Patient experiences and perspectives of health service access for carpal tunnel syndrome in Aotearoa New Zealand: a normalisation process theory-informed qualitative study.

BACKGROUND: Early access to care for carpal tunnel syndrome (CTS) can avoid higher rates of surgery and permanent harm yet is often delayed, particularly for populations more likely to underutilise care. OBJECTIVE: We sought to explore patient experiences and perspectives of health service access for CTS to inform an equity-focussed co-design of a health service for improving early care access. METHODS: In this Normalisation Process Theory (NPT)-informed qualitative study we conducted semistructured in-depth interviews with 19 adults with experience of CTS. Recruitment prioritised New Zealand Maori, Pasifika, low-income, and rural populations. Data were analysed using deductive then inductive thematic analysis. RESULTS: We identified five major themes: (1) the 'Significant Impact of CTS' of the sense-making and relational work to understand the condition, deciding when to get care, compelling clinicians to provide care, and garnering help from others; (2) 'Waiting and Paying for Care'- the enacting, relational, and appraising work to avoid long wait times unless paying privately, particularly where quality of care was low, employment relations poor, or injury compensation processes faltered; (3) circumstances of 'Occupation and CTS Onset' whereby the burden of proof to relate onset of CT symptoms to occupation created excessive relational and enacting work; (4) the 'Information Scarcity' of good information about CTS and the high relational and appraising work associated with using online resources; (5) 'Negotiating Telehealth Perspectives' where telehealth was valued if it meant earlier access for all despite the challenges it held for many. CONCLUSION: Quality, culturally and linguistically responsive information and communication from clinicians and health services will improve equitable early access to CTS care including realising the potential of telehealth modes of care. Policy changes that reduce individual burden of proof in injury compensation claims processes, enable time off work to attend health appointments, and increase public funding for surgical resources would improve early access to CTS care particularly for Maori and Pacific populations and those in small and rural workplaces. NPT is valuable for understanding where opportunities lie to reduce inequitable delays to accessing care including the impact of racism, particularly for populations more likely to underutilise care.

Patient and Provider Attitudes, Beliefs, and Biases That Contribute to a Marginalized Process of Care and Outcomes in Chronic Musculoskeletal Pain: A Systematic Review-Part I: Clinical Care.

OBJECTIVE: Chronic musculoskeletal pain (CMP) outcomes are affected by numerous variables, including the clinical conversation. When good therapeutic/working alliances are formed, congruent clinical conversations can lead to improved CMP outcomes. Identifying patient/provider attitudes, beliefs, and biases in CMP that can influence the clinical conversation, and thus clinical management decisions, is foundationally important. DESIGN: The aims of this systematic review were to 1) summarize the evidence of the attitudes and beliefs of patients and health care providers (HCPs) involved in the clinical conversation about CMP, and 2) examine whether and how these perceptions impacted the process of care. METHODS: A systematic search of CINAHL, PubMed, Scopus, Sociology Database in ProQuest, and Web of Science used the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Included studies were those investigating vulnerable adult populations with chronic pain. Study bias was examined with the Downs and Black tool. RESULTS: Seven retrospective studies were included. When making pharmaceutical management decisions, HCPs demonstrated negative implicit biases toward minorities and women. When making referrals to multidisciplinary care, HCPs demonstrated negative implicit biases toward women with lower educational attainment. Unmet patient expectations resulted in higher dropout rates at multidisciplinary pain management programs. Patients' trust was influenced by the health care setting, and patients often had limited options secondary to health insurance type/status. CONCLUSION: These findings suggest that patients with CMP may experience a marginalized process of care due to HCPs' negative implicit biases, unmet patient expectations, and the health care setting. Results suggest several factors may contribute to inequitable care and the recalcitrant nature of CMP, particularly in vulnerable populations with limited health care choices.

A meta-analysis comparing the diagnostic performance of abbreviated MRI and a full diagnostic protocol in breast cancer.

