Perceptions and experiences of paramedics managing people with non-traumatic low back pain: a qualitative study of Australian paramedics.

BACKGROUND: Paramedics are often first providers of care to patients experiencing non-traumatic low back pain (LBP), though their perspectives and experiences with managing these cases remain unclear. OBJECTIVES: This study explored paramedic views of the management of non-traumatic LBP including their role and experience with LBP management, barriers to referral and awareness of ambulance service guidelines. DESIGN: Qualitative study using semistructured interviews conducted between January and April 2023. SETTING: New South Wales Ambulance service. PARTICIPANTS: A purposive sample of 30 paramedics of different specialities employed by New South Wales Ambulance were recruited. RESULTS: Paramedic accounts demonstrated the complexity, challenge, frustration and reward associated with managing non-traumatic LBP. Paramedics perceived that their primary role focused on the assessment of LBP, and that calls to ambulance services were often driven by misconceptions surrounding the management of LBP, and a person's pain severity. Access to health services, patient factors, defensive medicine, paramedic training and education and knowledge of guidelines influenced paramedic management of LBP. CONCLUSION: Paramedics often provide care to non-traumatic LBP cases yet depending on the type of paramedic speciality find these cases to be frustrating, challenging or rewarding to manage due to barriers to referral including access to health services, location, patient factors and uncertainty relating to litigation. Future research should explore patient perspectives towards ambulance service use for the management of their LBP.

The effectiveness of allied health and nurse practitioner models-of-care in managing musculoskeletal conditions in the emergency department: a systematic review and meta-analysis.

BACKGROUND: Musculoskeletal conditions are the most common health condition seen in emergency departments. Hence, the most effective approaches to managing these conditions is of interest. This systematic review aimed to evaluate the effectiveness of allied health and nursing models of care for the management of musculoskeletal pain in ED. METHODS: MEDLINE, EMBASE, CINAHL and LILACS databases were searched from inception to March 2023 for published randomised trials that compared the effectiveness of allied health and nursing models of care for musculoskeletal conditions in ED to usual ED care. Trials were eligible if they enrolled participants presenting to ED with a musculoskeletal condition including low back pain, neck pain, upper or lower limb pain and any soft tissue injury. Trials that included patients with serious pathology (e.g. malignancy, infection or cauda equina syndrome) were excluded. The primary outcome was patient-flow; other outcomes included pain intensity, disability, hospital admission and re-presentation rates, patient satisfaction, medication prescription and adverse events. Two reviewers performed search screening, data extraction, quality and certainty of evidence assessments. RESULTS: We identified 1746 records and included 5 randomised trials (n = 1512 patients). Only one trial (n = 260) reported on patient-flow. The study provides very-low certainty evidence that a greater proportion of patients were seen within 20 min when seen by a physician (98%) than when seen by a nurse (86%) or physiotherapist (77%). There was no difference in pain intensity and disability between patients managed by ED physicians and those managed by physiotherapists. Evidence was limited regarding patient satisfaction, inpatient admission and ED re-presentation rates, medication prescription and adverse events. The certainty of evidence for secondary outcomes ranged from very-low to low, but generally did not suggest a benefit of one model over another. CONCLUSION: There is limited research to judge the effectiveness of allied health and nursing models of care for the management of musculoskeletal conditions in ED. Currently, it is unclear as to whether allied health and nurse practitioners are more effective than ED physicians at managing musculoskeletal conditions in ED. Further high-quality trials investigating the impact of models of care on service and health outcomes are needed.

Paramedic management of back pain: a scoping review.

