Activity-Based Therapy for Mobility, Function and Quality of Life after Spinal Cord Injuries-A Mixed-Methods Case Series.

(1) Background: Despite inconclusive evidence on the benefits of activity-based therapies (ABTs) in people with spinal cord injuries, implementation has occurred in clinics worldwide in response to consumers' requests. We explored the clinical changes and participants' perceptions from engaging in an ABT program in the community. (2) Methods: This mixed-methods study involved a pragmatic observational multiple-baseline design and an evaluation of participants' perceptions. Fifteen participants were included. Outcome measures were balance in sitting using the Seated Reach Distance test, mobility using the Modified Rivermead Mobility Index and quality of life using the Quality of Life Index SCI version pre- and post-participation in an ABT community-based program. Linear mixed models and logistic regressions were used to analyse the effects of intervention. Semi-structured interviews explored participants' perceptions using inductive thematic analysis. (3) Results: There was an increase of 9% in the standardised reach distance (95% CI 2-16) for sitting balance, 1.33 points (95% CI: 0.81-1.85) in mobility and 1.9 points (0.17-2.1) in quality of life. Two themes emerged from the interviews: (1) reduced impact of disability and an increased sense of life as before, and (2) the program was superior to usual rehabilitation. No adverse events related to the intervention were observed. (4) Conclusion: ABT delivered in the community improved clinical outcomes in people with a chronic SCI. High levels of satisfaction with the program were reported.

Who crashes their car following wrist fracture?

BACKGROUND: Wrist fractures are common injuries associated with high disability in the early recovery period. The impact of wrist fractures on safe return to drive is not understood. PURPOSE: (1) To compare the proportion of adults who were drivers in car crashes before and after wrist fracture; (2) To examine potential factors (demographic and/or clinical) associated with increased odds of being a driver in a car crash following wrist fracture. STUDY DESIGN: Retrospective cohort study. METHODS: Three state-wide government datasets (MainRoads Western Australia [WA], Hospital Morbidity Data Collection and the Emergency Department Data Collection) were used to obtain and link demographic, clinical and car crash information relating to adults with a wrist fracture sustained between 2008 and 2017. McNemar's tests were used to compare the proportion of drivers in a car crash within the 2 years prior to and following the fracture date. Multivariable logistic regressions were used to identify if any variables were associated with increased odds of crashing in the post-fracture period. RESULTS: Data relating to 37,107 adults revealed a 3.3% (95% CI 3.0%-3.6%, p < 0.05) decrease in the proportion of drivers in a car crash following wrist fracture, persisting for the entire 2 years post-fracture, when compared to the proportion who crashed before their fracture. Those with more severe wrist fracture injury patterns had 79%(95% CI 1.07-3.0, p = 0.03) higher odds of having a crash in the first 3 months following their injury, compared to those with isolated wrist fracture injuries. CONCLUSIONS: These results inform and update return to drive recommendations. The reduced proportion of drivers involved in crashes following wrist fracture persisted for 2 years; longer than the expected physical recovery timeframe. It is important that hand therapists actively educate the sub-group of adults with more severe wrist fracture injury patterns of the increased likelihood of car crash for the 3 months following their fracture.

Implementation of a risk-stratified, guideline-based clinical pathway of care to improve health outcomes following whiplash injury (Whiplash ImPaCT): a multicentre, randomized, controlled trial.

ABSTRACT: Current pathways of care for whiplash follow a "stepped care model," result in modest treatment outcomes and fail to offer efficient management solutions. This study aimed to evaluate the effectiveness of a risk-stratified clinical pathway of care (CPC) compared with usual care (UC) in people with acute whiplash. We conducted a multicentre, 2-arm, parallel, randomised, controlled trial in primary care in Australia. Participants with acute whiplash (n = 216) were stratified for risk of a poor outcome (low vs medium/high risk) and randomised using concealed allocation to either the CPC or UC. In the CPC group, low-risk participants received guideline-based advice and exercise supported by an online resource, and medium-risk/high-risk participants were referred to a whiplash specialist who assessed modifiable risk factors and then determined further care. The UC group received care from their primary healthcare provider who had no knowledge of risk status. Primary outcomes were neck disability index (NDI) and Global Rating of Change (GRC) at 3 months. Analysis blinded to group used intention-to-treat and linear mixed models. There was no difference between the groups for the NDI (mean difference [MD] [95% confidence interval (CI)] -2.34 [-7.44 to 2.76]) or GRC (MD 95% CI 0.08 [-0.55 to 0.70]) at 3 months. Baseline risk category did not modify the effect of treatment. No adverse events were reported. Risk-stratified care for acute whiplash did not improve patient outcomes, and implementation of this CPC in its current form is not recommended.

