Variability in the prevalence of depression among adults with chronic pain: UK Biobank analysis through clinical prediction models.

BACKGROUND: The prevalence of depression among people with chronic pain remains unclear due to the heterogeneity of study samples and definitions of depression. We aimed to identify sources of variation in the prevalence of depression among people with chronic pain and generate clinical prediction models to estimate the probability of depression among individuals with chronic pain. METHODS: Participants were from the UK Biobank. The primary outcome was a "lifetime" history of depression. The model's performance was evaluated using discrimination (optimism-corrected C statistic) and calibration (calibration plot). RESULTS: Analyses included 24,405 patients with chronic pain (mean age 64.1 years). Among participants with chronic widespread pain, the prevalence of having a "lifetime" history of depression was 45.7% and varied (25.0-66.7%) depending on patient characteristics. The final clinical prediction model (optimism-corrected C statistic: 0.66; good calibration on the calibration plot) included age, BMI, smoking status, physical activity, socioeconomic status, gender, history of asthma, history of heart failure, and history of peripheral artery disease. Among participants with chronic regional pain, the prevalence of having a "lifetime" history of depression was 30.2% and varied (21.4-70.6%) depending on patient characteristics. The final clinical prediction model (optimism-corrected C statistic: 0.65; good calibration on the calibration plot) included age, gender, nature of pain, smoking status, regular opioid use, history of asthma, pain location that bothers you most, and BMI. CONCLUSIONS: There was substantial variability in the prevalence of depression among patients with chronic pain. Clinically relevant factors were selected to develop prediction models. Clinicians can use these models to assess patients' treatment needs. These predictors are convenient to collect during daily practice, making it easy for busy clinicians to use them.

Outcome Heterogeneity in Prehabilitation Trials-Are We Comparing Apples and Oranges?

INTRODUCTION: Over the last decade, the number of prehabilitation randomised controlled trials (RCTs) has increased significantly. Therefore, this review aimed to describe the outcomes reported in prehabilitation RCTs in patients undergoing cancer surgery. METHODS: A search was conducted in Embase, Allied and Complementary Medicine Database, The Cochrane Library, PsycINFO, MEDLINE, and Cumulated Index to Nursing and Allied Health Literature from inception to July 2021. We included RCTs evaluating the effectiveness of preoperative exercise, nutrition, and psychological interventions on postoperative complications and length of hospital stay in adult oncology patients who underwent thoracic and gastrointestinal cancer surgery. The verbatim outcomes reported in each article were extracted, and each outcome was assessed to determine whether it was defined and measured using a validated tool. Verbatim outcomes were grouped into standardized outcomes and categorized into domains. The quality of outcome reporting in each identified article was assessed using the Harman tool (score range 0-6, where 0 indicated the poorest quality). RESULTS: A total of 74 RCTs were included, from which 601 verbatim outcomes were extracted. Only 110 (18.3%) of the verbatim outcomes were defined and 270 (44.9%) were labeled as either "primary" or "secondary" outcomes. Verbatim outcomes were categorized into 119 standardized outcomes and assigned into one of five domains (patient-reported outcomes, surgical outcomes, physical/functional outcomes, disease activity, and intervention delivery). Surgical outcomes were the most common outcomes reported (n = 71 trials, 95.9%). The overall quality of the reported outcomes was poor across trials (median score: 2.0 [IQR = 0.00-3.75]). CONCLUSIONS: Prehabilitation RCTs display considerable heterogeneity in outcome reporting, and low outcome reporting quality. The development of standardized core outcome sets may help improve article quality and enhance the clinical utility of prehabilitation following cancer surgery.

A review of patient recruitment in randomised controlled trials of preoperative exercise.

BACKGROUND: Randomised controlled trials (RCTs) are considered the gold standard design to determine the effectiveness of an intervention, as the only method of decreasing section bias and minimising random error. However, participant recruitment to randomised controlled trials is a major challenge, with many trials failing to recruit the targeted sample size accordingly to the planned protocol. Thus, the aim of this review is to detail the recruitment challenges of preoperative exercise clinical trials. METHODS: A comprehensive search was performed on MEDLINE, Embase, The Cochrane Library, CINAHL, AMED and PsycINFO from inception to July 2021. Randomised controlled trials investigating the effectiveness of preoperative exercise on postoperative complication and/or length of hospital stay in adult cancer patients were included. Main outcomes included recruitment rate, retention rate, number of days needed to screen and recruit one patient and trial recruitment duration. Descriptive statistics were used to summarise outcomes of interest. RESULTS: A total of 27 trials were identified, including 3656 patients screened (N = 21) and 1414 randomised (median recruitment rate (interquartile range) = 53.6% (25.2%-67.6%), N = 21). The sample size of the included trials ranged from 19 to 270 (median = 48.0; interquartile range = 40.0-85.0) and the duration of trial recruitment ranged from 3 to 50 months (median = 19.0 months; interquartile range = 10.5-34.0). Overall, a median of 3.6 days was needed to screen one patient, whereas 13.7 days were needed to randomise one participant. Over the trials duration, the median dropout rate was 7.9%. Variations in recruitment outcomes were observed across trials of different cancer types but were not statistically significant. CONCLUSION: The recruitment of participants to preoperative exercise randomised controlled trials is challenging, but patient retention appears to be less of a problem. Future trials investigating the effectiveness of a preoperative exercise programme following cancer surgery should consider the time taken to recruit patients. Strategies associated with improved recruitment should be investigated in future studies.

