Co-development and testing of an extended community pharmacy model of service delivery for managing osteoarthritis: protocol for a sequential, multi-methods study (PharmOA)

BACKGROUND

Osteoarthritis is a common, painful and disabling long-term condition. Delivery of high-quality guideline-informed osteoarthritis care that successfully promotes and maintains supported self-management is imperative. However, osteoarthritis care remains inconsistent, including under use of core non-pharmacological approaches of education, exercise and weight loss. Community pharmacies are an accessible healthcare provider. United Kingdom government initiatives are promoting their involvement in a range of long-term conditions, including musculoskeletal conditions. It is not known what an enhanced community pharmacy role for osteoarthritis care should include, what support is needed to deliver such a role, and whether it would be feasible and acceptable to community pharmacy teams. In this (PharmOA) study, we aim to address these gaps, and co-design and test an evidence-based extended community pharmacy model of service delivery for managing osteoarthritis.

METHODS

Informed by the Theoretical Domains Framework, Normalisation Process Theory, and the Medical Research Council (MRC) framework for developing complex interventions, we will undertake a multi-methods study involving five phases: 1. Systematic review to summarise currently available evidence on community pharmacy roles in supporting adults with osteoarthritis and other chronic (non-cancer) pain. 2. Cross-sectional surveys and one-to-one qualitative interviews with patients, healthcare professionals and pharmacy staff to explore experiences of current, and potential extended community pharmacy roles, in delivering osteoarthritis care. 3. Stakeholder co-design to: a) agree on the extended role of community pharmacies in osteoarthritis care; b) develop a model of osteoarthritis care within which the extended roles could be delivered (PharmOA model of service delivery); and c) refine existing tools to support community pharmacies to deliver extended osteoarthritis care roles (PharmOA tools). 4. Feasibility study to explore the acceptability and feasibility of the PharmOA model of service delivery and PharmOA tools to community pharmacy teams. 5. Final stakeholder workshop to: a) finalise the PharmOA model of service delivery and PharmOA tools, and b) if applicable, prioritise recommendations for its wider future implementation.

DISCUSSION

This novel study paves the way to improving access to and availability of high-quality guideline-informed, consistent care for people with osteoarthritis from within community pharmacies.

Supported self-management for all with musculoskeletal pain: an inclusive approach to intervention development: the EASIER study

BACKGROUND

Supported self-management interventions for patients with musculoskeletal (MSK) conditions may not adequately support those with limited health literacy, leading to inequalities in care and variable outcomes. The aim of this study was to develop a model for inclusive supported self-management intervention(s) for MSK pain that take account of health literacy.

METHODS

A mixed methods study with four work-packages was conducted: work package 1: secondary analysis of existing data to identify potential targets for intervention; work package 2: evidence synthesis to assess effective components of self-management interventions taking into account health literacy; work package 3: views of community members and healthcare professionals (HCPs) on essential components; work package 4: triangulation of findings and an online modified Delphi approach to reach consensus on key components of a logic model.

FINDINGS

Findings identified targets for intervention as self-efficacy, illness perceptions, and pain catastrophizing. A range of intervention components were identified (e.g. information in diverse formats offered at specific times, action planning and visual demonstrations of exercise). Support should be multi-professional using a combination of delivery modes (e.g. remote, face-to-face).

CONCLUSIONS

This research has developed a patient-centred model for a multi-disciplinary, multi-modal approach to supported self-management for patients with MSK pain and varying levels of health literacy. The model is evidence-based and acceptable to both patients and HCPs, with potential for significant impact on the management of MSK pain and for improving patient health outcomes. Further work is needed to establish its efficacy.

The functions of self-harm in young people and their perspectives about future general practitioner-led care: A qualitative study

BACKGROUND

Self-harm in young people is a serious concern but a deeper understanding of the functions of self-harm in young people can tailor care and inform new clinical interventions to reduce repeat self-harm and suicide risk. General practitioners (GPs), as frontline healthcare professionals, have an important role in managing self-harm in young people. This study aimed to explore the functions of self-harm in young people and their perspectives on future GP-led care.

METHODS

A qualitative study using interviews with young people aged between 16 and 25 years with a personal history of self-harm was conducted. Interviews were transcribed and analysed using reflexive thematic analysis.

FINDINGS

Four distinct functions were identified: (1) handling emotional states; (2) self-punishment; (3) coping with mental illness and trauma; and (4) positive thoughts and protection. Young people valued GP-led support and felt future GP interventions should include self-help and be personalised.

CONCLUSIONS

These findings support clinicians, including GPs, to explore the functions of self-harm in young people aged 16-25 in a personalised approach to self-harm care. It should be noted that self-harm may serve more than one function for a young person and thus interventions should recognise this.

PATIENT AND PUBLIC CONTRIBUTION

A group consisting of young people with lived experience of self-harm, carers, the public, and those who work with young people who harm themselves conceived this study idea, informed recruitment methods and the interview topic guide, and supported the interpretation of findings.

Prognostic factors for persistent pain after a distal radius fracture: a systematic review

Introduction

The aim of this systematic review was to synthesize the evidence regarding prognostic factors for persistent pain, including Complex Regional Pain Syndrome (CRPS), after a distal radius fracture (DRF), a common condition after which persistent pain can develop.

Methods

Medline, Pubmed, Embase, Psychinfo, CINAHL, BNI, AMED and the Cochrane Register of Clinical Trials were searched from inception to May 2021 for prospective longitudinal prognostic factor studies investigating persistent pain in adults who had sustained a DRF. The Quality in Prognostic Studies (QUIPS) tool and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework were used to assess the strength of evidence.

Results

A search yielded 440 studies of which 7 studies met full eligibility criteria. From five studies we found low evidence for high baseline pain or an ulnar styloid fracture as prognostic factors for persistent pain, and very low evidence for diabetes or older age. From two studies, investigating an outcome of CRPS, there was low evidence for high baseline pain, slow reaction time, dysynchiria, swelling and catastrophising as prognostic factors, and very low evidence for depression. Sex was found not to be a prognostic factor for CRPS or persistent pain.

Conclusions

The associations between prognostic factors and persistent pain following a DRF are unclear. The small number of factors investigated in more than one study, along with poor reporting and methodological limitations contributed to an assessment of low to very low strength of evidence. Further prospective studies, investigating psychosocial factors as candidate predictors of multidimensional pain outcomes are recommended.