The Natural Helper approach to culturally responsive disease management: protocol for a type 1 effectiveness-implementation cluster randomised controlled trial of a cultural mentor programme.

INTRODUCTION: Chronic disease is a leading cause of death and disability that disproportionately burdens culturally and linguistically diverse (CALD) communities. Self-management is a cornerstone of effective chronic disease management. However, research suggests that patients from CALD communities may be less likely to engage with self-management approaches. The Natural Helper Programme aims to facilitate patient engagement with self-management approaches (ie, 'activation') by embedding cultural mentors with lived experience of chronic disease into chronic disease clinics/programmes. The Natural Helper Trial will explore the effect of cultural mentors on patient activation, health self-efficacy, coping efforts and health-related quality of life (HRQoL) while also evaluating the implementation strategy. METHODS AND ANALYSIS: A hybrid type-1 effectiveness-implementation cluster-randomised controlled trial (phase one) and a mixed-method controlled before-and-after cohort extension of the trial (phase 2). Hospital clinics in highly multicultural regions in Australia that provide healthcare for patients with chronic and/or complex conditions, will participate. A minimum of 16 chronic disease clinics (clusters) will be randomised to immediate (active arm) or delayed implementation (control arm). In phase 1, the active arm will receive a multifaceted strategy supporting them to embed cultural mentors in their services while the control arm continues with usual care. Each cluster will recruit an average of 15 patients, assessed at baseline and 6 months (n=240). In phase 2, clusters in the control arm will receive the implementation strategy and evaluate the intervention on an additional 15 patients per cluster, while sustainability in active arm clusters will be assessed qualitatively. Change in activation over 6 months, measured using the Patient Activation Measure will be the primary effectiveness outcome, while secondary effectiveness outcomes will explore changes in chronic disease self-efficacy, coping strategies and HRQoL. Secondary implementation outcomes will be collected from patient-participants, mentors and healthcare providers using validated questionnaires, customised surveys and interviews aligning with the Reach, Effectiveness, Adoption, Implementation, Maintenance framework to evaluate acceptability, reach, dose delivered, sustainability, cost-utility and healthcare provider determinants. ETHICS AND DISSEMINATION: This trial has full ethical approval (2021/ETH12279). The results from this hybrid trial will be presented at scientific meetings and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ACTRN12622000697785.

Back pain beliefs among Indian migrants in Australia: a cross-sectional study.

PURPOSE: One of the largest migrant communities in Australia is the Indian migrant community. Current back pain guidelines recommend assessment of patients' beliefs; however, little is known about these beliefs in Indian communities. We aimed to investigate beliefs about back pain among Indian migrants living in Sydney. MATERIAL AND METHODS: An online questionnaire with demographic information, participant characteristics, the Back Beliefs Questionnaire (BBQ) and open-ended questions relating to beliefs about causes of back pain and treatment preferences was completed by 386 Indian migrants in Sydney. RESULTS: The overall BBQ score was 25.1 ± 6.7. We found significant but slightly more positive beliefs among Indian females than Indian males (standardized regression coefficient, ß = 0.134, p = 0.014). Presence and severity of pain did not affect back pain beliefs. There seemed to be a belief in physical and structural/anatomical causes of back pain, and a belief in the effectiveness of exercise, medications, and Indian traditional approaches for pain management. CONCLUSIONS: Beliefs of Indian migrants aligned with a "western traditional" biomedical model for the cause of pain, but with a belief in the effectiveness of both Indian traditional and western treatment approaches. Awareness of these beliefs could enable an effective therapeutic alliance between clinicians and Indian patients.IMPLICATIONS FOR REHABILITATIONBack pain beliefs of Australian Indian migrants are similar to their western counterparts, so the current guidelines for back pain can potentially be implemented without too much adjustment for this migrant community.Awareness of these beliefs is likely to improve the therapeutic alliance between clinician and an Indian migrant patient.