AIM: To undertake a meta-analysis of the diagnostic performance of abbreviated (ABB) magnetic resonance imaging (MRI) and full diagnostic protocol MRI (FDP-MRI) in breast cancer. MATERIALS AND METHODS: This meta-analysis was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Diagnostic Test Accuracy (PRISMA-DTA) guidelines. The PubMed and EMBASE databases were searched through August 2019 for studies comparing the diagnostic performance of ABB-MRI and FDP-MRI in the breast. Studies were reviewed by two authors independently according to eligibility and exclusion criteria and split into two subgroups (screening population studies and studies using cohorts enriched with known cancers) to avoid bias. Quality assessment and bias for diagnostic accuracy was determined with Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). The diagnostic accuracy for each subgroup was pooled using a bivariate random effects model and summary receiver operating characteristic (sROC) curves produced. Sensitivities and specificities were compared using a paired t-test. RESULTS: Five screening (62/2,588 cancers/patients) and eight enriched cohort (540/1,432 cancers/patients) studies were included in the meta-analysis. QUADAS-2 assessment showed a low risk of bias in most studies. The pooled sensitivity/specificity/area under the receiver operating characteristic curve (AUC) for screening studies was 0.90/0.92/0.94 for ABB-MRI and 0.92/0.95/0.97 for FDP-MRI. The pooled sensitivity/specificity/AUC for enriched cohort studies was 0.93/0.83/0.94 for ABB-MRI and 0.93/0.84/0.95 for FDP-MRI. There was no significant difference in sensitivity or specificity using ABB-MRI or FDP-MRI (p=0.18 and 0.27, p=0.18 and 0.93, respectively). CONCLUSION: The diagnostic performances of the ABB-MRI and FDP-MRI protocols used in either screening or enriched cohorts were comparable. There was a large variation in patient population, study methodology, and abbreviated protocols reported.

Opportunities in cancer imaging: risk-adapted breast imaging in screening.

In the UK, women between 50-70 years are invited for 3-yearly mammography screening irrespective of their likelihood of developing breast cancer. The only risk adaption is for women with >30% lifetime risk who are offered annual magnetic resonance imaging (MRI) and mammography, and annual mammography for some moderate-risk women. Using questionnaires, breast density, and polygenic risk scores, it is possible to stratify the population into the lowest 20% risk, who will develop <4% of cancers and the top 4%, who will develop 18% of cancers. Mammography is a good screening test but has low sensitivity of 60% in the 9% of women with the highest category of breast density (BIRADS D) who have a 2.5- to fourfold breast cancer risk. There is evidence that adding ultrasound to the screening mammogram can increase the cancer detection rate and reduce advanced stage interval and next round cancers. Similarly, alternative tests such as contrast-enhanced mammography (CESM) or abbreviated MRI (ABB-MRI) are much more effective in detecting cancer in women with dense breasts. Scintimammography has been shown to be a viable alternative for dense breasts or for follow-up in those with a personal history of breast cancer and scarring as result of treatment. For supplemental screening to be worthwhile in these women, new technologies need to reduce the number of stage II cancers and be cost effective when tested in large scale trials. This article reviews the evidence for supplemental imaging and examines whether a risk-stratified approach is feasible.

A randomized controlled trial investigating effects of an individualized pedometer driven walking program on chronic low back pain.