BACKGROUND: Research examining paramedic care of back pain is limited. OBJECTIVE: To describe ambulance service use and usual paramedic care for back pain, the effectiveness and safety of paramedic care of back pain, and the characteristics of people with back pain who seek care from paramedics. METHODS: We included published peer-reviewed studies of people with back pain who received any type of paramedic care on-scene and/or during transport to hospital. We searched MEDLINE, EMBASE, CINAHL, Web of Science and SciELO from inception to July 2022. Two authors independently screened and selected the studies, performed data extraction, and assessed the methodological quality using the PEDro, AMSTAR 2 and Hawker tools. This review followed the JBI methodological guidance for scoping reviews and PRISMA extension for scoping reviews. RESULTS: From 1987 articles we included 26 articles (25 unique studies) consisting of 22 observational studies, three randomised controlled trials and one review. Back pain is frequently in the top 3 reasons for calls to an ambulance service with more than two thirds of cases receiving ambulance dispatch. It takes ~ 8 min from time of call to an ambulance being dispatched and 16% of calls for back pain receive transport to hospital. Pharmacological management of back pain includes benzodiazepines, NSAIDs, opioids, nitrous oxide, and paracetamol. Non-pharmacological care is poorly reported and includes referral to alternate health service, counselling and behavioural interventions and self-care advice. Only three trials have evaluated effectiveness of paramedic treatments (TENS, active warming, and administration of opioids) and no studies provided safety or costing data. CONCLUSION: Paramedics are frequently responding to people with back pain. Use of pain medicines is common but varies according to the type of back pain and setting, while non-pharmacological care is poorly reported. There is a lack of research evaluating the effectiveness and safety of paramedic care for back pain.

Paramedic care for back pain: A review of Australian and New Zealand clinical practice guidelines.

BACKGROUND: Back pain is one of the most common reasons for a person to call an ambulance service, yet how ambulance services manage back pain has not been described. METHODS: Australian-state and New Zealand ambulance service jurisdiction websites were searched between 25th January to 3rd February 2022. Pain management guidelines were included where no specific back pain guideline was found. Identified guidelines were screened, appraised using AGREE II tool and recommendations on pharmacological and non-pharmacological management of back pain, ambulance transport and alerting features were extracted, summarised, and compared to two primary care guidelines. RESULTS: Nine guidelines were identified including four back pain and 5 pain management guidelines. All four back pain guidelines recommend paracetamol or ibuprofen as analgesic options to manage back pain. These guidelines recommend transport to the emergency department when there are alerting features for serious disease, lack of pain control or where the patient is unable to ambulate. 2 out of 9 ambulance guidelines were recommended for use in their existing format following quality appraisal using AGREE II tool. Ambulance guidelines scored significantly lower than primary care guidelines for back pain. CONCLUSION: Ambulance service guidelines for back pain recommend advice, reassurance, paracetamol and referral to primary care.

Spinal pain in childhood: prevalence, trajectories, and diagnoses in children 6 to 17 years of age.

This study aimed to investigate the trajectories of spinal pain frequency from 6 to 17 years of age and describe the prevalence and frequency of spinal pain and related diagnoses in children following different pain trajectories. First through fifth-grade students from 13 primary schools were followed for 5.5 years. Occurrences of spinal pain were reported weekly via text messages. Children reporting spinal pain were physically evaluated and classified using International Classification of Disease criteria. Trajectories of spinal pain frequency were modeled from age 6 to 17 years with latent class growth analysis. We included data from 1556 children (52.4% female, mean (SD) baseline age = 9.1 (1.9) years) and identified 10,554 weeks of spinal pain in 329,756 weeks of observation. Sixty-three percent of children reported one or more occurrences of spinal pain. We identified five trajectories of spinal pain frequency. Half the children (49.8%) were classified as members of a "no pain" trajectory. The remaining children followed "rare" (27.9%), "rare, increasing" (14.5%), "moderate, increasing" (6.5%), or "early-onset, decreasing" (1.3%) spinal pain trajectories. The most common diagnoses in all trajectory groups were non-specific (e.g., "back pain"). Tissue-specific diagnoses (e.g., muscle strain) were less common and pathologies (e.g., fracture) were rare.  Conclusion: From childhood through adolescence, spinal pain was common and followed heterogeneous courses comprising stable, increasing, and early-onset trajectories. These findings accord with recommendations from adult back pain guidelines that most children with spinal pain can be reassured that they do not have a serious disease and encouraged to stay active. What is Known: • Spinal pain imposes a large burden on individuals and society. • Although many people first experience the condition in childhood, little is known about the developmental trajectories of spinal pain from childhood to adolescence. What is New: • Data from 1556 children and 329,756 participant weeks showed five unique spinal pain trajectories from 6 to 17 years: most children rarely reported spinal pain, while one in five followed increasing or early-onset trajectories. • Most pain occurrences were non-specific; pathological diagnoses were rare.