Patient and public involvement in implementation of evidence-based guidance for musculoskeletal conditions: a scoping review of current advances and gaps

Advances in musculoskeletal (MSK) research have been successfully curated into widely endorsed evidence-based recommendations and guidelines. However, there continues to exist significant variations in care and quality of care, and the global health and socio-economic burdens associated with MSK conditions continues to increase. Limited accessibility, and applicability of guideline recommendations have been suggested as contributory factors to less than adequate guideline implementation. Since patient and public involvement (PPI) is being credited with increasing relevance, dissemination and uptake of MSK research, the success of guidelines implementation strategies may also be maximised through increasing opportunities for PPI input. We therefore conducted a scoping review of literature to explore PPI in implementation of evidence-based guidance for MSK conditions. A comprehensive search was used to identify relevant literature in three databases (Medline, Embase, Cinahl) and two large repositories (WHO, G-IN), supplemented by grey literature search. Eligibility was determined with criteria established a priori and narrative synthesis was used to summarise PPI activities, contexts, and impact on implementation of MSK related evidence-based guidance across ten eligible studies (one from a low-and middle-income country LMIC). A prevalence of low-level PPI (mainly consultative activities) was found in the current literature and may partly account for current experiences of significant variations and quality of care for MSK patients. The success of PPI in MSK research may be lessened by the oversight of PPI in implementation. This has implications for both high- and low-resource healthcare systems, especially in LMICs where evidence is limited. Patient and public partnership for mobilising knowledge, maximising guideline uptake, and bridging the research-practice gap particularly in low resource settings remain important and should extend beyond PPI in research and guideline dissemination activities only. This review is a clarion call to stakeholders, and all involved, to transform PPI in MSK research into real world benefits through implementation approaches underpinned by patient and public partnerships. We anticipate that this will enhance and drive quality improvements in MSK care with patients and for patients across health and care settings.

Overall Effects and Moderators of Rehabilitation in Patients With Wrist Fracture: A Systematic Review

OBJECTIVE

Wrist fractures constitute the most frequently occurring upper limb fracture. Many individuals report persistent pain and functional limitations up to 18 months following wrist fracture. Identifying which individuals are likely to gain the greatest benefit from rehabilitative treatment is an important research priority. This systematic review aimed to summarize effectiveness of rehabilitation after wrist fracture for pain and functional outcomes and identify potential effect moderators of rehabilitation.

METHODS

A comprehensive search of 7 databases (including MEDLINE, EMBASE, and the Physiotherapy Evidence Database) was performed for randomized controlled trials involving adults >50 years of age who sustained wrist fracture and had received 1 or more conservative treatments (eg, exercise/manual therapy, lifestyle, diet, or other advice). Study selection, data extraction, and risk-of-bias assessment were conducted independently by 2 reviewers. Results of included trials were summarized in a narrative synthesis.

RESULTS

A total of 3225 titles were screened, and 21 studies satisfying all eligibility criteria were reviewed. Over one-half of the included studies (n = 12) comprised physical therapist and/or occupational therapist interventions. Rehabilitative exercise/manual therapy was generally found to improve function and reduce pain up to 1 year after wrist fracture. However, effects were small, and home exercises were found to be comparable with physical therapist-led exercise therapy. Evidence for the effects of other nonexercised therapy (including electrotherapy, whirlpool) was equivocal and limited to the short term (<3 months). Only 2 studies explored potential moderators, and they did not show evidence of moderation by age, sex, or patient attitude of the effects of rehabilitation.

CONCLUSION

Effectiveness of current rehabilitation protocols after wrist fracture is limited, and evidence for effect moderators is lacking. Currently available trials are not large enough to produce data on subgroup effects with sufficient precision. To aid clinical practice and optimize effects of rehabilitation after wrist fracture, potential moderators need to be investigated in large trials or meta-analyses using individual participant data.

IMPACT

Many patients report persistent pain and functional limitations up to 18 months following wrist fracture. Effectiveness of current rehabilitation protocols after wrist fracture is limited and may be due to insufficient targeting of specific rehabilitation to individuals who are likely to benefit most. However, evidence for effect moderators is lacking within the currently available literature. To aid clinical practice and optimize effects of rehabilitation, investigating potential moderators of rehabilitation in individuals with wrist fracture via large trials or meta-analysis of individual participant data is research and policy imperative.

Burnout among primary health-care professionals in low- and middle-income countries: systematic review and meta-analysis

Objective

To estimate the prevalence of burnout among primary health-care professionals in low- and middle-income countries and to identify factors associated with burnout.

Methods

We systematically searched nine databases up to February 2022 to identify studies investigating burnout in primary health-care professionals in low- and middle-income countries. There were no language limitations and we included observational studies. Two independent reviewers completed screening, study selection, data extraction and quality appraisal. Random-effects meta-analysis was used to estimate overall burnout prevalence as assessed using the Maslach Burnout Inventory subscales of emotional exhaustion, depersonalization and personal accomplishment. We narratively report factors associated with burnout.

Findings

The search returned 1568 articles. After selection, 60 studies from 20 countries were included in the narrative review and 31 were included in the meta-analysis. Three studies collected data during the coronavirus disease 2019 pandemic but provided limited evidence on the impact of the disease on burnout. The overall single-point prevalence of burnout ranged from 2.5% to 87.9% (43 studies). In the meta-analysis (31 studies), the pooled prevalence of a high level of emotional exhaustion was 28.1% (95% confidence interval, CI: 21.5–33.5), a high level of depersonalization was 16.4% (95% CI: 10.1–22.9) and a high level of reduced personal accomplishment was 31.9% (95% CI: 21.7–39.1).

Conclusion

The substantial prevalence of burnout among primary health-care professionals in low- and middle-income countries has implications for patient safety, care quality and workforce planning. Further cross-sectional studies are needed to help identify evidence-based solutions, particularly in Africa and South-East Asia.

P119 The Alliance - a framework for conceptualising patient and public involvement in rheumatic and musculoskeletal guidelines implementation

Background/Aims

Over the last two decades, patient and public involvement (PPI) have improved the relevance, appropriateness, quality, and acceptability of rheumatic and musculoskeletal (MSK) research. This has in turn been successfully curated into widely endorsed evidence-based recommendations and guidelines. However, uptake and applicability of guideline recommendations is less than optimal, significant variation exist in care, and health and socio-economic burdens attributed to MSK continues to rise, suggesting an implementation challenge. We conducted a rapid review to investigate the role of PPI in rheumatic/MSK guideline implementation.