Pain experiences of Hindi-speaking Indian migrants in Sydney: a qualitative study.

Cultural beliefs and values are increasingly understood to influence the experience of pain, health-seeking, and pain management behaviours. Research exploring cultural beliefs about pain is particularly needed for Indian migrants, who have a high prevalence of pain and are among the largest migrant communities in Australia and internationally. The objective of this study was to explore pain-related beliefs and coping strategies of Hindi-speaking Indian migrants with chronic back pain living in Sydney. Indian migrants (n = 26) completed a demographic survey, standardised pain questionnaires (RMDQ, PSEQ and BBQ) and participated in one of five focus group discussions. This cohort had low levels of disability: Mean (SD) [RMDQ 5.04 (3.2)], high self-efficacy [PSEQ 44.6 (8.8)], and relatively positive beliefs about back pain [BBQ 28.6 (4.4)]. Three categories of interconnected beliefs emerged from the focus groups: causative, treatment/coping-related, and prognostic beliefs underpinned by a core cultural belief in 'the philosophy of Karma'. Within this core philosophy, three cultural values were central to the experience of pain and the construction of pain-related beliefs: collectivism and contribution, gendered roles, and mind-body wellness. The incorporation of holistic approaches to back pain management with an emphasis on mindfulness, exercise, and physical activity aligned with family-oriented goals could be considered for management of chronic back pain among Indian migrant communities. CONTRIBUTION OF THE PAPER.

Cross-cultural adaptation, reliability and validity of the Marathi versions of the Back Beliefs Questionnaire and Pain Self-Efficacy Questionnaire in people living with chronic low back pain.

PURPOSE: To translate and cross-culturally adapt the Back Beliefs Questionnaire (BBQ) and Pain Self-Efficacy Questionnaire (PSEQ) into Marathi, and to evaluate their clinimetric properties in a native Marathi speaking population with chronic low back pain. MATERIAL AND METHODS: The BBQ and PSEQ were translated into Marathi using international published guidelines. Fifty native Marathi speakers were recruited. Reliability (n = 43) was evaluated in terms of internal consistency (Cronbach α) and test-retest reliability [intra class correlation coefficient, ICC (2, 1)] and 95% confidence interval (CI). Convergent validity (n = 50) was assessed by correlating the Marathi versions of BBQ and PSEQ with the Marathi version of Roland Morris Disability Questionnaire (RMDQ). RESULTS: Internal consistency of BBQ (Cronbach α  =  0.67) was good and that for PSEQ (Cronbach α  =  0.93) was high. Test-retest reliability for BBQ (ICC =  0.80; 95% CI: 0.66 to 0.89) was good and PSEQ (ICC = 0.85; 95% CI: 0.74 to 0.92) was excellent. A significant, low negative correlation was found between RMDQ and BBQ scores (r = -0.298; p = 0.036) and PSEQ (r = -0.28; p = 0.049). CONCLUSIONS: The BBQ and PSEQ were successfully cross-culturally adapted into Marathi. Clinimetric evaluation of these questionnaires in a sample of native Marathi speaking populations with chronic low back pain demonstrated good acceptability, acceptable internal consistency, and high test-retest reliability.Implications for rehabilitationThe Back Beliefs Questionnaire (BBQ) and Pain Self Efficacy Questionnaire (PSEQ) were successfully cross-culturally adapted into Marathi.The Marathi versions of BBQ and PSEQ have good acceptability, acceptable internal consistency, and high test-retest reliability.They can be used by clinicians and researchers to evaluate beliefs about back pain and pain self-efficacy in Marathi speaking patients with chronic low back pain.

Sunbeam Program Reduces Rate of Falls in Long-Term Care Residents With Mild to Moderate Cognitive Impairment or Dementia: Subgroup Analysis of a Cluster Randomized Controlled Trial.