BACKGROUND: Walking is an easily prescribed physical activity for people with low back pain (LBP). However, the evidence for its effectiveness to improve pain and disability levels for people with chronic low back pain (CLBP) within a community setting has not been evaluated. This study evaluates the effectiveness of a clinician guided, pedometer-driven, walking intervention for increasing physical activity and improving clinical outcomes compared to education and advice. METHODS: Randomized controlled trial recruiting N = 174 adults with CLBP. Participants were randomly allocated into either a standardized care group (SG) or pedometer based walking group (WG) using minimization allocation with a 2:1 ratio to the WG. Prior to randomization all participants were given a standard package of education and advice regarding self-management and the benefits of staying active. Following randomization the WG undertook a physiotherapist guided pedometer-driven walking program for 12 weeks. This was individually tailored by weekly negotiation of daily step targets. Main outcome was the Oswestry Disability Index (ODI) recorded at baseline, 12 weeks, 6 and 12 months. Other outcomes included, numeric pain rating, International Physical Activity Questionnaire (IPAQ), Fear-Avoidance Beliefs Questionnaire (FABQ), Back Beliefs questionnaire (BBQ), Physical Activity Self-efficacy Scale, and EQ-5D-5L quality of life estimate. RESULTS: N = 138 (79%) participants completed all outcome measures at 12 weeks reducing to N = 96 (55%) at 12 months. Both observed and intention to treat analysis did not show any statistically significant difference in ODI change score between the WG and the SG at all post-intervention time points. There were also no significant between group differences for change scores in all secondary outcome measures. Post hoc sensitivity analyses revealed moderately disabled participants (baseline ODI ≥ 21.0) demonstrated a greater reduction in mean ODI scores at 12 months in the WG compared to SG, while WG participants with a daily baseline step count < 7500 steps demonstrated a greater reduction in mean ODI scores at 12 weeks. CONCLUSIONS: Overall, we found no significant difference in change of levels of (ODI) disability between the SG and WG following the walking intervention. However, ODI responses to a walking program for those with moderate levels of baseline disability and those with low baseline step count offer a potential future focus for continued research into the benefit of walking as a management strategy for chronic LBP. TRIAL REGISTRATION: United States National Institutes of Health Clinical Trails registry (http://ClinicalTrials.gov/) No. NCT02284958 (27/10/2014).

Filtering Statistics on Networks.

Compression, filtering, and cryptography, as well as the sampling of complex systems, can be seen as processing information. A large initial configuration or input space is nontrivially mapped to a smaller set of output or final states. We explored the statistics of filtering of simple patterns on a number of deterministic and random graphs as a tractable example of such information processing in complex systems. In this problem, multiple inputs map to the same output, and the statistics of filtering is represented by the distribution of this degeneracy. For a few simple filter patterns on a ring, we obtained an exact solution of the problem and numerically described more difficult filter setups. For each of the filter patterns and networks, we found three key numbers that essentially describe the statistics of filtering and compared them for different networks. Our results for networks with diverse architectures are essentially determined by two factors: whether the graphs structure is deterministic or random and the vertex degree. We find that filtering in random graphs produces much richer statistics than in deterministic graphs, reflecting the greater complexity of such graphs. Increasing the graph's degree reduces this statistical richness, while being at its maximum at the smallest degree not equal to two. A filter pattern with a strong dependence on the neighbourhood of a node is much more sensitive to these effects.

Effectiveness of splinting for pain and function in people with thumb carpometacarpal osteoarthritis: a systematic review with meta-analysis.

OBJECTIVE: To examine the effectiveness of splinting for reducing pain and improving function and health-related quality of life (HR-QoL) in people with thumb carpometacarpal osteoarthritis (CMC OA). DESIGN: The Cochrane Library, MEDLINE, Embase, CINAHL, ISI Web of Science, Scopus and Google Scholar, 3 trial registries and 4 conference proceedings were systematically searched for randomised and non-randomised controlled trials up to March 17th, 2018. Two reviewers independently applied the inclusion criteria to select potential studies and assess risk of methodologic bias using the Cochrane Collaboration's Risk of Bias Tool. Studies were pooled using the inverse variance method to calculate standardised mean difference (SMD). Sensitivity analyses were conducted and the quality of evidence for each outcome was judged following the Grades of Recommendation Assessment, Development and Evaluation (GRADE) approach. RESULTS: Twelve studies were retrieved (n = 1353), 4 comparing a splint to control and 8 to another splint. In the medium-term (3-12 months), low quality evidence showed that splints cause a moderate to large reduction in pain (SMD 0.7 [95% confidence interval (CI) 1.04, 0.35], P < 0.0001) and small to moderate improvement in function (SMD 0.42 [95% CI 0.77, 0.08], P = 0.02). No significant effect was found at short-term or for different types of splints. No studies reported HR-QoL. CONCLUSIONS: Splinting demonstrated a moderate to large effect for pain and small to moderate effect for function in the medium-term but not in the short term. Quality of the evidence is low. Major challenges are the lack of diagnostic criteria and of a gold-standard outcome measure for thumb CMC OA.