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

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

Leadership and capacity building in chiropractic research: report from the first CARL cohort.

The Chiropractic Academy for Research Leadership (CARL) was formed in 2016 in response to a need for a global network of early career researchers and leaders in the chiropractic profession. Thirteen fellows were accepted competitively and have since worked together at residentials and virtually on many research and leadership projects. In 2020, the CARL program ended for this first cohort, and it is now timely to take stock and reflect on the achievements and benefits of the program. In this paper we present the structure of CARL, the scientific and leadership outputs as well as the personal value of CARL for the participating fellows. As a result of the success of the first CARL cohort, organizations from Europe, North America, and Australia have supported a second cohort of 14 CARL fellows, who were competitively accepted into the program in early 2020.

Chiropractic students' cognitive dissonance to statements about professional identity, role, setting and future: international perspectives from a secondary analysis of pooled data.

BACKGROUND: Chiropractic students demonstrate philosophically opposing views about the chiropractic profession. The primary aim was to describe chiropractic students' responses to statements about chiropractic identity, role, setting, and future direction. A secondary aim was to describe the frequency of internally conflicting responses. METHODS: Three datasets from Europe, North America, and Australia/New Zealand were pooled in a secondary data analysis. Chiropractic students from 25 chiropractic training institutions completed interrelating surveys (combined response rate 21.9%) between 2013 and 2018. The survey instrument investigated student viewpoints about chiropractic professional identity, role, practice setting and future direction of chiropractic practice. Student attitudes about chiropractic were described using weighted proportions to adjust for unequal population sampling across the three geographical regions. The frequency of concordant and discordant student responses was described by combining identity items with items that explored responses about practice role, setting and future direction. The relationship between student characteristics (age, sex, education, association membership and geographical region) and ideologically conflicting responses were assessed using the Chi-squared test and Cramér's V. RESULTS: Data from 2396 student chiropractors (50.8% female; from Europe 36.2%, North America 49.6% and Australia/New Zealand 14.5%) were analysed. For identity, nearly half of the chiropractic students (weighted 45.1%) agreed that it is important for chiropractors to hold strongly to the traditional chiropractic theory that adjusting the spine corrects "dis-ease" and agreed (weighted 55.5%) that contemporary and evolving scientific evidence is more important than traditional chiropractic principles. The frequency of discordant (ideologically conflicting) student responses ranged from 32.5% for statements about identity versus role, to 51.4% for statements about identity versus future. There was no association between student age, sex and internally conflicting responses. Chiropractic students' professional association membership status, pre-chiropractic education and geographical region were associated with ideologically conflicting responses. CONCLUSIONS: Chiropractic students in this analysis show traditional and progressive attitudes towards the chiropractic profession. Individual student responses frequently contradict in terms of professional ideology, but most (approximately half) students demonstrate concordant progressive and mainstream attitudes. Ideological conflict may raise concerns about some students' ability to learn and make clinical judgements, and potential for disharmony in the chiropractic fraternity.

Impact of the COVID-19 Pandemic on Manual Therapy Service Utilization within the Australian Private Healthcare Setting.