Global prevalence of musculoskeletal pain in rural and urban populations. A systematic review with meta-analysis. Musculoskeletal pain in rural and urban populations.

INTRODUCTION: To systematically compare the global prevalence of musculoskeletal pain and care-seeking in rural and urban populations. METHODS: A systematic review with meta-analysis of observational studies reporting a direct comparison of rural and urban populations was conducted worldwide and included back, knee, hip, shoulder, neck pain and a broad diagnosis of 'musculoskeletal pain'. A search strategy combining terms related to 'prevalence', 'musculoskeletal pain' and 'rural' was used on the following databases: MEDLINE, Embase, CINAHL, Scopus, and rural and remote health from their inception to 1 June 2022. Random-effects meta-analysis was used to pool the data. Results were presented as odds ratios (OR) along with 95% confidence intervals (95% CI). RESULTS: A total of 42 studies from 24 countries were included with a total population of 489 439 participants. The quality scores for the included studies, using the modified Newcastle Ottawa Scale tool, showed an average score of 0.78/1, which represents an overall good quality. The pooled analysis showed statistically greater odds of hip (OR = 1.62, 95% CI = 1.23-2.15), shoulder (OR = 1.42, 95% CI = 1.06-1.90) and overall musculoskeletal pain (OR = 1.26, 95% CI = 1.08-1.47) in rural populations compared to urban populations. Although the odds of seeking treatment were higher in rural populations this relationship was not statistically significant (OR = 0.76, 95% CI = 0.55-1.03). CONCLUSION: Very low-certainty evidence suggests that musculoskeletal, hip and shoulder pain are more prevalent in rural than urban areas, although neck, back and knee pain, along with care-seeking, showed no significant difference between these populations. Strategies aimed to reduce the burden of musculoskeletal pain should consider the specific needs and limited access to quality evidence-based care for musculoskeletal pain of rural populations.

Preoperative Cardiopulmonary Exercise Test Associated with Postoperative Outcomes in Patients Undergoing Cancer Surgery: A Systematic Review and Meta-Analyses.

BACKGROUNDS: There is mixed evidence on the value of preoperative cardiorespiratory exercise test (CPET) to predict postoperative outcomes in patients undergoing a cancer surgical procedure. The purpose of this review was to investigate the association between preoperative CPET variables and postoperative complications, length of hospital stay, and quality of life in patients undergoing cancer surgery. METHODS: A search was conducted on MEDLINE, Embase, AMED, and Web of science from inception to April 2020. Cohort studies investigating the association between preoperative CPET variables, including peak oxygen uptake (peak VO2), anaerobic threshold (AT), or ventilatory equivalent for carbon dioxide (VE/VCO2), and postoperative outcomes (complications, length of stay, and quality of life) were included. Risk of bias was assessed using the QUIPS tool. A random-effect model meta-analysis was performed whenever possible. RESULTS: Fifty-two unique studies, including 10,030 patients were included. Overall, most studies were rated as having low risk of bias. Higher preoperative peak VO2 was associated with absence of postoperative complications (mean difference [MD]: 2.28; 95% confidence interval [CI]: 1.26-3.29) and no pulmonary complication (MD: 1.47; 95% CI: 0.49-2.45). Preoperative AT and VE/VCO2 also demonstrated some positive trends. None of the included studies reported a negative trend. CONCLUSIONS: This systematic review and meta-analysis demonstrated a significant association between superior preoperative CPET values, especially peak VO2, and better postoperative outcomes. The assessment of preoperative functional capacity in patients undergoing cancer surgery has the potential to facilitate treatment decision making.

Clinical Course of Pain and Function Following Total Knee Arthroplasty: A Systematic Review and Meta-Regression.