Methods

A comprehensive search was used to identify relevant literature in three databases (Medline, Embase, Cinahl) and two large repositories (WHO, G-IN). A priori eligibility criteria and systematic review-based methods were used to identify primary studies with explicit reference to PPI involvement in a rheumatic/MSK guideline implementation activity. Extracted data from included studies was interrogated by authors for details regarding activities, contexts, outcomes, and impact of PPI in implementation of MSK guidelines and further discussed in review project meetings. Findings were brought together in a narrative synthesis. Recommendations for future research and practice, and a conceptual framework for PPI in rheumatic and musculoskeletal guidelines implementation were co-developed with research team including a public contributor.

Results

Ten papers were included, only one from the global south. A prevalence of consultative PPI activities in rheumatic/MSK guideline dissemination (e.g., language translations, patient versions of guidelines) was found. Few studies explicitly report high-level PPI engagement in relation to care pathway adjustments, care commissioning, institutional operations and policy with a view to MSK guideline implementations. Training, development, and practice of PPI in MSK guideline implementation were not evidenced to have spread much beyond Europe, though it is acknowledged that these activities may be occurring at low levels but are not yet well reported in literature nor rightly accrued as PPI activities in guideline implementation. The Alliance framework highlighting an iterative process of “creative thinking/co-production” and “strategic doing” was developed to address the challenge of PPI in MSK guideline implementation. The framework guides knowledge translation from guidelines to ensure real world benefits and drive quality improvement for MSK care with patients and for patients, across and within care settings in the global North and South.

Conclusion

Despite success of PPI in rheumatic/MSK research, oversight or ineffective PPI in guideline implementation may hamper translation of novel advances in MSK care into real world practice and therefore patient benefit. The Alliance framework prioritises effective PPI in MSK guideline implementation design, delivery, and evaluation, ideally applied in parallel with the development of evidence-based guidance recommendations. It highlights continuous application of innovative thinking, dynamic, and impactful collaborations for bridging the evidence-practice gap and improving quality of care for MSK patients globally through novel partnerships.

Disclosure

O.O. Babatunde: None. S. Dawson: None. J. Brammar: None. K. Dziedzic: None. A.O. Adebajo: None.

Long-term clinical and socio-economic outcomes following wrist fracture: a systematic review and meta-analysis

A comprehensive review of studies shows that patients with wrist fracture, aged over 50 years, experience pain and functional limitation long after fracture. This is associated with increased healthcare costs, and reduced quality of life. Understanding factors that predict poor outcomes is important for future healthcare policy and planning.

PURPOSE

To summarise and appraise evidence on the prognosis and long-term clinical and socio-economic outcomes following wrist fracture among adults aged 50 years and over.

METHODS

Five databases (MEDLINE, EMBASE, AMED, CINAHL-P and PsycINFO) were comprehensively searched (supplemented by a grey-literature search) from inception till June 2021 for prospective/retrospective cohort studies of patients (≥ 50 years) with a history of wrist fracture and reporting long-term (≥ 6 months) outcomes. Peer study selection, data extraction and risk of bias assessment were conducted. A random effects meta-analysis was used to summarise estimates of pain and function outcomes.

RESULTS

78 studies (n = 688,041 patients) were included. Patients report persistent moderate to severe pain (range: 7.5%-62%) and functional limitations (range: 5.5-78%) up to 12-months or later after wrist fracture. Mean Patient-Rated Wrist Evaluation (PRWE) score for pain and function (9 studies, n = 1759 patients) was 15.23 (95%CI 12.77, 17.69) at 6-months to 13-years follow-up. Mean disabilities of the arm, shoulder and hand (DASH) score (9 studies, n = 1346 patients) was 13.82 (95%CI 12.71, 14.93)( at 6- to 17-months follow-up. A 10-20% increase in healthcare encounters in the first 12-months after fracture was observed. Twelve prognostic factors were associated with poor long-term outcomes.

CONCLUSION

Evidence shows that a high proportion of people aged over 50 years with wrist fracture experience pain and functional limitation > 6 months after fracture. This is associated with increased healthcare costs, and reduced quality of life. Exploratory evidence was found for several candidate prognostic factors. Their predictive performance needs to be investigated further.

PROSPERO

CRD42018116478.

Evaluation of the responses of broiler chickens to varying concentrations of phytate phosphorus and phytase. Ⅱ. Grower phase (day 12-23 post hatching)

A randomized complete block design study used 768 male broiler chickens to investigate the effects of phytate P (PP) and a novel consensus bacterial phytase variant (PhyG) concentration on growth performance, bone mineralization, apparent ileal digestibility (AID), and total tract retention (TTR) of nutrients in broiler chickens. Treatments were arranged in a 1 + 3 × 5 factorial with a nutrient-adequate positive control diet (PC) with 2.8 g PP/kg, 3 nutrient-reduced negative control diets (NC: PC minus 88 kcal/kg ME, 0.8 g/kg dig. Lys, 2.0 g/kg available P, 2.0 g/kg Ca and 0.5 g/kg Na) with varying PP (g/kg) levels, mainly from rice bran, at 2.3 (NC1), 2.8 (NC2), or 3.3 (NC3) and 5 PhyG doses at 0, 500, 1,000, 2,000, or 4,000 FTU/kg. All treatments had 6 replicate cages with 8 birds/cage. A commercial starter diet was fed from d 0 to 12 and the experimental diets from d 12 to 23 post hatching. Birds fed the NC2 diet without phytase had lower (P < 0.01) BW, BW gain, and feed intake (FI) as compared with birds fed the PC with the same PP level. With increasing phytate, there was a decrease (P < 0.05) in BW, BW gain, and FI. Phytase increased (P < 0.01) BW and feed efficiency of broiler chickens. An interaction (P < 0.05) between PP and phytase concentrations was observed on the AID of Met, Cys, and Thr. Linear decrease (P < 0.01) in the AID and TTR of P and Ca with increasing PP concentrations were observed. Phytase supplementation increased (P ≤ 0.05) the AID of P, Ca, and all AA. The TTR of P, Ca, and Zn was linearly increased (P < 0.01) by 112, 123, and 46%, respectively, when birds fed NC diets with 0 and 4,000 FTU/kg were compared. In conclusion, phytate reduced the growth performance and nutrient utilization of broiler chickens from d 12 to 23 post hatching while phytase ameliorated these negative effects.

Comparative effectiveness of treatment options for subacromial shoulder conditions: a systematic review and network meta-analysis

Background:

There are currently many treatment options for patients with subacromial shoulder conditions (SSCs). Clinical decision-making regarding the best treatment option is often difficult. This study aims to evaluate the comparative effectiveness of treatment options for relieving pain and improving function in patients with SSCs.