The COVID-19 pandemic has impacted a wide range of health services. This study aimed to quantify the impact of the COVID-19 pandemic on manual therapy service utilization within the Australian private healthcare setting during the first half of 2020. Quarterly data regarding the number and total cost of services provided were extracted for each manual therapy profession (i.e., chiropractic, osteopathy, and physiotherapy) for the period January 2015 to June 2020 from the Australian Prudential Regulation Authority. Time series forecasting methods were used to estimate absolute and relative differences between the forecasted and observed values of service utilization. An estimated 1.3 million (13.2%) fewer manual therapy services, with a total cost of AUD 84 million, were provided within the Australian private healthcare setting during the first half of 2020. Reduction in service utilization was considerably larger in the second quarter (21.7%) than in the first quarter (5.7%), and was larger in physiotherapy (20.6%) and osteopathy (12.7%) than in chiropractic (5.2%). The impact varied across states and territories, with the largest reductions in service utilization observed in New South Wales (17.5%), Australian Capital Territory (16.3%), and Victoria (16.2%). The COVID-19 pandemic has had a profound impact on manual therapy service utilization in Australia. The magnitude of the decline in service utilization varied considerably across professions and locations. The long-term consequences of this decline in manual therapy utilization remain to be determined.

Service utilisation trends in the manual therapy professions within the Australian private healthcare setting between 2008 and 2017.

BACKGROUND: Better understanding of the dynamics and temporal changes in manual therapy service utilisation may assist with healthcare planning and resource allocation. The objectives of this study were to quantify, describe, and compare service utilisation trends in the manual therapy professions within the Australian private healthcare setting between 2008 and 2017. METHODS: Data regarding the number of services, total cost, and benefits paid were extracted for each manual therapy profession (i.e. chiropractic, osteopathy, and physiotherapy) for the period 2008-2017 from the Australian Prudential Regulation Authority. The number of registered providers for each profession were obtained from the Australian Health Practitioner Regulation Agency. Descriptive statistics were produced for two time periods (i.e. 2008-2012 and 2013-2017) for each manual therapy profession. Annual percentage change during each time period was estimated by fitting Poisson regression models. Test for the equality of regression coefficients was used to compare the trends in the two time periods within each profession, and to compare the trends across professions within a time period. RESULTS: A cumulative total of 198.6 million manual therapy services with a total cost of $12.8 billion was provided within the Australian private healthcare setting between 2008 and 2017. Although service utilisation and total cost increased throughout the ten-year period, the annual growth was significantly lower during 2013-2017 than 2008-2012. Whereas osteopathy and physiotherapy experienced significant annual growth in the number of services and total cost during 2013-2017, negative growth in the number of services was observed for chiropractic during the same period. The annual number of services per provider declined significantly for chiropractic and physiotherapy between 2013 and 2017. CONCLUSION: Service provision under private health insurance general treatment cover constitute a major source of revenue for manual therapy professions in Australia. Although manual therapy service utilisation increased throughout the ten-year period from 2008 to 2017, the annual growth declined. There were diverging trends across the three professions, including significantly greater decline in annual growth for chiropractic than for osteopathy and physiotherapy.

The bench-top accuracy of the VerteTrack spinal stiffness assessment device.

BACKGROUND: The assessment of spinal stiffness by manual palpation in clinical settings has demonstrated both poor accuracy and reliability. More recently, mechanical methods for assessment of spinal stiffness have demonstrated superior accuracy and reliability. However, mechanical methods of spinal stiffness assessment can be expensive, time consuming and/or unsuited to clinical practice. While a new device has been designed to address these issues (VerteTrack), its benchtop performance remains unknown. AIM: To measure the bench-top performance of VerteTrack. METHODS: A series of laboratory-based experiments were conducted in February 2018 to investigate the accuracy (precision and bias) of load and displacement measurements obtained by VerteTrack and then were compared against an appropriate reference standard. Measurements of both multiple-level continuous assessment (multiple spinal levels measured), and single-level assessment (single spinal level measured) were performed on a viscoelastic foam medium (AIREX® balance beam, Switzerland) and the resulting stiffness calculated. RESULTS: VerteTrack demonstrated high precision at all loads and displacements. There was minimal systematic measurement bias identified for applied versus reference load (mean bias = - 0.123 N; 95%CI - 0.182 to 0.428 N, p < .001), and no systematic measurement bias for measured versus reference displacement (mean difference = 0.02 mm; 95%CI - 0.09 to 0.14 mm, p < .001). The magnitude of stiffness obtained during multiple-level continuous assessment was on average 0.25 N/mm (2.79%) less than that for single-level assessment (95%CI - 0.67 to 0.17 N/mm, p < .001). CONCLUSIONS: VerteTrack demonstrated high accuracy (high precision, low bias) under bench-top conditions. The difference in stiffness found between multiple versus single spinal levels should be considered in the research context, but is unlikely to be clinically relevant. The results of this study demonstrate that VerteTrack may be suitable for both single and multi-level spinal stiffness measurements in-vivo.