BACKGROUND: Total knee arthroplasty (TKA) is widely considered a successful intervention for osteoarthritis and other degenerative knee diseases. This study addresses the need for a high-quality meta-analysis that outlines the clinical course of pain and function post-TKA. METHODS: The review included prospective cohort studies assessing pain or function of patients undergoing primary TKA at baseline (preoperatively) and at least 2 additional time points including one at least 12 months postoperatively. Two reviewers independently screened references, extracted data, and assessed risk of bias using the Quality in Prognosis Studies tool. The time course of recovery of pain and function was modeled using fractional polynomial meta-regression. RESULTS: In total, 191 studies with 59,667 patients were included, most with low risk of bias. The variance-weighted mean pain score (/100, 0 = no pain) was 64.0 (95% confidence interval [CI] 60.2-67.7) preoperatively, 24.1 (95% CI 20.3-27.9) at 3 months, 20.4 (95% CI 16.7-24.0) at 6 months, and 16.9 (95%CI 13.6-20.3) at 12 months, and remained low (10.1; 95% CI 4.8-15.4) at 10 years postoperatively. The variance-weighted mean function score (/100, 0 = worst function) was 47.1 (95% CI 45.7-48.4) preoperatively, 72.8 (95% CI 71.3-74.4) at 3 months, 76.3 (95% CI 74.7-77.8) at 6 months, and 78.1 (95%CI 76.4-79.7) at 12 months. Function scores were good (79.7; 95% CI 77.9-81.5) at 10 years postoperatively. CONCLUSION: Patients undergoing primary TKA can expect a large and rapid but incomplete recovery of pain and function in the first postoperative year. At 10 years, the gains in pain scores may still remain while there is an improvement in function.

Preliminary evidence for physical activity following pelvic exenteration: a pilot longitudinal cohort study.

BACKGROUND: The physical activity (PA) level of patients undergoing major cancer surgery remains unclear. This pilot study aimed to: (i) Compare preoperative PA level between patients undergoing major cancer surgery and the general population; (ii) describe PA trajectories following major cancer surgery; (iii) Compare objective versus subjective PA measures in patients undergoing major cancer surgery; and (iv) Investigate the association between preoperative PA level and postoperative outcomes. METHODS: Patients undergoing pelvic exenteration between September/2016 and September/2017 were included and followed at preoperative, 6-weeks and 6-months postoperative. PA was measured using the International Physical Activity Questionnaire Short-Form and McRoberts activity monitor. Analyses were performed using SPSS. RESULTS: This pilot study included 16 patients. When compared to the general population, patients undergoing major cancer surgery presented a reduced preoperative PA level. PA levels decreased at 6 weeks but returned to preoperative levels at 6 months postoperative. Objective and subjective measures of PA were comparable, with some variables presenting strong correlations. A higher preoperative level PA was associated with an absence of postoperative complications and better quality of life outcomes. CONCLUSIONS: Patients undergoing major cancer surgery demonstrated lower PA levels when compared to the general population. PA trajectories decreased at 6 weeks postoperative, returning to preoperative levels within 6-months. In this cohort, it seems that higher preoperative PA level may improve postoperative surgical outcomes; however, this preliminary evidence should be confirmed in a larger cohort.

Preoperative exercise halves the postoperative complication rate in patients with lung cancer: a systematic review of the effect of exercise on complications, length of stay and quality of life in patients with cancer.

OBJECTIVE: To investigate the effectiveness of preoperative exercises interventions in patients undergoing oncological surgery, on postoperative complications, length of hospital stay and quality of life. DESIGN: Intervention systematic review with meta-analysis. DATA SOURCES: MEDLINE, Embase and PEDro. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Trials investigating the effectiveness of preoperative exercise for any oncological patient undergoing surgery were included. The outcomes of interest were postoperative complications, length of hospital stay and quality of life. Relative risks (RRs), mean differences (MDs) and 95% CI were calculated using random-effects models. RESULTS: Seventeen articles (reporting on 13 different trials) involving 806 individual participants and 6 tumour types were included. There was moderate-quality evidence that preoperative exercise significantly reduced postoperative complication rates (RR 0.52, 95% CI 0.36 to 0.74) and length of hospital stay (MD -2.86 days, 95% CI -5.40 to -0.33) in patients undergoing lung resection, compared with control. For patients with oesophageal cancer, preoperative exercise was not effective in reducing length of hospital stay (MD 2.00 days, 95% CI -2.35 to 6.35). Although only assessed in individual studies, preoperative exercise improved postoperative quality of life in patients with oral or prostate cancer. No effect was found in patients with colon and colorectal liver metastases. CONCLUSIONS: Preoperative exercise was effective in reducing postoperative complications and length of hospital stay in patients with lung cancer. Whether preoperative exercise reduces complications, length of hospital stay and improves quality of life in other groups of patients undergoing oncological surgery is uncertain as the quality of evidence is low. PROSPEROREGISTRATION NUMBER.