"How are running shoes assessed? A systematic review of characteristics and measurement tools used to describe running footwear".

Background: Many footwear characteristics are argued as risk factors for running related injuries (RRI). Several footwear assessment tools are available; however, their use in studies of RRI is unknown. Objective: This systematic review evaluated the characteristics and methods of assessing footwear in studies of RRI. Design: Five online databases were searched for studies on adult runners, in running style footwear, who experienced running-related pain or injury. The methodological quality of included articles was independently assessed by two raters using a modified Downs and Black checklist. Study and participant characteristics, footwear assessment tools used, and footwear characteristics reported were extracted for qualitative synthesis. Results: Twenty-four articles were included in the review. Low risk of bias was determined for 11 (44%) of the included studies. Twenty-eight different footwear characteristics were grouped into four categories: nomenclature, measurements, qualitative features, and subjective features. Fifteen different methods for assessing the 28 footwear characteristics were reported among the included studies. Only three methods were described previously, as valid and reliable. Conclusion: Differences in assessing footwear may mask the link between footwear characteristics and injury risk. Systematic footwear assessments and nomenclature are needed to evaluate the effects of footwear characteristics on RRI.

Maximizing Participation During Walking in Children With Disabilities: Is Response to Unpredictability Important?

Walking ability is one of the primary components of human motor function, and interventions aimed at improving walking ability are common in physical therapy, particularly in children. One element encountered in a participatory, or natural, environment is unpredictability, defined as the presence of an unexpected obstacle, stimulus, or alteration of the environmental conditions. Little research has assessed the influence of unpredictability on biomechanical adaptations to walking in children who are developing typically or children with motor disabilities. A variety of impairments may result in an inadequate response to unpredictability, and we propose that there may be a relationship between response to an unpredictable visual cue and mobility-based participation.

Low level laser therapy (Photobiomodulation therapy) for breast cancer-related lymphedema: a systematic review.

BACKGROUND: Breast cancer related lymphedema (BCRL) is a prevalent complication secondary to cancer treatments which significantly impacts the physical and psychological health of breast cancer survivors. Previous research shows increasing use of low level laser therapy (LLLT), now commonly referred to as photobiomodulation (PBM) therapy, for BCRL. This systematic review evaluated the effectiveness of LLLT (PBM) in the management of BCRL. METHODS: Clinical trials were searched in PubMed, AMED, Web of Science, and China National Knowledge Infrastructure up to November 2016. Two reviewers independently assessed the methodological quality and adequacy of LLLT (PBM) in these clinical trials. Primary outcome measures were limb circumference/volume, and secondary outcomes included pain intensity and range of motion. Because data were clinically heterogeneous, best evidence synthesis was performed. RESULTS: Eleven clinical trials were identified, of which seven randomized controlled trials (RCTs) were chosen for analysis. Overall, the methodological quality of included RCTs was high, whereas the reporting of treatment parameters was poor. Results indicated that there is strong evidence (three high quality trials) showing LLLT (PBM) was more effective than sham treatment for limb circumference/volume reduction at a short-term follow-up. There is moderate evidence (one high quality trial) indicating that LLLT (PBM) was more effective than sham laser for short-term pain relief, and limited evidence (one low quality trial) that LLLT (PBM) was more effective than no treatment for decreasing limb swelling at short-term follow-up. CONCLUSIONS: Based upon the current systematic review, LLLT (PBM) may be considered an effective treatment approach for women with BCRL. Due to the limited numbers of published trials available, there is a clear need for well-designed high-quality trials in this area. The optimal treatment parameters for clinical application have yet to be elucidated.

Acupuncture for chronic low back pain: a randomized controlled feasibility trial comparing treatment session numbers.