An Australian survey on health and injuries in adult competitive surfing.

BACKGROUND: There is limited research that explores health and injuries of surfers. The aim of this study is to describe the health and injury profile of adult Australian competitive surfers. METHODS: In this cross-sectional study, all registered participants at the 2014 Australian Surfing Titles were invited to complete an online survey comprising: 1) demographic and surfing information; 2) health-related quality of life using the SF-12 questionnaire; and 3) surfing injury history. Descriptive statistics were used to describe the survey responses. The sample consisted of 227 (77% male) surfers with mean age of 35.0±13.2 years. They spent on average, 10.0±6.5 hours per week surfing. RESULTS: The mean SF-12 physical and mental health component scores were significantly higher than the population norm at 53.3±5.4 and 55.6±6.2, respectively. A total of 175 (81%) respondents reported incurring at least one surfing-related injury in their lifetimes, while 90 (58%) respondents reported incurring at least one surfing-related injury in the current season. The most commonly injured body regions were the lower back, foot, knee, and ankle, while the most frequent types of injury were abrasion and laceration. CONCLUSIONS: Although adult Australian competitive surfers report greater physical and mental health-related quality of life compared to the general population, surfing-related injuries are relatively common. The present study reveals a higher burden of lower back injuries compared to previous reports as well as differences in injury profiles amongst the surfing disciplines.

The identity, role, setting, and future of chiropractic practice: a survey of Australian and New Zealand chiropractic students.

OBJECTIVE:: To evaluate Australian and New Zealand chiropractic students' opinions regarding the identity, role setting, and future of chiropractic practice. METHODS:: An online, cross-sectional survey was administered to chiropractic students in all chiropractic programs in Australia and New Zealand. The survey explored student viewpoints about the identity, role/scope, setting, and future of chiropractic practice as it relates to chiropractic education and health promotion. Associations between the number of years in the program, highest degree preceding chiropractic education, institution, and opinion summary scores were evaluated by multivariate analysis of variance tests. RESULTS:: A total of 347 chiropractic students participated in the study. For identity, most students (51.3%) hold strongly to the traditional chiropractic theory but also agree (94.5%) it is important that chiropractors are educated in evidence-based practice. The main predictor of student viewpoints was a student's chiropractic institution (Pillai's trace =.638, F[16, 1368] = 16.237, p < .001). Chiropractic institution explained over 50% of the variance around student opinions about role/scope of practice and approximately 25% for identity and future practice. CONCLUSIONS:: Chiropractic students in Australia and New Zealand seem to hold both traditional and mainstream viewpoints toward chiropractic practice. However, students from different chiropractic institutions have divergent opinions about the identity, role, setting, and future of chiropractic practice, which is most strongly predicted by the institution. Chiropractic education may be a potential determinant of chiropractic professional identity, raising concerns about heterogeneity between chiropractic schools.

Leadership and capacity building in international chiropractic research: introducing the chiropractic academy for research leadership (CARL).

