013.00301.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2013] [Indexed: 11/09/2022]
Abstract
Identification of prognostic factors for surgery in patients with sciatica is important to be able to predict surgery in an early stage. Identification of prognostic factors predicting persistent pain, disability and recovery are important for better understanding of the clinical course, to inform patient and physician and support decision making. Consequently, we aimed to systematically review prognostic factors predicting outcome in non-surgically treated patients with sciatica. A search of Medline, Embase, Web of Science and Cinahl, up to March 2012 was performed for prospective cohort studies on prognostic factors for non-surgically treated sciatica. Two reviewers independently selected studies for inclusion and assessed the risk of bias. Outcomes were pain, disability, recovery and surgery. A best evidence synthesis was carried out in order to assess and summarize the data. The initial search yielded 4392 articles of which 23 articles reporting on 14 original cohorts met the inclusion criteria. High clinical, methodological and statistical heterogeneity among studies was found. Reported evidence regarding prognostic factors predicting the outcome in sciatica is limited. The majority of factors that have been evaluated, e.g., age, body mass index, smoking and sensory disturbance, showed no association with outcome. The only positive association with strong evidence was found for leg pain intensity at baseline as prognostic factor for subsequent surgery.
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Affiliation(s)
- A J H Verwoerd
- Department of General Practice, Erasmus MC University Medical Center Rotterdam, The Netherlands.
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Driessen MT, Lin CWC, van Tulder MW. Cost-effectiveness of conservative treatments for neck pain: a systematic review on economic evaluations. Eur Spine J 2012; 21:1441-50. [PMID: 22447407 PMCID: PMC3535241 DOI: 10.1007/s00586-012-2272-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Revised: 01/09/2012] [Accepted: 03/10/2012] [Indexed: 11/30/2022]
Abstract
Purpose Various conservative interventions have been used for the treatment of non-specific neck pain. The aim of this systematic review was to investigate the cost-effectiveness of conservative treatments for non-specific neck pain. Methods Clinical and economic electronic databases, reference lists and authors’ databases were searched up to 13 January 2011. Two reviewers independently selected studies for inclusion, performed the risk of bias assessment and data extraction. Results A total of five economic evaluations met the inclusion criteria. All studies were conducted alongside randomised controlled trials and included a cost-utility analysis, and four studies also conducted a cost-effectiveness analysis. Most often, the economic evaluation was conducted from a societal or a health-care perspective. One study found that manual therapy was dominant over physiotherapy and general practitioner care, whilst behavioural graded activity was not cost-effective compared to manual therapy. The combination of advice and exercise with manual therapy was not cost-effective compared to advice and exercise only. One study found that acupuncture was cost-effective compared to a delayed acupuncture intervention, and another study found no differences on cost-effectiveness between a brief physiotherapy intervention compared to usual physiotherapy. Pooling of the data was not possible as heterogeneity existed between the studies on participants, interventions, controls, outcomes, follow-up duration and context related socio-political differences. Conclusion At present, the limited number of studies and the heterogeneity between studies warrant no definite conclusions on the cost-effectiveness of conservative treatments for non-specific neck pain.
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Affiliation(s)
- Maurice T Driessen
- Department of Health Sciences, The EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands.
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Lin CWC, Moseley AM, Refshauge KM. Effects of rehabilitation after ankle fracture: a Cochrane systematic review. Eur J Phys Rehabil Med 2009; 45:431-441. [PMID: 19078904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND Ankle fracture is one of the most common lower limb fractures. People experience limitations in activities after ankle fracture. OBJECTIVES The aim of this review was to evaluate the effects of rehabilitation interventions after ankle fracture in adults. METHODS Electronic databases, reference lists of included studies and relevant systematic reviews, and clinical trials registers were searched for randomised and quasi-randomised controlled trials with adults undergoing any interventions for rehabilitation after ankle fracture. The primary outcomes were activity limitation and adverse events. Two reviewers independently screened search results, assessed methodological quality, and extracted data. RESULTS Thirty-one studies were included. Clinical and statistical heterogeneity, or the low number of studies in the comparison, prevented meta-analyses in most instances. After surgical fixation, commencing exercise in a removable brace or splint significantly improved activity limitation but also led to a higher rate of adverse events (relative risk 2.61, 95% CI 1.72 to 3.97). Most other rehabilitation interventions did not show an effect in improving activity limitation. CONCLUSIONS There is limited evidence supporting the use of a removable type of immobilisation and exercise during the immobilisation period for improving activity limitation. Because of the potential increased risk, the patient's ability to comply with this treatment regimen is essential. More clinical trials that are well-designed and adequately-powered are required to strengthen current evidence.
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Affiliation(s)
- C W C Lin
- George Institute for International Health, University of Sydney, NSW, Australia.
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