OBJECTIVE: To evaluate the feasibility of a randomized controlled trial investigating the optimal number of treatment sessions of acupuncture, used as an adjunct to usual care, for managing chronic low back pain. METHODS: In total, 45 participants with chronic low back pain were recruited and randomly allocated to receive usual care plus 4, 7, or 10 sessions of acupuncture (15/group). Primary outcomes were recruitment rate, randomization rate, treatment compliance, completion of the outcome measures, and retention rates. Secondary outcomes included back function, pain intensity and bothersomeness, generic health status, activity disability, and participant satisfaction. Data were collected at baseline and discharge, and at 6 and 12 weeks post randomization. RESULTS: The recruitment method was demonstrated to be successful: recruitment rate was 43.7%, and randomization rate was 100%. Compliance with treatment was high among participants (86.7%, 86.7%, and 100% for the 4-, 7-, and 10-session group, respectively). Outcome questionnaires used in this study were found to be appropriate for a future randomized controlled trial. Participant retention rates were 88.9% at discharge and at 6 weeks post randomization and 84.4% at 12 weeks post randomization. Secondary outcomes (except for pain intensity) favored the 10-session acupuncture group at 12 weeks post randomization. Over 90% of participants indicated that they were "very satisfied" and/or "extremely satisfied" with the acupuncture treatment. CONCLUSION: This study demonstrated that a full-scale randomized controlled trial using the methodology described above is feasible, and such a trial is essential to test the dose dependence of acupuncture.

Putting Physical Activity While Experiencing Low Back Pain in Context: Balancing the Risks and Benefits.

OBJECTIVE: To analyze attitudes and beliefs about movement and physical activity in people with low back pain (LBP) and compare these beliefs between people with acute and chronic LBP. DESIGN: Qualitative inductive analysis of data collected via face-to-face semistructured interviews. Interviews were audio-recorded and transcribed verbatim. SETTING: Participants were purposively recruited from 1 region of New Zealand. PARTICIPANTS: Persons with LBP (N=23), consisting of individuals with acute LBP (<6wk; n=12) and chronic LBP (>3mo; n=11). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Themes that emerged from participant interview transcripts using analysis based on Interpretative Description. RESULTS: Participants with acute and chronic LBP made judgments about physical activity and rest using the same conceptual model. Concerns about creating more pain, tissue damage, or impairment influenced the physical activity judgments of most participants with acute and chronic LBP. These perceived risks were balanced against the perceived benefits, the most important of which were psychological or social rather than physical. Judgments made by those with acute and chronic LBP were context dependent and influenced by the nature and duration of pain, the type of physical activity, the importance of the activity, and the participant's previous experience. Participants with acute pain who had not experienced back pain previously often expressed more uncertainty, whereas those with chronic LBP appeared to have developed cognitive rules that determined physical activity decisions. CONCLUSIONS: Exploring the perceived risks, benefits, and contextual factors that influence decisions about physical activity and rest may help clinicians to understand the behavior of patients with acute and chronic LBP. Clinicians may best support their patients to engage in physical activity by providing an informed assessment of risks and an explanation about the range of potential benefits.

Physical performance tests predict injury in National Collegiate Athletic Association athletes: a three-season prospective cohort study.

BACKGROUND: The ability to predict injury is difficult. Prior injury is the only risk factor that has been reported consistently in multiple research studies. Convenient and easy to perform, physical performance tests (PPTs) have great allure as prognostic factors. METHODS: 11 PPTs were issued to 359 participants over the course of three seasons of National Collegiate Athletic Association Division I athletic competition. Injuries were monitored and reported in a centralised university tracking system. Exploratory factor analysis was performed in order to group the PPTs into constructs. The relationship between injury and these PPT-based constructs and other known predictors of injury was explored using univariate and multivariate regression. RESULTS: PPTs clustered into five constructs: (1) active motion, (2) power, (3) hip stability, (4) flexibility and (5) motor control. When these five were placed into a multiple regression equation along with known risk factors (age, body mass index (BMI), gender, excessive flexibility and past injury), hip stability and active motion were predicted injury. In addition, motor control predicted non-traumatic injury. Past injury did not predict injury in the multivariate model. SUMMARY: In college athletes, hip stability, active motion and motor control as assessed through PPTs can be useful as part of preseason screening. These PPT-related constructs seem to have a mediating effect on the relationship between past injury and future injury. This study provides the rationale to test targeted interventions to address these limitations. CLINICAL TRIAL REGISTRATION NUMBER: NCT01804894.