In an evidence-based health care environment, healthcare professions require a sustainable research culture to remain relevant. At present however, there is not a mature research culture across the chiropractic profession largely due to deficiencies in research capacity and leadership, which may be caused by a lack of chiropractic teaching programs in major universities. As a response to this challenge the Chiropractic Academy for Research Leadership, CARL, was created with the aim of develop a global network of successful early-career chiropractic researchers under the mentorship of three successful senior academics from Australia, Canada, and Denmark. The program centres upon an annual week-long program residential that rotates continental locations over the first three-year cycle and between residentials the CARL fellows work on self-initiated research and leadership initiatives. Through a competivite application process, the first cohort was selected and consists of 13 early career researchers from five professions in seven countries who represent diverse areas of interests of high relevance for chiropractic. The first residential was held in Odense, Denmark, with the second being planned in April 2018 in Edmonton, Canada, and the final residential to be held in Sydney, Australia in 2019.

Short-term Clinical Course of Knee Pain in Children and Adolescents: A Feasibility Study Using Electronic Methods of Data Collection.

BACKGROUND AND PURPOSE: Musculoskeletal disorders, such as knee pain, are common in children and adolescents, but there is a lack of high quality research that evaluates the clinical course of these conditions. The objective of this study was to evaluate the feasibility of conducting a prospective study of children and adolescents with knee pain using electronic methods of data collection. METHODS: Children and adolescents with knee pain that presented to primary care physiotherapy clinics were enrolled and followed-up on a weekly basis via short messaging service (SMS) until their knee pain had recovered (i.e. two consecutive weeks of no pain). Feasibility was assessed in terms of recruitment, retention and response rates to SMS and an online questionnaire. Baseline and 6-month follow-up measures included pain, disability, physical function, physical activity and health related quality of life. Kaplan-Meier survival analysis was used to estimate the median time to knee pain recovery. RESULTS: Thirty participants (mean age 13.0 ± 2.2 years, 53% boys) were recruited over 26 months. The overall response rate to weekly SMS follow-up was 71.3% (809 received/1135 sent). One third of participants stopped responding to SMS prior to recovery, and these participants typically had a much lower response rate during the time they remained in the study. At 6-month follow-up, 80% of the cohort completed the final online questionnaire, and 29% of participants still reported current knee pain (≥1/10 VAS). The median time for knee pain recovery was 8 weeks (95%CI: 5, 10). CONCLUSION: Electronic data collection alone seems insufficient to track pain recovery in young people and may need to be supplemented with more traditional data collection methods. Researchers should consider further measures to address slow recruitment rates and high attrition when designing large prospective studies of children and adolescents in the future. Copyright © 2016 John Wiley & Sons, Ltd.

Match injuries in amateur Rugby Union: a prospective cohort study - FICS Biennial Symposium Second Prize Research Award.

BACKGROUND: The majority of Rugby Union (rugby) players participate at the amateur level. Knowledge of player characteristics and injury risks is predominantly ascertained from studies on professional or junior athletes in rugby. The objectives of the current study are to: (1) describe the health-related quality of life (HRQoL) and physical characteristics of a cohort of amateur rugby players; (2) describe the incidence, severity and mechanism of match injuries in amateur rugby, and; (3) explore factors associated with rates of match injury in this population. METHODS: Participants (n = 125) from one amateur men's rugby club were followed in a one-season (2012) prospective cohort study. Match injury and match time exposure data were collected. A participant match exposure log was maintained. Baseline variables collected include: participant's age, playing experience, position of play, the SF-36v2 health survey, height and weight. Injury incidence rates (IIRs) per 1000 match-hours exposure were calculated. Injury sub-groups were compared by calculating rate ratios of two IIRs. Poisson mixed-effects generalised linear modelling was used to explore relationships between IIRs and baseline predictors. RESULTS: A total of 129 injuries occurred during a combined period of 2465 match-hours of exposure. The overall IIR was 52.3 (43.7-62.2) /1000 match-hours exposure. Moderate-severe injuries (>1 week time-loss from play) comprised 36 % of all injuries. Tackling was the most common mechanism of injury, the head/face was the most common body region of injury and sprain/ligament injuries were the most common injury type. Fewer years of rugby participation, lower BMI and lower SF-36v2 mental component summary score were associated with higher IIR in amateur rugby. Age, player position i.e., backs versus forwards and SF-36v2 physical component summary score were not associated with injury incidence. CONCLUSION: Amateur rugby players report similar HRQoL as the general population. We found amateur players had a higher rate of injury and lower injury severity than previous amateur studies, but location, type, and mechanism were similar. In this study pre-season HRQoL and BMI were weakly associated with higher injury rate when controlling for other factors; a finding that should be interpreted with caution and clarified with future research.