Methods:

Eight databases [including MEDLINE, Embase, CINAHL, AMED, PEDro, Cochrane Database of Systematic Reviews and World Health Organization (WHO) International Clinical Trials Registry] were searched from inception until April 2020. Randomised clinical/controlled trials of adult patients investigating the effects of nonsurgical (e.g. corticosteroid injections, therapeutic exercise, shockwave therapy) and surgical treatment for SSCs, compared with each other, placebo, usual care or no treatment, were retrieved. Pairs of reviewers screened studies independently, quality appraised eligible studies using the Cochrane risk of bias tool, extracted and checked data for accuracy. Primary outcomes were pain and disability in the short term (⩽3 months) and long term (⩾6 months). Direct and indirect evidence of treatment effectiveness was synthesised using random-effects network meta-analysis.

Results:

The review identified 177 eligible trials. Summary estimates (based on 99 trials providing suitable data, 6764 patients, 20 treatment options) showed small to moderate effects for several treatments, but no significant differences on pain or function between many active treatment comparisons. The primary analysis indicated that exercise and laser therapy may provide comparative benefit in terms of both pain and function at different follow-up time-points, with larger effects found for laser in the short term at 2–6 weeks, although direct evidence was provided by one trial only, and for exercise in the longer term [standardised mean difference (SMD) 0.39, 95% confidence interval (CI) 0.18, 0.59 at 3–6 months] compared with control. Sensitivity analyses excluding studies at increased risk of bias confirmed only the comparative effects of exercise as being robust for both pain and function up until 3-month follow-up.

Conclusion:

Current evidence shows small to moderate effect sizes for most treatment options for SSCs. Six treatments had a high probability of being most effective, in the short term, for pain and function [acupuncture, manual therapy, exercise, exercise plus manual therapy, laser therapy and Microcurrent (MENS) (TENS)], but with low certainty for most treatment options. After accounting for risk of bias, there is evidence of moderate certainty for the comparative effects of exercise on function in patients with SSCs. Future large, high-quality pragmatic randomised trials or meta-analyses are needed to better understand whether specific subgroups of patients respond better to some treatments than others.

Evaluation of the responses of broiler chickens to varying concentrations of phytate phosphorus and phytase. Ⅰ. Starter phase (day 1-11 post hatching)

Growth performance, tibia ash, apparent ileal digestibility (AID), and total tract retention (TTR) of nutrients responses of broiler chickens fed diets containing varying concentrations of phytate P (PP) and a novel consensus bacterial 6-phytase variant (PhyG) from d 1 to 11 post hatching were evaluated with 1,152 broiler chicks. Diets were a nutrient-adequate positive control diet (PC) with 2.8 g PP/kg or one of 15 nutrient-reduced negative control (NC: PC minus 88 kcal/kg ME, 0.8 g/kg dig. Lys, 2.0 g/kg available P, 1.8 g/kg Ca and 0.5 g/kg Na) diets with 3 PP (g/kg) levels, mainly from rice bran, at 2.3 (NC1), 2.8 (NC2), or 3.3 (NC3) and 5 PhyG supplementation at 0, 500, 1,000, 2,000, or 4,000 FTU/kg in a 1 + 3 × 5 factorial. All treatments had 6 replicate cages with 12 birds per cage. Despite comparable PP levels, birds fed the PC diet had greater (P ≤ 0.01) body weight (BW), feed intake (FI), tibia ash, AID of energy, AA, P, and Ca as compared with birds fed the NC2 without phytase. There was no interaction between PP and phytase for all responses. Increasing PP concentrations linearly decreased (P < 0.01) BW, FI, AID, and TTR of P and Ca. With phytase supplementation, there was a quadratic response (P < 0.05) in BW, FI, tibia ash, and a linear increase (P < 0.05) in the AID of energy, nitrogen, and all the measured AA. Increasing phytase dose from 0 to 4,000 FTU/kg increased (P < 0.01) AID of P and Ca by 88 and 18%, respectively. There was also a quadratic response (P ≤ 0.05) on TTR of P and Ca with increasing phytase dose. In conclusion, increasing levels of PP reduced growth performance and most nutrient utilization responses of broiler chickens while phytase supplementation positively impacted the responses of broiler chickens during d 1 to 11 post hatching.

Markers of dementia-related health in primary care electronic health records

OBJECTIVES

Identifying routinely recorded markers of poor health in patients with dementia may help treatment decisions and evaluation of earlier outcomes in research. Our objective was to determine whether a set of credible markers of dementia-related health could be identified from primary care electronic health records (EHR).

METHODS

The study consisted of (i) rapid review of potential measures of dementia-related health used in EHR studies; (ii) consensus exercise to assess feasibility of identifying these markers in UK primary care EHR; (iii) development of UK EHR code lists for markers; (iv) analysis of a regional primary care EHR database to determine further potential markers; (v) consensus exercise to finalise markers and pool into higher domains; (vi) determination of 12-month prevalence of domains in EHR of 2328 patients with dementia compared to matched patients without dementia.

RESULTS

Sixty-three markers were identified and mapped to 13 domains: Care; Home Pressures; Severe Neuropsychiatric; Neuropsychiatric; Cognitive Function; Daily Functioning; Safety; Comorbidity; Symptoms; Diet/Nutrition; Imaging; Increased Multimorbidity; Change in Dementia Drug. Comorbidity was the most prevalent recorded domain in dementia (69%). Home Pressures were the least prevalent domain (1%). Ten domains had a statistically significant higher prevalence in dementia patients, one (Comorbidity) was higher in non-dementia patients, and two (Home Pressures, Diet/Nutrition) showed no association with dementia.

CONCLUSIONS

EHR captures important markers of dementia-related health. Further research should assess if they indicate dementia progression. These markers could provide the basis for identifying individuals at risk of faster progression and outcome measures for use in research.