Walking away from back pain: one step at a time - a community-based randomised controlled trial.

BACKGROUND: Low back pain is highly prevalent and a significant public health burden in Western society. Feasibility studies suggest personalised pedometer-driven walking is an acceptable and effective motivating tool in the management of chronic low back pain (CLBP ≥ 12 weeks). The proposed study will investigate pedometer-driven walking as a low cost, easily accessible, and sustainable means of physical activity to improve disability and clinical outcomes for people with CLBP in Saskatchewan, Canada. METHODS/DESIGN: A fully-powered single-blinded randomised controlled trial will compare back care advice and education with back care advice and education followed by a 12-week pedometer-driven walking programme in adults with CLBP. Adults with self-reported CLBP will be recruited from the community and screened for elibility. Two-hundred participants will be randomly allocated to one of two intervention groups. All participants will receive a single back care advice and education session with a physiotherapist. Participants in the walking group will also receive a physiotherapist-facilitated pedometer based walking programme. The physiotherapist will facilitate the participant to monitor and progress the walking programme, by phone, on a weekly basis over 10 weeks following two face-to-face sessions. Outcome measures of self-reported disability, physical activity, participants' low back pain beliefs/perceptions, quality of life and direct/indirect cost estimates will be gathered at baseline, three months, six months, and 12 months by a different physiotherapist blinded to group allocation. Following intervention, focus groups will be used to explore participants' thoughts and experiences of pedometer-driven walking as a management tool for CLBP. DISCUSSION: This paper describes the design of a community-based RCT to determine the effectiveness of a pedometer-driven walking programme in the management of CLBP. TRIAL REGISTRATION: United States National Institutes of Health Clinical Trails registry (http://ClinicalTrials.gov/) No. NCT02284958 . Registered on 27(th) October 2014).

Clinician-friendly lower extremity physical performance measures in athletes: a systematic review of measurement properties and correlation with injury, part 1. The tests for knee function including the hop tests.

OBJECTIVE: To review the measurement properties of physical performance tests (PPTs) of the knee as each pertain to athletes, and to determine the relationship between PPTs and injury in athletes age 12 years to adult. METHODS: A search strategy was constructed by combining the terms 'lower extremity' and synonyms for 'performance test', and names of performance tests with variants of the term 'athlete'. In this, part 1, we report on findings in the knee. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed and the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist was used to critique the methodological quality of each paper. A second measure was used to analyse the quality of the measurement properties of each test. RESULTS: In the final analysis, we found 29 articles pertinent to the knee detailing 19 PPTs, of which six were compiled in a best evidence synthesis. The six tests were: one leg hop for distance (single and triple hop), 6 m timed hop, crossover hop for distance, triple jump and single leg vertical jump. The one leg hop for distance is the most often studied PPT. There is conflicting evidence regarding the validity of the hop and moderate evidence that the hop test is responsive to changes during rehabilitation. No test has established reliability or measurement error as assessed by the minimal important change or smallest detectable change. No test predicts knee injury in athletes. CONCLUSIONS: Despite numerous published articles addressing PPTs at the knee, there is predominantly limited and conflicting evidence regarding the reliability, agreement, construct validity, criterion validity and responsiveness of commonly used PPTs. There is a great opportunity for further study of these tests and the measurement properties of each in athletes.

Online technology use in physiotherapy teaching and learning: a systematic review of effectiveness and users' perceptions.