Accuracy of clinical tests in the diagnosis of anterior cruciate ligament injury: a systematic review.

BACKGROUND: Numerous clinical tests are used in the diagnosis of anterior cruciate ligament (ACL) injury but their accuracy is unclear. The purpose of this study is to evaluate the diagnostic accuracy of clinical tests for the diagnosis of ACL injury. STUDY DESIGN: Systematic review. The review protocol was registered through PROSPERO (CRD42012002069). Electronic databases (PubMed, MEDLINE, EMBASE, CINAHL) were searched up to 19th of June 2013 to identify diagnostic studies comparing the accuracy of clinical tests for ACL injury to an acceptable reference standard (arthroscopy, arthrotomy, or MRI). Risk of bias was appraised using the QUADAS-2 checklist. Index test accuracy was evaluated using a descriptive analysis of paired likelihood ratios and displayed as forest plots. RESULTS: A total of 285 full-text articles were assessed for eligibility, from which 14 studies were included in this review. Included studies were deemed to be clinically and statistically heterogeneous, so a meta-analysis was not performed. Nine clinical tests from the history (popping sound at time of injury, giving way, effusion, pain, ability to continue activity) and four from physical examination (anterior draw test, Lachman's test, prone Lachman's test and pivot shift test) were investigated for diagnostic accuracy. Inspection of positive and negative likelihood ratios indicated that none of the individual tests provide useful diagnostic information in a clinical setting. Most studies were at risk of bias and reported imprecise estimates of diagnostic accuracy. CONCLUSION: Despite being widely used and accepted in clinical practice, the results of individual history items or physical tests do not meaningfully change the probability of ACL injury. In contrast combinations of tests have higher diagnostic accuracy; however the most accurate combination of clinical tests remains an area for future research. CLINICAL RELEVANCE: Clinicians should be aware of the limitations associated with the use of clinical tests for diagnosis of ACL injury.

The provision of chiropractic, physiotherapy and osteopathic services within the Australian private health-care system: a report of recent trends.

BACKGROUND: Chiropractors, physiotherapists, and osteopaths receive training in the diagnosis and management of musculoskeletal conditions. As a result there is considerable overlap in the types of conditions that are encountered clinically by these practitioners. In Australia, the majority of benefits paid for these services come from the private sector. The purpose of this article is to quantify and describe the development in service utilization and the cost of benefits paid to users of these healthcare services by private health insurers. An exploration of the factors that may have influenced the observed trends is also presented. METHODS: A review of data from the Australian Bureau of Statistics, Australian Health Practitioner Regulation Agency, and the Australian Government Private Health Insurance Administration Council was conducted. An analysis of chiropractic, physiotherapy and osteopathic service utilisation and cost of service utilisation trend was performed along with the level of benefits and services over time. RESULTS: In 2012, the number of physiotherapists working in the private sector was 2.9 times larger than that of chiropractic, and 7.8 times that of the osteopathic profession. The total number of services provided by chiropractors, physiotherapists, and osteopaths increased steadily over the past 15 years. For the majority of this period, chiropractors provided more services than the other two professions. The average number of services provided by chiropractors was approximately two and a half times that of physiotherapists and four and a half times that of osteopaths. CONCLUSIONS: This study highlights a clear disparity in the average number of services provided by chiropractors, physiotherapists, and osteopaths in the private sector in Australia over the last 15 years. Further research is required to explain these observed differences and to determine whether a similar trend exists in patients who do not have private health insurance cover.