Diagnostic accuracy of the Ottawa Ankle and Midfoot Rules: a systematic review with meta-analysis.

OBJECTIVE: To review the diagnostic accuracy of the Ottawa Ankle and Midfoot Rules and explore if clinical features and/or methodological quality of the study influence diagnostic accuracy estimates. DESIGN: Systematic review with meta-analysis. DATA SOURCES: MEDLINE, EMBASE, CINAHL, SPORTDiscus and Cochrane Library. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Primary diagnostic studies reporting the accuracy of the Rules in people with ankle and/or midfoot injury were retrieved. Diagnostic accuracy estimates, overall and for subgroups (patient's age, profession of the assessor and setting of application), were made. Sensitivity analyses included studies with a low risk of bias and studies where all patients received radiographs. RESULTS: 66 studies were included. Ankle and Midfoot Rules presented similar accuracies, which were homogeneous and high for sensitivity and negative likelihood ratios and poor and heterogeneous for specificity and positive likelihood ratios (mean, 95% CI pooled sensitivity of Ankle Rules: 99.4%, 97.9% to 99.8%; specificity: 35.3%, 28.8% to 42.3%). Sensitivity of the Ankle Rules was higher in adults than in children, but the profession of the assessor did not appear to influence accuracy. Specificity was higher for Midfoot than for Ankle Rules. There were not enough studies to allow comparison according to setting of application. Studies with a low risk of bias and where all patients received radiographs provided lower accuracy estimates. Specificity heterogeneity was not explained by assessor training, use of imaging in all patients and low risk of bias. CONCLUSIONS: Study features and the methodological quality influence estimates of the diagnostic accuracy of the Ottawa Ankle and Midfoot Rules.

Rehabilitation After Immobilization for Ankle Fracture: The EXACT Randomized Clinical Trial.

IMPORTANCE: The benefits of rehabilitation after immobilization for ankle fracture are unclear. OBJECTIVES: To determine the effectiveness of a supervised exercise program and advice (rehabilitation) compared with advice alone and to determine if effects are moderated by fracture severity or age and sex. DESIGN, SETTING, AND PARTICIPANTS: The EXACT trial was a pragmatic, randomized clinical trial conducted from December 2010 to June 2014. Patients with isolated ankle fracture presenting to fracture clinics in 7 Australian hospitals were randomized on the day of removal of immobilization. Of 571 eligible patients, 357 chose not to participate and 214 were allocated to rehabilitation (n = 106) or advice alone (n = 108), with 194 (91%) followed up at 1 month, 173 (81%) at 3 months, and 170 (79%) at 6 months. There were no withdrawals attributed to adverse effects. Recruitment terminated early on December 31, 2013 (planned enrollment, 342; actual, 214), because funding was exhausted. INTERVENTIONS: Supervised exercise program and advice about self-management (rehabilitation) (individually tailored, prescribed, monitored, and progressed) or advice alone, both delivered by a physical therapist. MAIN OUTCOMES AND MEASURES: Primary outcomes were activity limitation assessed using the Lower Extremity Functional Scale (score range, 0-80; higher scores indicate better activity), and quality of life assessed using the Assessment of Quality of Life (score range, 0-1; higher scores indicate better quality of life), measured at baseline and at 1, 3 (primary time point), and 6 months. RESULTS: Mean activity limitation and quality of life at baseline were 30.1 (SD, 12.5) and 0.51 (SD, 0.24), respectively, for advice and 30.2 (SD, 13.2) and 0.54 (SD, 0.24) for rehabilitation, increasing to 64.3 (SD, 13.5) and 0.85 (SD, 0.17) for advice vs 64.3 (SD, 15.1) and 0.85 (SD, 0.20) for rehabilitation at 3 months. Rehabilitation was not more effective than advice for activity limitation (mean effect at 3 months, 0.4 [95% CI, -3.3 to 4.1]) or quality of life (-0.01 [95% CI, -0.06 to 0.04]). Treatment effects were not moderated by fracture severity or age and sex. CONCLUSIONS AND RELEVANCE: A supervised exercise program and advice did not confer additional benefits in activity limitation or quality of life compared with advice alone for patients with isolated and uncomplicated ankle fracture. These findings do not support the routine use of supervised exercise programs after removal of immobilization for patients with isolated and uncomplicated ankle fracture. TRIAL REGISTRATION: anzctr.org.au Identifier: ACTRN12610000979055.