Prevalence of osteoarthritis in lower middle- and low-income countries: a systematic review and meta-analysis

Evidence from the Global Burden of Disease studies suggests that osteoarthritis (OA) is a significant cause of disability globally; however, it is less clear how much of this burden exists in low-income and lower middle-income countries. This study aims to determine the prevalence of OA in people living in low-income and lower middle-income countries. Four electronic databases (MEDLINE, EMBASE, CINAHL and Web of Science) were systematically searched from inception to October 2018 for population-based studies. We included studies reporting the prevalence of OA among people aged 15 years and over in low-income and lower middle-income countries. The prevalence estimates were pooled across studies using random effects meta-analysis. Our study was registered with PROSPERO, number CRD42018112870.The search identified 7414 articles, of which 356 articles were selected for full text assessment. 34 studies were eligible and included in the systematic review and meta-analysis. The pooled prevalence of OA was 16·05% (95% confidence interval (CI) 12·55-19·89), with studies demonstrating a substantial degree of heterogeneity (I2 = 99·50%). The pooled prevalence of OA was 16.4% (CI 11·60-21.78%) in South Asia, 15.7% (CI 5·31-30·25%) in East Asia and Pacific, and 14.2% (CI 7·95-21·89%) in Sub Saharan Africa. The meta-regression analysis showed that publication year, study sample size, risk of bias score and country-income categories were significantly associated with the variations in the prevalence estimates. The prevalence of OA is high in low-income and lower middle-income countries, with almost one in six of the study participants reported to have OA. With the changing population demographics and the shift to the emergence of non-communicable diseases, targeted public health strategies are urgently needed to address this growing epidemic in the aging population.

Shared decision making in musculoskeletal pain consultations in low- and middle-income countries: a systematic review

BACKGROUND

Global populations, especially those in low- and middle-income countries (LMICs), are at an increased risk of musculoskeletal (MSK) pain, a leading cause of years lived with disability. Shared decision making (SDM) in the management of these conditions may drive improvements in healthcare outcomes and quality. This study aimed to synthesize and appraise available evidence regarding SDM in MSK pain consultations in LMICs.

METHODS

Comprehensive literature searches were conducted in 12 databases for primary studies investigating SDM in MSK pain consultations across all healthcare and community settings in LMICs. Study eligibility screening, data extraction and quality appraisal (using the Critical Appraisals Skills Programme tool) were completed by pairs of reviewers. Findings were brought together using thematic synthesis of data from all the primary studies.

RESULTS

Seven studies (mostly moderate quality) were included. There was low awareness of SDM among healthcare professionals (HCPs); however, this is not explicitly practised due to cultural and operational barriers. HCP training and patient empowerment through health literacy were proposed facilitators. The traditional paternalistic approach to treatment poses a key barrier to SDM, decreases adherence to prescribed treatments and raises the risk of poor clinical outcomes.

CONCLUSIONS

SDM is still a relatively 'foreign concept' within consultations and management of MSK pain patients in LMICs. There is a dearth of research in SDM and patient-centred care. Given the socio-economic impact of MSK pain, further research into the value of SDM in LMIC healthcare settings requires further consideration.

Additivity of apparent and standardized ileal digestibility of phosphorus in mixed diets containing corn and soybean meal fed to broiler chickens

Phosphorus (P) is an integral part of diet formulation for broiler chickens as P is required for various biochemical processes essential to life. A study was designed to examine the additivity of apparent ileal digestibility (AID) and standardized ileal digestibility (SID) of P in mixed diets containing corn and soybean meal (SBM) with or without phytase supplementation. Birds were fed a commercial starter diet from day 0 to 21 after hatching and then allotted to 7 dietary treatments in a randomized complete block design with the BW as a blocking factor. Four semipurified diets were prepared to contain corn or SBM as the sole source of P with or without the addition of phytase at 1,000 phytase units/kg of diet. Two mixed diets were also prepared to contain corn and SBM with or without the addition of phytase at 1,000 phytase units/kg diet. A P-free diet (PFD) was formulated to determine the basal ileal endogenous loss of P. There were 16 replicate cages of the PFD and 8 replicate cages of the 6 experimental diets, with 8 birds per replicate cage for a total of 512 birds. Diets were fed for 3 d. The ileal digesta of birds were collected from the distal two-thirds of the ileum on day 24 after hatching. The SID of P in corn and SBM were 52.2 and 65.4%, respectively (SEM = 1.37). The addition of phytase improved (P < 0.05) both the AID and SID of P in the corn, SBM, and mixed diets. The determined AID or SID in the corn and SBM with or without phytase was used to predict the AID or SID in the mixed diets. There were no differences between the predicted and determined digestibility values in the mixed diets for either AID or SID of P and thus additive. Phytase supplementation of the mixed diet did not influence the additivity of AID or SID. In conclusion, the AID or SID of P in the corn and SBM was additive in the mixed diets containing corn and SBM with or without the addition of phytase.

Additivity of apparent and standardised ileal digestibility of phosphorus in corn and canola meal mixed diets; basal endogenous loss of phosphorus responses to phytase and age in broiler chickens

1. The additivity of apparent ileal digestibility (AID) and standardised ileal digestibility (SID) of phosphorus (P) in mixed diets containing corn and canola meal (CCM) with or without phytase supplementation and the impact of age on the basal ileal endogenous loss (BEL) of P were investigated in broiler chickens.2. Treatments were arranged as a 2 × 3 × 2 factorial with two ages (13 d or 21 d post hatching), three diets (corn, canola meal, or CCM), and two phytase levels (0 or 1,000 FYT/kg diet) in a randomised complete block design. There were eight or six birds per cage at 13 d and 21 d of age, respectively, and six replicate cages per treatment, with a total of 588 birds. A P-free diet (PFD) treatment was included at each age to determine the basal endogenous loss (BEL) of P.3. Birds were fed a commercial starter diet from d 1 to d 10 or d 18 and then fed the experimental diets for 3 d until d 13 or d 21, respectively. Predicted digestibility values calculated from the individual feed ingredients were used to test additivity in the mixed diets. Chromium oxide was included in diets as an indigestible marker.4. The ileal digesta, collected from birds at d 13 or d 21, was used to determine nutrient digestibility.5. The AID and SID of P at d 13 was higher (P < 0.01) when compared with older birds at d 21, regardless of dietary phytase supplementation. Regardless of age or phytase supplementation, AID and SID of P were additive, as there were no differences between predicted and determined values in the mixed diets. The BEL of P (g/kg DM intake) in birds at d 13 was higher (P < 0.05) than birds at d 21 (0.197 vs. 0.159).6. In conclusion, age had an impact on the BEL of P and the utilisation of minerals in the diets. The apparent and standardised ileal digestibility of P in the mixed diet containing corn and canola meal were additive, regardless of age or phytase supplementation.