OBJECTIVES: The Sunbeam trial significantly reduced falls in long-term aged care (LTC) residents. The current study's primary objective was to undertake subgroup analysis of the Sunbeam trial, to determine whether the intervention was effective for reducing falls in LTC residents with mild-moderate cognitive impairment/dementia. Secondary objectives were to determine intervention effects on cognitive and physical function. DESIGN: Subgroup analysis of a cluster randomized controlled trial (RCT). SETTING AND PARTICIPANTS: Permanent residents of LTC in Australia who participated in the Sunbeam trial with Addenbrooke's Cognitive Examination-Revised (ACE-R) scores <83 (Mini-Mental State Examination >14 = main trial inclusion criteria). METHODS: Of 221 participants, 148 had an ACE-R <83 and were included in this study. Sixteen LTC residences (clusters) were randomized to receive either the Sunbeam program or usual care. The Sunbeam program involved two 1-hour sessions/week of tailored and progressive resistance and balance training for 25 weeks followed by a maintenance program (two 30-min sessions/week of nonprogressive exercise for 6 months). Assessments were conducted at baseline, 6 months, and 12 months. Falls were recorded using routinely collected data from the LTC incident management systems. RESULTS: Rate of falls (50%) and risk of falls (31%), multiple falls (40%), and injurious falls (44%) were reduced in the intervention group. The intervention group had significantly better balance (static and dynamic) and sit-to-stand ability when compared with the control group at 6 months and significantly better dynamic balance at 12 months. There were no serious adverse events. CONCLUSIONS AND IMPLICATIONS: The Sunbeam Program significantly reduced falls and improved physical performance in cognitively impaired LTC residents. This is a novel and important finding, as many previous studies have excluded people with cognitive impairment/dementia and inconsistent findings have been reported when this population has been studied. Our findings suggest that progressive resistance and balance exercise is a safe and effective fall prevention intervention in LTC residents with mild-moderate cognitive impairment/dementia.

Associations between potentially modifiable clinical factors and sagittal balance of the spine in older adults from the general population.

PURPOSE: Spinal sagittal balance is associated with back pain and quality of life. Enhancing understanding of the clinical factors associated with sagittal balance is essential for guiding the development of effective non-operative treatment. We aimed to evaluate the associations between spinal sagittal balance and potentially modifiable clinical factors and interactions between current back pain and the evaluated clinical factors. METHODS: We conducted a cross-sectional study where sagittal alignment, measured radiographically by EOS, was defined by sagittal vertical axis (SVA). The clinical factors included non-radiographic (NR) lumbar lordosis angle, balance (Berg balance scale), hip and back extension range of motion (ROM) and extensor strength, and back pain. Pearson's correlation coefficients and multivariable regression analyses were conducted in 63 adult participants (70% female, mean age 73 (SD 8.6) years) from the general population. RESULTS: We identified correlations between SVA and age (r = 0.4, p < 0.001), body mass index (BMI) (r = 0.3, p = 0.008), balance (r = - 0.5, p < 0.001) and NR lumbar lordosis angle (r = - 0.5, p < 0.001). The final model (R2 = 58%) identified that, after controlling for age and BMI, larger SVA was associated with lower NR lumbar lordosis (R2 = 15%, p < 0.001), poorer balance (R2 = 7%, p = 0.02), greater hip extensor strength (R2 = 4%, p = 0.053), and among people with back pain, NR lumbar extension ROM (R2 = 3%, p = 0.034). Hip ROM and lumbar strength were not significant. CONCLUSION: Reduced NR lumbar lordosis magnitude and ROM, balance and hip strength are associated with SVA; however, it is unclear if these factors are compensatory, contributing, or modifiable. Hence, future longitudinal studies are needed.

Increase in ACC GABA+ levels correlate with decrease in migraine frequency, intensity and disability over time.