Effectiveness of an eHealth-Delivered Program to Empower People With Musculoskeletal Pain in Rural Australia: A Randomized Controlled Trial.

OBJECTIVE: Our objective was to evaluate the effectiveness of a three-month physiotherapist-delivered eHealth physical activity program compared with usual care to improve function in adults with low back pain or knee osteoarthritis in rural Australia. METHODS: This was a parallel, two-group, pragmatic, superiority, randomized controlled trial involving three- and six-month posttreatment follow-ups. There was a total of 156 adults with chronic nonspecific low back pain (n = 97) or knee osteoarthritis (n = 59) from rural Australia. The intervention involved an eHealth physical activity and an exercise program that included five to eight teleconsultations with a physiotherapist (primary time point three months) or usual care (eg, general practitioner, physiotherapy, and pain medication). The primary outcome was the Patient-Specific Functional Scale (0-30), with a three-point difference between groups being considered the minimum clinically important difference. RESULTS: Participants receiving the eHealth intervention (n = 78) reported significantly greater and clinically worthwhile improvements in function (mean between-group difference 3.6; 95% confidence interval [CI] 1.3-5.9) compared to participants receiving usual care (n = 78). Small but statistically significantly greater improvements in disability (7.2 of 100; 95% CI 2.1-12.3) and quality of life (4.5 of 100; 95% CI 0.0-9.0) also favored the eHealth group. No clinical or statistical differences between groups were found for the secondary outcomes of pain, coping skills, and physical activity levels. CONCLUSION: A physiotherapist-delivered eHealth intervention is effective and provides clinically meaningful improvements in function compared to usual care for people with musculoskeletal pain in rural communities. These findings highlight the potential for eHealth-based programs to improve access to evidence-based exercise interventions for people with musculoskeletal pain in rural communities.

Clinical guidelines are silent on the recommendation of physical activity and exercise therapy for low back pain: A systematic review.

OBJECTIVES: To synthesise and evaluate the quality of the recommendations for exercise therapy and physical activity from guidelines for the prevention and/or management of low back pain. DESIGN: Systematic review. METHODS: Included clinical practice guidelines for the management of low back pain published between 2014 and 2022 and searched in 9 databases until September 2022. The quality of evidence was evaluated with the Appraisal of Guidelines, Research and Evaluation tool (AGREE-II instrument). RESULTS: After screening 3448 studies, 18 clinical practice guidelines were included in this review. Only five (27 %) guidelines were judged as having a satisfactory quality of evidence (i.e., rigour of development and applicability), and 13 (72 %) of guidelines are discussed and rated as critical. Regarding physical activity, no guidelines provided recommendations for the primary prevention of low back pain or incorporated adequate physical activity aspects considering type, dosage, frequency, and intensity. For exercises, all (100 %) guidelines recommended at least one type of supervised exercise in the management of low back pain, and 16 (88 %) provided an overall recommendation for people to stay active. CONCLUSIONS: Guidelines offer minimal or, sometimes, no detail regarding physical activity or specific exercise regimens for the management and prevention of low back pain. When some guidance is provided, the recommendations typically lack specificity concerning the type, intensity, duration, and frequency of exercise and, in many cases, they represent a combination of scarce available evidence and stakeholder perspectives.

Effect of Braces on Performance in the Context of Chronic Ankle Instability.

Ankle braces are commonly recommended for prevention of ankle sprains, especially secondary sprains, rehabilitation, and return to normal activity or sport after injury. One common resistance to use is the feeling that braces will impede functional performance. For people with chronic ankle instability, the limited research indicates that the use of semirigid, lace-up, or soft-shell braces will not affect, and in some cases, may enhance performance. Activities that could be enhanced are jumping, hopping, and dynamic balance.

Barriers and facilitators to reducing paracetamol use in low back pain: A qualitative study.

BACKGROUND: Paracetamol is widely used for low back pain (LBP), but research questions its efficacy and safety. Patient education booklets have been explored for promoting deprescribing, but barriers and facilitators specific to LBP deprescribing remain unexamined. OBJECTIVE: To identify contextual factors facilitating and obstructing successful deprescribing of paracetamol for LBP after receiving an educational booklet. STUDY DESIGN: This study is part of an uncontrolled cohort feasibility study (CEASE NOW) in the community, recruiting from Musculoskeletal Australia and painaustralia. PATIENT SAMPLE: Twenty-four participants with acute, sub-acute, or chronic LBP, self-reporting paracetamol consumption, were included. METHODS: Thematic content analysis was used to analyze qualitative data on barriers and facilitators. Data were categorized by deprescribing outcomes: i) successful deprescribing, ii) attempted but failed, or iii) no attempt. Semi-structured telephone interviews were conducted within one week after each participant completed the one-month follow-up. RESULTS: Successful deprescribing was facilitated by supportive healthcare professionals, willingness, high self-efficacy, fear of future illness, and diverse strategies for deprescribing plans. Barriers included unsupportive healthcare professionals and fear of flare-ups. Participants not attempting deprescribing believed it unnecessary, perceived it as effortful, unquestioningly trusted healthcare professionals, and lacked risk awareness. CONCLUSIONS: Support from healthcare professionals, patient willingness, perceived necessity, risk awareness, effort, and varied strategies influence deprescribing outcomes for LBP patients using paracetamol. Addressing these factors is crucial when designing interventions to promote safe and effective deprescribing in LBP management.