A systematic review and evidence synthesis of non-medical triage, self-referral and direct access services for patients with musculoskeletal pain

Introduction

The demand for musculoskeletal (MSK) care is rising, and is a growing challenge for general practice. Direct access to physiotherapy and other healthcare services may offer appropriate care for MSK pain patients but there is uncertainty regarding the effectiveness or efficiency of this approach in practice. This study aimed to review the evidence regarding characteristics, outcomes, barriers and facilitators of MSK triage and direct access services.

Methods

A comprehensive search of eight databases (including MEDLINE, EMBASE, and Cochrane library) up to February 2018 was conducted to identify studies (trials, cohorts and qualitative evidence) on direct access services for MSK in primary care settings. Using predefined inclusion and exclusion criteria, titles, abstracts, and subsequent full texts were independently screened by reviewers. Methodological quality of eligible studies was assessed using the mixed methods appraisal tool, and extracted data regarding study characteristics and results were independently reviewed. A narrative synthesis and grading of evidence was undertaken. Approaches to MSK triage and direct access were profiled along with their respective outcomes of care relating to patient-oriented and socioeconomic outcomes. Barriers and facilitators of each model of direct access services were also highlighted.

Results

9010 unique citations were screened, of which 26 studies were eligible. Three approaches (open access, combination and service pathway models) to MSK triage and direct access shared similar goals but were heterogeneous in application. MSK patients using direct access showed largely similar characteristics (age, sex and duration of symptoms) compared to GP-led care, although they were often younger, slightly more educated and with better socio-economic status than patients seen through GP-led care. Although many studies showed limitations in design or methods, outcomes of care (patient oriented outcomes of pain, and disability) did not show large differences between direct access and GP-led care. In most studies direct access patients were reported to have lower healthcare utilisation (fewer physiotherapy or GP consultations, analgesics or muscle relaxants prescriptions, or imaging procedures) and less time off work compared to GP-led care.

Discussion

This study provides insight into the current state of evidence regarding MSK triage and direct access services and highlights potential implications for future research, healthcare services planning, resource utilisation and organising care for MSK patients in primary care. There is consistent, although limited, evidence to suggest that MSK triage and direct access services lead to comparable clinical outcomes with lower healthcare consumption, and can help to manage GP workload. However, due to the paucity of strong empirical data from methodologically robust studies, a scale up and widespread roll out of direct access services cannot as yet be assumed to result in long term health and socio-economic gains. PROSPERO-ID: CRD42018085978.

The impact of age and feeding length on phytase efficacy during the starter phase of broiler chickens

Phytase is of importance to the poultry industry because of its ability to hydrolyze phytate and release phosphorus (P) for use by poultry. However, the effect of age on phytase efficacy is not fully understood. A total of 864 day-old broiler chicks were used to investigate the effect of age and feeding length on phytase efficacy using growth performance, mineral utilization, and tibia ash as response criteria of evaluation. The experiment was arranged as a 3 × 2 × 2 factorial in a randomized complete block design with 3 diets including; a positive control (PC; 0.4% non-phytate P (nPP)), a negative control (NC; 0.2% nPP) and a NC diet supplemented with phytase at 2,000 FYT/kg; 2 ages (i.e., days 14 and 22); and 2 feeding lengths (i.e., 2 and 5 D) with 8 replicates each. Birds fed the NC had decreased (P < 0.01) body weight gain and feed efficiency compared with birds fed the PC regardless of age or feeding length. Similarly, birds fed the phytase-supplemented diet had improved (P < 0.01) performance as compared to birds fed the NC regardless of age. There were no significant differences in P utilization between birds fed for 2 to 14 D or 22 D and birds fed for 5 D to both ages. However, phytase was more efficacious at day 14 than day 22 when mineral utilization was considered because the super dose of phytase elicited greater response in birds fed the phytase supplemented diet for 2 D until day 14. In contrast, percentage tibia ash improved (P < 0.01) in birds fed phytase supplemented diet for 5 D at both ages as compared with birds fed for 2 D. In conclusion, testing phytase products, even at high doses, for 2 D during the second week in the life cycle of broiler chicks, can be recommended from the results of this study.

Influence of age and duration of feeding low-phosphorus diet on phytase efficacy in broiler chickens during the starter phase

A total of 1,408 male broiler chickens were used to evaluate the impact of age and duration of feeding low-phosphorus (P) diet on the efficacy of phytase using growth performance, nutrient utilization, tibia ash, and plasma indices. Diets were formulated with 2 non-phytate P (nPP) concentrations (i.e., 0.20 and 0.40%) and 2 phytase concentrations (i.e., 1,000 and 2,000 FTU/kg) added to the 0.20% nPP diet. Four dietary treatments with 8 replicate cages each were fed to broiler chicks at different ages and for different duration. Specifically, these were days 6 to 8 (12 birds per replicate), 12 to 14, 9 to 14, 20 to 22, or 6 to 22 (8 birds per replicate). Parameters were measured on the last day of each period. Duration of feeding effect was examined by comparing responses of birds fed for 2 or 5 D at day 14 and for 2 or 16 D at day 22; age effect was determined by comparing responses of birds fed for 2 D at age 8, 14 and 22 D post-hatching. Body weight gain and gain-to-feed ratio were increased (P < 0.01) in birds fed diets supplemented with phytase; however, an increase in duration of feeding improved (P < 0.01) feed efficiency with birds fed for 16 D performing better than birds fed for 2 D at day 22. In addition, phytase supplementation improved (P < 0.01) apparent P and calcium digestibility and retention, but the age effect on phytase efficacy was more apparent at day 14 and the duration of feeding effect was evident in birds fed for 2 D due to the increased levels of mineral utilization at that age/duration of feeding as compared with the other groups. The results of this study show that phytase efficacy was at optimum in birds fed low-P diet for 2 D at day 14. This period can be recommended for further bioefficacy studies of phytase.

Understanding self-harm in older adults: A qualitative study

BACKGROUND

Self-harm is the leading risk factor for suicide, with elevated rates reported amongst older populations. This study explores how older adults experience self-harm, identifying factors leading to self-harm.

METHODS

Semi-structured interviews with older adults (≥ 60 years) engaging in self-harm and support workers from third sector services in England. Older adults were invited to participate in a follow-up interview. Interviews were recorded, transcribed verbatim and data analysed thematically. Ethical approval obtained from Keele University's Ethics Review Panel. A Patient Involvement group contributed to study design, data analysis and interpretation.