BACKGROUND: The use of online technologies in health professionals' education, including physiotherapy, has been advocated as effective and well-accepted tools for enhancing student learning. The aim of this study was to critically review the effectiveness, and user perceptions of online technology for physiotherapy teaching and learning. METHODS: Following databases were systematically searched on the 31(st) of August 2013 for articles describing implementation of online technologies into physiotherapy teaching and learning: ERIC, CINAHL, Web of Science, Academic search complete, ProQuest Nursing and Allied Health Source, Medline, Embase, and Scopus. No language, design or publishing date restrictions were imposed. Risk of bias was assessed using the 2011 Mixed Methods Appraisal Tool checklist (MMAT). RESULTS: A total of 4133 articles were retrieved; 22 articles met the inclusion criteria and were accepted for final analysis: 15 on the effectiveness of technology, and 14 on users' perceptions. Included studies used three designs: case study (14 articles), controlled trial (3), and randomized controlled trial (5). Studies investigated both pre-registration physiotherapy students (1523) and physiotherapy professionals (171). The quality of studies ranged from 67 to 100 % on the MMAT checklist which can be considered moderate to excellent. More than half of the studies (68 %) received scores greater than 80 %. Studies typically investigated websites and discussion boards. The websites are effective in enhancing practical skills performance, and discussion boards in knowledge acquisition, as well as in development of critical and reflective thinking. Students' perceptions of the use of websites were mostly positive, providing students with entertaining, easy accessible resources. Perceived barriers to the use of websites included difficulties with internet connection, insufficiently interactive material, or personal preference for paper-based materials. Discussion boards were perceived as deepening students' thinking and facilitating reflection, allowing for learning from multiple perspectives, and providing easy communication and support. CONCLUSIONS: The results of this review suggest that online technologies (i.e., websites and discussion boards) have many benefits to offer for physiotherapy teaching and learning; There was minimal evidence of barriers for the use of online technologies, however, addressing the identified ones could enhance adherence to use of online technologies in health professionals' education.

Acute low back pain management in general practice: uncertainty and conflicting certainties.

BACKGROUND: Low back pain (LBP) is a significant health problem and common reason to visit the GP. Evidence suggests GPs experience difficulty applying evidence-based guidelines. OBJECTIVE: Explore GPs' underlying beliefs about acute LBP and how these influence their clinical management of patients. METHODS: Eleven GPs from one geographical region within New Zealand were recruited by purposive sampling. Audio recordings of semi-structured qualitative interviews were transcribed verbatim. Data were analysed with an Interpretive Description framework. RESULTS: Four key themes emerged related to the causes of acute LBP, GP confidence, communicating diagnostic uncertainty and encouraging movement and activity. Acute LBP was seen as a direct representation of tissue injury, consequently the assessment and management of patients' attitudes and beliefs was not a priority. Participants' confidence was decreased due to a perceived inability to diagnose or influence the tissue injury. Despite this, diagnoses were provided to patients to provide reassurance and meet expectations. Guideline recommendations regarding activity conflicted with a perceived need to protect damaged tissue, resulting in reported provision of mixed messages about the need to be both active and careful. CONCLUSIONS: GPs' initial focus upon tissue injury during acute care, and providing a diagnostic label, may influence patients' subsequent alignment with a biomedical perspective and contribute to consultation conflict and patients' perception of blame when discussion of psychosocial influences is introduced. Demonstrating the relevance of the biopsychosocial model to acute LBP may improve GPs' alignment with guidelines, improve their confidence to manage these patients and ultimately improve outcomes.

Early experience of MAGEC magnetic growing rods in the treatment of early onset scoliosis.

PURPOSE: Magnetically controlled growing rod systems have been introduced over recent years as an alternative to traditional growing rods for management of early onset scoliosis. The purpose of this paper is to report our early experience of a magnetically controlled growing rod system (MAGEC, Ellipse). METHODS: Review of pre-operative, postoperative and follow-up Cobb angles and spinal growth in case series of eight patients with a minimum 23 months' follow-up (23-36 months). RESULTS: A total of six patients had dual rod constructs implanted and two patients received single-rod constructs. Four patients had MAGEC rods as a primary procedure. Four were revisions from other systems. Mean age at surgery in the primary group was 4.5 years (range 3.9-6.9). In patients who had MAGEC as a primary procedure, mean pre-operative Cobb angle was 74° (63-94), with postoperative Cobb angle of 42° (32-56) p ≤ 0.001 (43% correction). Mean Cobb angle at follow-up was 42° (35-50). Spinal growth rate was 6 mm/year. One sustained proximal screw pull out. A final patient sustained a rod fracture. Mean age at surgery in the revision group was 10.9 years (range 9-12.6). Mean pre-operative Cobb angle was 45° (34-69). Postoperative Cobb angle was 42° (33-63) (2% correction). Mean Cobb angle at follow-up was 44° (28-67). Mean spinal growth rate was 12 mm/year. Two patients developed loss of distraction. CONCLUSION: MAGEC growing rod system effectively controls early onset scoliosis when used as either a primary or revision procedure. Although implant-related complications are not uncommon, the avoidance of multiple surgeries following implantation is beneficial compared with traditional growing rod systems.