The impact of aggregate positive lifestyle behaviors on low back pain resilience and care seeking.

BACKGROUND CONTEXT: Low back pain (LBP) is a global issue, and the high associated costs are mainly attributed to a small proportion of people with LBP who seek care. Importantly, the impact of aggregate positive lifestyle behaviors on LBP resilience and care seeking is not known. PURPOSE: This study aimed to evaluate the relationship between positive lifestyle behaviors and LBP resilience. STUDY DESIGN: This study was a prospective longitudinal cohort study. PATIENT SAMPLE: Data was collected as part of the AUstralian Twin BACK Study (AUTBACK). Participants who reported a lifetime previous history of LBP at baseline were included in this analysis (n = 340). OUTCOME MEASURES: The outcomes of interest were the number of weeks without activity limiting LBP and total number of days of healthcare usage, health practitioner care, self-management care, and medication intake. METHODS: A lifestyle behavior score was built using variables of body mass index (BMI), physical activity, smoking status, and sleep quality. Negative binomial regression analyses were used to assess the relationship between the positive lifestyle behavior score and the count outcomes of number of weeks without activity limiting LBP and number of days participants used care. RESULTS: After adjusting for covariates, no association was found between participants' positive lifestyle behavior score and their number of weeks without activity limiting LBP (IRR: 1.02, 95% CI 1.00-1.05). There was a statistically significant relationship between higher positive lifestyle behavior scores and fewer number of days of participants' total healthcare usage (IRR:0.69, 95% CI 0.56-0.84), healthcare practitioner visits (IRR:0.62, 95% CI 0.45-0.84), use of self-management strategies (IRR:0.74, 95% CI 0.60-0.91), and use of pain medication (IRR:0.55, 95% CI 0.44-0.68). CONCLUSION: People who adopt optimal lifestyle behaviors, such as engaging in adequate physical activity, achieving optimal quality sleep, maintaining an ideal BMI, and not smoking, may not experience less time suffering from activity limiting LBP, but are less likely to use healthcare and pain medication for their LBP.

Rehabilitation for ankle fractures in adults.