OUTCOMES

Between September 2017 to September 2018, 24 interviews were conducted involving 16 participants: nine older adults and seven support workers. Eight older adults consented to follow-up interviews. All older adults reported diagnoses of mental illness in addition to physical illness. Participants identified diverse stressors accumulating over the life-course leaving older adults particularly vulnerable to self-harm. Such stressors included adverse events, loss, interpersonal and health problems. A sense of shame and stigma amongst older people using self-harm to manage distress was also reported.

INTERPRETATION

Self-harm is often concealed due to stigma and shame, being further accentuated amongst older adults, which may result in low levels of medical help-seeking behaviour for self-harm. Self-harm occurred along a spectrum of no-suicidal intent to high-levels of intent, suggesting self-harm holds different functions to older adults. Clinicians should be aware of the existence of self-harm in this age-group, and the heightened risk amongst those with comorbidities so adequate assessment, support and/or referral is provided.

Additivity of apparent and standardized ileal digestibility of amino acids in wheat, canola meal, and sorghum distillers dried grains with solubles in mixed diets fed to broiler chickens

An experiment was conducted to investigate which method, apparent ileal digestibility (AID) or standardized ileal digestibility (SID), more accurately predicts the digestibility of crude protein (CP) and amino acids (AA) in mixed diets fed to broiler chickens. Male Ross 308 broiler chickens received a standard starter diet from d 0 to 16 post hatching, thereafter grouped into 8 blocks, based on body weight (BW), of 10 birds/cage, and randomly allotted to 6 diets in a randomized complete block design. The 6 diets consisted of a nitrogen-free diet, 3 semi-purified diets, and 2 mixed diets to test the additivity of AID and SID in mixed diets. On d 21 post hatching, digesta from two-thirds of the distal ileum was collected. Using the determined AID or SID for CP and AA in wheat, canola meal (CM), or sorghum distillers dried grains with solubles (DDGS), the AID or SID for 2 mixed diets based on wheat-CM or wheat-CM-DDGS were predicted and compared with determined AID or SID, respectively. The results revealed that the predicted SID of CP and AA in the wheat-CM mixed diet were consistent with determined values except for Asp and Ser, and all the predicted SID of CP and AA were consistent with the determined values in the wheat-CM-DDGS mixed diet. The determined AID of Ile, Met, Thr, Val, Ala, Cys, Ser, and Tyr in the wheat-CM mixed diet were greater (P < 0.05) than predicted AID values. For the wheat-CM-DDGS mixed diet, the determined AID of Trp, Cys, and Glu were greater (P < 0.05) than the predicted AID values. However, there were more inconsistencies between the determined and predicted values in AID values for wheat-CM than the wheat-CM-DDGS mixed diet than SID values for both diets. In conclusion, the present study confirmed that the SID of CP and AA was more additive than the AID of CP and AA when a mixed diet contained wheat, CM, and DDGS as protein sources in broiler chickens.

Comparative effectiveness of treatment options for plantar heel pain: a systematic review with network meta-analysis

OBJECTIVE

To evaluate the comparative effectiveness of current treatment options for plantar heel pain (PHP).

DESIGN

Systematic review and network meta-analysis (NMA).

DATA SOURCES

Medline, EMBASE, CINAHL, AMED, PEDro, Cochrane Database, Web of Science and WHO Clinical Trials Platform were searched from their inception until January 2018.

STUDY SELECTION

Randomised controlled trials (RCTs) of adults with PHP investigating common treatments (ie, corticosteroid injection, non-steroidal anti-inflammatory drugs, therapeutic exercise, orthoses and/or extracorporeal shockwave therapy (ESWT)) compared with each other or a no treatment, placebo/sham control.

DATA EXTRACTION AND ANALYSIS

Data were extracted and checked for accuracy and completeness by pairs of reviewers. Primary outcomes were pain and function. Comparative treatment effects were analysed by random effects NMA in the short term, medium term and long term. Relative ranking of treatments was assessed by surface under the cumulative ranking probabilities (0-100 scale).

RESULTS

Thirty-one RCTs (total n=2450 patients) were included. There was no evidence of inconsistency detected between direct and indirect treatment comparisons in the networks, but sparse data led to frequently wide CIs. Available evidence does not suggest that any of the commonly used treatments for the management of PHP are better than any other, although corticosteroid injections, alone or in combination with exercise, and ESWT were ranked most likely to be effective for the management of short-term, medium-term and long-term pain or function; placebo/sham/control appeared least likely to be effective; and exercise appeared to only be beneficial for long-term pain or function.

CONCLUSIONS

Current evidence is equivocal regarding which treatment is the most effective for the management of PHP. Given limited understanding of long-term effects, there is need for large, methodologically robust multicentre RCTs investigating and directly comparing commonly used treatments for the management of PHP.

PROSPERO REGISTRATION NUMBER

CRD42016046963.

Evidence flowers: An innovative, visual method of presenting "best evidence" summaries to health professional and lay audiences

BACKGROUND & AIMS

Barriers to dissemination and engagement with evidence pose a threat to implementing evidence-based medicine. Understanding, retention, and recall can be enhanced by visual presentation of information. The aim of this exploratory research was to develop and evaluate the accessibility and acceptability of visual summaries for presenting evidence syntheses with multiple exposures or outcomes to professional and lay audiences.

METHODS

"Evidence flowers" were developed as a visual method of presenting data from 4 case scenarios: 2 complex evidence syntheses with multiple outcomes, Cochrane reviews, and clinical guidelines. Petals of evidence flowers were coloured according to the GRADE evidence rating system to display key findings and recommendations from the evidence summaries. Application of evidence flowers was observed during stakeholder workshops. Evaluation and feedback were conducted via questionnaires and informal interviews.

RESULTS

Feedback from stakeholders on the evidence flowers collected from workshops, questionnaires, and interviews was encouraging and helpful for refining the design of the flowers. Comments were made on the content and design of the flowers, as well as the usability and potential for displaying different types of evidence.

CONCLUSIONS

Evidence flowers are a novel and visually stimulating method for presenting research evidence from evidence syntheses with multiple exposures or outcomes, Cochrane reviews, and clinical guidelines. To promote access and engagement with research evidence, evidence flowers may be used in conjunction with other evidence synthesis products, such as (lay) summaries, evidence inventories, rapid reviews, and clinical guidelines. Additional research on potential adaptations and applications of the evidence flowers may further bridge the gap between research evidence and clinical practice.

Effective treatment options for musculoskeletal pain in primary care: A systematic overview of current evidence

Background & aims

Musculoskeletal pain, the most common cause of disability globally, is most frequently managed in primary care. People with musculoskeletal pain in different body regions share similar characteristics, prognosis, and may respond to similar treatments. This overview aims to summarise current best evidence on currently available treatment options for the five most common musculoskeletal pain presentations (back, neck, shoulder, knee and multi-site pain) in primary care.