A systematic review of studies using pedometers as an intervention for musculoskeletal diseases.

BACKGROUND: Physical activity (PA) plays an important role in the prevention and management of a number of chronic conditions. AIM: to investigate the evidence for effectiveness of pedometer-driven walking programs to promote physical activity among patients with musculoskeletal disorders (MSDs). METHOD: A comprehensive systematic review was performed using 11 electronic databases up to 20 February 2014. Keywords and MeSH terms included "musculoskeletal disorders", "walking", and "pedometer". Randomized controlled trials, published in English, that examined the effects of a pedometer-based walking intervention to increase physical activity levels and improve physical function and pain in patients with musculoskeletal disorders were included. RESULT: Of the 1996 articles retrieved, seven studies ranging in date of publication from 1998 to 2013 met the inclusion criteria, allowing data extraction on 484 participants with an age range of 40 to 82 years. Interventions lasted from 4 weeks to 12 months and the results across studies showed significant increases in step count (p < 0.05) following the intervention. Across these studies, there was a mean increase in PA of 1950 steps per day relative to baseline. Four studies reported improved scores for pain and/or physical function at the intervention completion point relative to controls. CONCLUSION: This study provides strong evidence for the effectiveness of pedometer walking interventions in increasing PA levels for patients with MSDs. Our findings suggest that a combination of interventions is likely to be the most effective strategy to maximize health benefits in the short term. Further research should include larger sample sizes, and longer intervention durations are required to support the role of pedometer walking interventions as a long term intervention for management of musculoskeletal disorders.

Establishing key components of yoga interventions for musculoskeletal conditions: a Delphi survey.

BACKGROUND: Evidence suggests yoga is a safe and effective intervention for the management of physical and psychosocial symptoms associated with musculoskeletal conditions. However, heterogeneity in the components and reporting of clinical yoga trials impedes both the generalization of study results and the replication of study protocols. The aim of this Delphi survey was to address these issues of heterogeneity, by developing a list of recommendations of key components for the design and reporting of yoga interventions for musculoskeletal conditions. METHODS: Recognised experts involved in the design, conduct, and teaching of yoga for musculoskeletal conditions were identified from a systematic review, and invited to contribute to the Delphi survey. Forty-one of the 58 experts contacted, representing six countries, agreed to participate. A three-round Delphi was conducted via electronic surveys. Round 1 presented an open-ended question, allowing panellists to individually identify components they considered key to the design and reporting of yoga interventions for musculoskeletal conditions. Thematic analysis of Round 1 identified items for quantitative rating in Round 2; items not reaching consensus were forwarded to Round 3 for re-rating. RESULTS: Thirty-six panellists (36/41; 88%) completed the three rounds of the Delphi survey. Panellists provided 348 comments to the Round 1 question. These comments were reduced to 49 items, grouped under five themes, for rating in subsequent rounds. A priori group consensus of ≥80% was reached on 28 items related to five themes concerning defining the yoga intervention, types of yoga practices to include in an intervention, delivery of the yoga protocol, domains of outcome measures, and reporting of yoga interventions for musculoskeletal conditions. Additionally, a priori consensus of ≥50% was reached on five items relating to minimum values for intervention parameters. CONCLUSIONS: Expert consensus has provided a non-prescriptive reference list for the design and reporting of yoga interventions for musculoskeletal conditions. It is anticipated future research incorporating the Delphi guidelines will facilitate high quality international research in this field, increase homogeneity of intervention components and parameters, and enhance the comparison and reproducibility of research into the use of yoga for the management of musculoskeletal conditions.