BACKGROUND: Rehabilitation after ankle fracture can begin soon after the fracture has been treated, either surgically or non-surgically, by the use of different types of immobilisation that allow early commencement of weight-bearing or exercise. Alternatively, rehabilitation, including the use of physical or manual therapies, may start following the period of immobilisation. This is an update of a Cochrane review first published in 2008. OBJECTIVES: To assess the effects of rehabilitation interventions following conservative or surgical treatment of ankle fractures in adults. SEARCH METHODS: We searched the Specialised Registers of the Cochrane Bone, Joint and Muscle Trauma Group and the Cochrane Rehabilitation and Related Therapies Field, CENTRAL via The Cochrane Library (2011 Issue 7), MEDLINE via PubMed, EMBASE, CINAHL, PEDro, AMED, SPORTDiscus and clinical trials registers up to July 2011. In addition, we searched reference lists of included studies and relevant systematic reviews. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials with adults undergoing any interventions for rehabilitation after ankle fracture were considered. The primary outcome was activity limitation. Secondary outcomes included quality of life, patient satisfaction, impairments and adverse events. DATA COLLECTION AND ANALYSIS: Two review authors independently screened search results, assessed risk of bias and extracted data. Risk ratios and 95% confidence intervals (95% CIs) were calculated for dichotomous variables, and mean differences or standardised mean differences and 95% CIs were calculated for continuous variables. End of treatment and end of follow-up data were presented separately. For end of follow-up data, short term follow-up was defined as up to three months after randomisation, and long-term follow-up as greater than six months after randomisation. Meta-analysis was performed where appropriate. MAIN RESULTS: Thirty-eight studies with a total of 1896 participants were included. Only one study was judged at low risk of bias. Eight studies were judged at high risk of selection bias because of lack of allocation concealment and over half the of the studies were at high risk of selective reporting bias.Three small studies investigated rehabilitation interventions during the immobilisation period after conservative orthopaedic management. There was limited evidence from two studies (106 participants in total) of short-term benefit of using an air-stirrup versus an orthosis or a walking cast. One study (12 participants) found 12 weeks of hypnosis did not reduce activity or improve other outcomes.Thirty studies investigated rehabilitation interventions during the immobilisation period after surgical fixation. In 10 studies, the use of a removable type of immobilisation combined with exercise was compared with cast immobilisation alone. Using a removable type of immobilisation to enable controlled exercise significantly reduced activity limitation in five of the eight studies reporting this outcome, reduced pain (number of participants with pain at the long term follow-up: 10/35 versus 25/34; risk ratio (RR) 0.39, 95% confidence interval (CI) 0.22 to 0.68; 2 studies) and improved ankle dorsiflexion range of motion. However, it also led to a higher rate of mainly minor adverse events (49/201 versus 20/197; RR 2.30, 95% CI 1.49 to 3.56; 7 studies).During the immobilisation period after surgical fixation, commencing weight-bearing made a small improvement in ankle dorsiflexion range of motion (mean difference in the difference in range of motion compared with the non-fractured side at the long term follow-up 6.17%, 95% CI 0.14 to 12.20; 2 studies). Evidence from one small but potentially biased study (60 participants) showed that neurostimulation, an electrotherapy modality, may be beneficial in the short-term. There was little and inconclusive evidence on what type of support or immobilisation was the best. One study found no immobilisation improved ankle dorsiflexion and plantarflexion range of motion compared with cast immobilisation, but another showed using a backslab improved ankle dorsiflexion range of motion compared with using a bandage.Five studies investigated different rehabilitation interventions following the immobilisation period after either conservative or surgical orthopaedic management. There was no evidence of effect for stretching or manual therapy in addition to exercise, or exercise compared with usual care. One small study (14 participants) at a high risk of bias found reduced ankle swelling after non-thermal compared with thermal pulsed shortwave diathermy. AUTHORS' CONCLUSIONS: There is limited evidence supporting early commencement of weight-bearing and the use of a removable type of immobilisation to allow exercise during the immobilisation period after surgical fixation. Because of the potential increased risk of adverse events, the patient's ability to comply with the use of a removable type of immobilisation to enable controlled exercise is essential. There is little evidence for rehabilitation interventions during the immobilisation period after conservative orthopaedic management and no evidence for stretching, manual therapy or exercise compared to usual care following the immobilisation period. Small, single studies showed that some electrotherapy modalities may be beneficial. More clinical trials that are well-designed and adequately-powered are required to strengthen current evidence.

The effect of ankle supports on lower limb biomechanics during functional tasks: A systematic review with meta-analysis.

OBJECTIVES: To systematically review the literature on the effects of ankle supports on lower extremity biomechanics during functional tasks. DESIGN: Systematic review with meta-analysis. METHODS: Eight electronic databases were searched from inception to July 2019. Studies of biomechanical outcomes during functional tasks that used a within-participant (repeated measures) design were included. Two independent reviewers screened studies, extracted data, assessed the methodological quality of the included studies and rated the quality of evidence. Meta-analysis was performed and reported as standardised mean differences and 95% confidence intervals. RESULTS: A total of 8350 studies were identified in the electronic search and 42 studies involving a total of 761 participants were included in the review (21 studies included for qualitative reporting and 21 studies in the meta-analysis). Most individual studies and the meta-analyses demonstrated no effect of ankle supports on ground reaction force or ankle inversion angle. However, there was high quality evidence that ankle taping decreased plantarflexion angle at initial contact during landing from a height (P = 0.0009, standerdised mean differences = 0.72, 95% confidence intervals = 1.15, 0.03, I 2 = 3%). The effect of ankle supports on transverse plane ankle biomechanics has not been adequately investigated. CONCLUSIONS: Ankle taping only decreased plantarflexion angle at initial contact during landing from a jump. Ankle supports did not affect inversion angle or forces in linear and multiplanar tasks. There was insufficient evidence on the effect of ankle supports on ankle transverse plane biomechanics.

The impact of different intensities and domains of physical activity on analgesic use and activity limitation in people with low back pain: A prospective cohort study with a one-year followup.