Methods

A systematic search was conducted. Initial searches identified clinical guidelines, clinical pathways and systematic reviews. Additional searches found recently published trials and those addressing gaps in the evidence base. Data on study populations, interventions, and outcomes of intervention on pain and function were extracted. Quality of systematic reviews was assessed using AMSTAR, and strength of evidence rated using a modified GRADE approach.

Results

Moderate to strong evidence suggests that exercise therapy and psychosocial interventions are effective for relieving pain and improving function for musculoskeletal pain. NSAIDs and opioids reduce pain in the short-term, but the effect size is modest and the potential for adverse effects need careful consideration. Corticosteroid injections were found to be beneficial for short-term pain relief among patients with knee and shoulder pain. However, current evidence remains equivocal on optimal dose, intensity and frequency, or mode of application for most treatment options.

Conclusion

This review presents a comprehensive summary and critical assessment of current evidence for the treatment of pain presentations in primary care. The evidence synthesis of interventions for common musculoskeletal pain presentations shows moderate-strong evidence for exercise therapy and psychosocial interventions, with short-term benefits only from pharmacological treatments. Future research into optimal dose and application of the most promising treatments is needed.

Association between depot medroxyprogesterone acetate (DMPA), physical activity and bone health

Physical activity has been advocated for women in the hope of offsetting progestin-only contraceptive-related loss in bone mineral density. There is limited evidence for the beneficial effect of physical activity on bone health of hypo-oestrogenic premenopausal women. The aim of this cross-sectional study was to examine the relationship between physical activity and bone health [as measured by quantitative ultrasound (QUS)] of depot-medroxyprogesterone acetate (DMPA) users, and to investigate whether QUS measurements of DMPA users and non-users differed according to physical activity. Bone health of 48 DMPA users and 48 age-matched controls (22.83 ± 3.2 years) was assessed using calcaneal broadband ultrasound attenuation (BUA). Participants were categorised into low and high levels of physical activity based on their exposure to bone-loading exercise. Analysis of covariance was conducted to determine if QUS measurements of DMPA users and non-DMPA users differed within levels of bone-loading physical activity after controlling for body mass index. The duration of DMPA use ranged from 6 to 132 months. Participants' reference bone-loading exposure time averaged 3.3 ± 1.8 years. Data analysis revealed that DMPA users had significantly lower BUA by 6.54 dB/MHz (t (95) = -2.411, p = 0.018) compared to non-users of DMPA. Concurrently high levels of physical activity and DMPA use led to 1.996 dB/MHz decreases in BUA. A cycle of prolonged DMPA use and concurrent engagement in high levels of physical activity appears detrimental to bone health. It is suggested that the lack of oestrogen may counteract the effects of physical activity by inhibiting bone formation in response to mechanical bone-loading.

Quantitative Ultrasound and bone's response to exercise: a meta analysis

The utility of Quantitative Ultrasound (QUS) for assessing and monitoring changes in bone health due to exercise is limited for lack of adequate research evidence. Restrictions to bone density testing and the enduring debate over repeat dual energy absorptiometry testing spells uncertainty over clinical and non-clinical evaluation of exercise for prevention of osteoporosis. This study, via systematic review and meta-analysis, aimed to paint a portrait of current evidence regarding QUS' application to monitoring bone's adaptive response to exercise interventions.

METHODS

Structured and comprehensive search of databases was undertaken along with hand-searching of key journals and reference lists to locate relevant studies published up to December 2011. Twelve articles met predetermined inclusion criteria. The effect of exercise interventions for improving bone health, as measured by QUS of the calcaneum, was examined across the age spectrum. Study outcomes for analysis: absolute (dB/MHz) or relative change (%) in broadband ultrasound attenuation (BUA) and/or os calcis stiffness index were compared by calculating standardised mean difference (SMD) using fixed- and random-effects models.

RESULTS

Quality of included trials varied from low to high on a scale of one to three. Four to 36months of exercise led to a significant improvement in calcaneum BUA (0.98 SMD, 95% CI 0.80, 1.16, overall effect Z-value=10.72, p=0.001) across the age spectrum.

CONCLUSION

The meta-analysis attests to the sensitivity of QUS to exercise-induced changes in bone health across the age groups. QUS may be considered for use in exercise-based bone health interventions for preventing osteoporosis.

A meta-analysis of brief high-impact exercises for enhancing bone health in premenopausal women

A snapshot of current evidence from 6 randomised controlled trials for the effects of short bouts of high-impact exercises in 256 women via meta-analysis reveals that ample osteogenic response could be realised at the femoral neck and trochanter of premenopausal women with rest-inserted bouts of few mechanical bone loading cycles.

INTRODUCTION

Exercise is an important means of improving bone health and preventing osteoporosis. Brief bouts of simple exercises may be useful for aiding lifestyle compliance to physical activity. This study aimed to review the evidence on the effect of brief, high-impact exercise on bone health among premenopausal women.

METHODS

A structured and comprehensive search of databases was undertaken along with hand searching of key journals and reference lists to locate relevant studies published and unpublished up to January 2011. Six randomised controlled trials met predetermined inclusion criteria. Brief high-impact exercises (<30 min) were examined for their effect on bone mineral density (BMD) among premenopausal women. Trial quality was assessed using the Effective Public Health Practice Project quality assessment tool. Study outcomes for analysis, absolute change (grams per square centimetre) or relative change (in percent) in BMD at femoral neck, trochanter and lumbar spine were compared by calculating standardised mean difference (SMD) using fixed- and random effects models.

RESULTS

Quality of included trials varied from medium to high on a scale of 1 to 3. Brief bouts of exercise led to significant increases in femoral neck BMD (SMD = 0.64, 95% confidence interval (CI) = 0.38, 0.90, overall effect Z value = 4.84, p = 0.001); a modest increase in trochanteric BMD (SMD = 0.36, 95% CI = 0.10, 0.61, Z value = 2.08, p = 0.04) and no increase in spinal BMD (SMD = 0.04, 95% CI= -0.23, 0.31, Z value = 0.26, p = 0.79).

CONCLUSION

Based on the meta-analysis, brief high-impact exercise improves BMD at the hip but not at the lumbar spine. Effectiveness of this form of exercise as a lifestyle physical activity for prevention of osteoporosis should be explored in larger populations.