BACKGROUND: An imbalance between inhibitory and excitatory neurometabolites has been implicated in chronic pain. Prior work identified elevated levels of Gamma-aminobutyric acid + macromolecules ("GABA+") using magnetic resonance spectroscopy (MRS) in people with migraine. What is not understood is whether this increase in GABA+ is a cause, or consequence of living with, chronic migraine. Therefore, to further elucidate the nature of the elevated GABA+ levels reported in migraine, this study aimed to observe how GABA+ levels change in response to changes in the clinical characteristics of migraine over time. METHODS: We observed people with chronic migraine (ICHD-3) over 3-months as their treatment was escalated in line with the Australian Pharmaceutical Benefits Scheme (PBS). Participants underwent an MRS scan and completed questionnaires regarding migraine frequency, intensity (HIT-6) and disability (WHODAS) at baseline and following the routine 3 months treatment escalation to provide the potential for some participants to recover. We were therefore able to monitor changes in brain neurochemistry as clinical characteristics potentially changed over time. RESULTS: The results, from 18 participants who completed both baseline and follow-up measures, demonstrated that improvements in migraine frequency, intensity and disability were associated with an increase in GABA+ levels in the anterior cingulate cortex (ACC); migraine frequency (r = - 0.51, p = 0.03), intensity (r = - 0.51, p = 0.03) and disability (r = - 0.53, p = 0.02). However, this was not seen in the posterior cingulate gyrus (PCG). An incidental observation found those who happened to have their treatment escalated with CGRP-monoclonal antibodies (CGRP-mAbs) (n = 10) had a greater increase in ACC GABA+ levels (mean difference 0.54 IU IQR [0.02 to 1.05], p = 0.05) and reduction in migraine frequency (mean difference 10.3 IQR [2.52 to 18.07], p = 0.01) compared to those who did not (n = 8). CONCLUSION: The correlation between an increase in ACC GABA+ levels with improvement in clinical characteristics of migraine, suggest previously reported elevated GABA+ levels may not be a cause of migraine, but a protective mechanism attempting to suppress further migraine attacks.

Allied health are key to improving health for people with chronic disease: but where are the outcomes and where is the strategy?

The global burden of chronic disease has forced health systems to focus on improved care. This has led to improved health outcomes for some populations, but not for all people or for all conditions. The rising prevalence of chronic disease has also significantly increased demands on healthcare systems, with unsustainable costs to funders. To improve health and social outcomes for all people with chronic disease, it is critical to embrace allied health professionals as key members of primary healthcare teams. The recognised efficacy and cost-effectiveness of many allied health interventions suggest that implementation into usual care would result in enhanced outcomes for people accessing healthcare, their families and communities, and for health systems. Our aim is to highlight the current unacceptable lack of allied health integration into primary healthcare teams, and illustrate the potential value of improved and equitable access to allied health professionals for managing chronic conditions and multimorbidity.

Sagittal spine shape literacy in the general adult population, assessed by a novel, simple graphical tool.

[Purpose] The sagittal shape of the spine is associated with back-pain, balance and quality of life. We developed, evaluated and report the responses of a graphical tool to assess sagittal spine shape knowledge (literacy). [Participants and Methods] Two hundred and fifty adults were randomly assigned, in a cross-sectional crossover study, to free-hand draw and select the "ideal" sagittal spine shape. We evaluated the inter and intra-rater reliability and agreement between tests and the sagittal and lordotic spine literacy between the drawing and selection test versions. [Results] Drawing test inter- and intra-rater agreement was 79% and 80% respectively. Drawing vs. selection agreement was 43%. More participants drew than selected the correct spine (30% vs. 21%) (p<0.001) and lumbar lordosis shape (56% vs. 42%) (p<0.001). Test order did not affect spine shape literacy scores. A significantly poorer literacy trend was observed with spine pain presence (p=0.02). [Conclusion] We developed a reliable method to evaluate spine shape literacy and established that only 21% and 42% of our sample demonstrated correct sagittal spine and lordotic spine shape literacy, respectively. The low literacy scores suggests that consideration of including spine shape literacy in health literacy and self-management programs may be warranted, especially in ageing populations.

Increased GABA+ in People With Migraine, Headache, and Pain Conditions- A Potential Marker of Pain.