BACKGROUND: Analgesics are the most common form of managing low back pain (LBP). No previous study has examined which domains and intensities of physical activity are most beneficial in reducing the frequency of analgesic use for LBP and its related activity limitation. METHODS: This cohort study forms part of the AUstralian Twin low BACK pain study, investigating the impact of physical activity on LBP. Information on demographics, LBP and health-related factors, including physical activity, were collected at baseline. Data on the total counts of analgesic use and activity limitation for LBP were collected weekly for one-year. Negative binomial regression models were conducted separately for each type of physical activity. Results were presented as incidence rate ratios (IRRs) and 95% confidence intervals (CIs). RESULTS: From an initial sample of 366 participants, 86 participants reported counts of analgesic use and 140 recorded counts of activity limitation across the follow-up period. The negative binomial regression models for analgesic use counts indicated that engagement in moderate-vigorous physical activity was protective for use of analgesics (IRR 0.97, 95% CI 0.96-0.99), while physical workload was associated with greater use (IRR 1.02, 95% CI 1.01-1.05). No other significant relationships were observed for the other measures of physical activity. For activity limitation counts, engagement in leisure activity was associated with less counts of activity limitation (IRR 0.94, 95% CI 0.81-0.99), while greater amounts of sedentary time was associated with higher counts (IRR 1.04, 95% CI 1.01-1.09). No other significant relationships were observed for the other measures of physical activity. CONCLUSIONS: Our findings highlight the potential importance of supporting engagement in moderate-vigorous and leisure physical activity as well as minimizing sedentary time and physical workload to reduce the risk of activity limitation and the need for analgesic use in people with LBP. SIGNIFICANCE: We examined which domains and intensities of physical activity are most beneficial in reducing the frequency of analgesic use for low back pain and its related activity limitation. Engaging in moderate-vigorous and leisure physical activity as well as minimizing sedentary time and physical workload has the potential to reduce the risk of activity limitation and the need for analgesic use in people with low back pain.

Individualised, targeted step count intervention following gastrointestinal cancer surgery: The Fit-4-Home randomised clinical trial.

BACKGROUND: To determine the effectiveness of an individualised, daily targeted step count intervention and usual care compared with usual care alone on improving surgical and patient reported outcomes. METHODS: The Fit-4-Home trial was a pragmatic, randomised controlled trial conducted from April 2019 to February 2021. Patients undergoing elective surgery for liver, stomach or pancreatic cancer in two Australian hospitals were recruited. Participants were randomly allocated to receive an individualised, targeted step count intervention and usual care (intervention) or usual care alone (control). A wearable activity tracker was provided to the intervention group to monitor their daily step count target. Primary outcome was the length of stay in the gastrointestinal ward. Secondary outcomes included postoperative complication rates, discharge destination, quality of life, physical activity, pain, fatigue, distress and hospital re-admission within 30 days. Outcome measures were compared between groups using non-parametric statistics. RESULTS: Of the 96 patients recruited, 47 were randomised to the intervention group and 49 were randomised to the control group. The median (interquartile) length of stay in the ward was 7 days (5.0-13.0) in the intervention group and 7 days (5.0- 12.0) in the control group (p = 0.330). Fatigue scores were worse in the intervention group when compared to control (p = 0.018). No other differences between groups were observed. CONCLUSIONS: An individualised, daily targeted step count intervention and usual care did not confer additional benefits in reducing the length of stay in the ward compared to usual care alone for patients undergoing gastrointestinal cancer surgery. TRIAL REGISTRATION: Registered with the Australia and New Zealand Clinical Trials Registry (ACTRN12619000194167).

EXACT: exercise or advice after ankle fracture. Design of a randomised controlled trial.

BACKGROUND: Ankle fractures are common. Management of ankle fractures generally involves a period of immobilisation followed by rehabilitation to reduce pain, stiffness, weakness and swelling. The effects of a rehabilitation program are still unclear. However, it has been shown that important components of rehabilitation programs may not confer additional benefits over exercise alone. The primary aim of this trial is to determine the effectiveness and cost-effectiveness of an exercise-based rehabilitation program after ankle fracture, compared to advice alone. METHODS/DESIGN: A pragmatic randomised trial will be conducted. Participants will be 342 adults with stiff, painful ankles after ankle fracture treated with immobilisation. They will be randomly allocated using a concealed randomisation procedure to either an Advice or Rehabilitation group. Participants in the Advice group will receive verbal and written advice about exercise at the time of removal of immobilisation. Participants in the Rehabilitation group will be provided with a 4-week rehabilitation program that is designed, monitored and progressed by a physiotherapist, in addition to verbal and written advice. Outcomes will be measured by a blinded assessor at 1, 3 and 6 months. The primary outcomes will be activity limitation and quality-adjusted life years. DISCUSSION: This pragmatic trial will determine if a rehabilitation program reduces activity limitation and improves quality of life, compared to advice alone, after immobilisation for ankle fracture.