Treatment outcomes for migraine and other chronic headache and pain conditions typically demonstrate modest results. A greater understanding of underlying pain mechanisms may better inform treatments and improve outcomes. Increased GABA+ has been identified in recent studies of migraine, however, it is unclear if this is present in other headache, and pain conditions. We primarily investigated GABA+ levels in the posterior cingulate gyrus (PCG) of people with migraine, whiplash-headache and low back pain compared to age- and sex-matched controls, GABA+ levels in the anterior cingulate cortex (ACC) and thalamus formed secondary aims. Using a cross-sectional design, we studied people with migraine, whiplash-headache or low back pain (n = 56) and compared them with a pool of age- and sex-matched controls (n = 22). We used spectral-edited magnetic resonance spectroscopy at 3T (MEGA-PRESS) to determine levels of GABA+ in the PCG, ACC and thalamus. PCG GABA+ levels were significantly higher in people with migraine and low back pain compared with controls (eg, migraine 4.89 IU ± 0.62 vs controls 4.62 IU ± 0.38; P = .02). Higher GABA+ levels in the PCG were not unique to migraine and could reflect a mechanism of chronic pain in general. A better understanding of pain at a neurochemical level informs the development of treatments that target aberrant brain neurochemistry to improve patient outcomes. PERSPECTIVE: This study provides insights into the underlying mechanisms of chronic pain. Higher levels of GABA+ in the PCG may reflect an underlying mechanism of chronic headache and pain conditions. This knowledge may help improve patient outcomes through developing treatments that specifically address this aberrant brain neurochemistry.

Implementation of a novel stratified PAthway of CarE for common musculoskeletal (MSK) conditions in primary care: protocol for a multicentre pragmatic randomised controlled trial (the PACE MSK trial).

INTRODUCTION: Musculoskeletal (MSK) conditions constitute the highest burden of disease globally, with healthcare services often utilised inappropriately and overburdened. The aim of this trial is to evaluate the effectiveness of a novel clinical PAthway of CarE programme (PACE programme), where care is provided based on people's risk of poor outcome. METHODS AND ANALYSIS: Multicentre randomised controlled trial. 716 people with MSK conditions (low back pain, neck pain or knee osteoarthritis) will be recruited in primary care. They will be stratified for risk of a poor outcome (low risk/high risk) using the Short Form Örebro Musculoskeletal Pain Screening Questionnaire (SF-ÖMSPQ) then randomised to usual care (n=358) or the PACE programme (n=358). Participants at low risk in the PACE programme will receive up to 3 sessions of guideline based care from their primary healthcare professional (HCP) supported by a custom designed website (mypainhub.com). Those at high risk will be referred to an allied health MSK specialist who will conduct a comprehensive patient-centred assessment then liaise with the primary HCP to determine further care. Primary outcome (SF 12-item PCS) and secondary outcomes (eg, pain self-efficacy, psychological health) will be collected at baseline, 3, 6 and 12 months. Cost-effectiveness will be measured as cost per quality-adjusted life-year gained. Health economic analysis will include direct and indirect costs. Analyses will be conducted on an intention-to-treat basis. Primary and secondary outcomes will be analysed independently, using generalised linear models. Qualitative and mixed-methods studies embedded within the trial will evaluate patient experience, health professional practice and interprofessional collaboration. ETHICS AND DISSEMINATION: Ethics approval has been received from the following Human Research Ethics Committees: The University of Sydney (2018/926), The University of Queensland (2019000700/2018/926), University of Melbourne (1954239), Curtin University (HRE2019-0263) and Northern Sydney Local Health District (2019/ETH03632). Dissemination of findings will occur via peer-reviewed publications, conference presentations and social media. TRIAL REGISTRATION NUMBER: ACTRN12619000871145.

Community-based interventions for chronic musculoskeletal health conditions in rural and remote populations: A systematic review.

Chronic musculoskeletal health conditions are highly prevalent in rural and remote areas, globally. It is unknown, however, whether interventions shown to be effective for urban populations are also effective for rural and remote populations. The purpose of the review was to evaluate the effectiveness of community-based interventions for management of chronic musculoskeletal health conditions in rural and remote populations. A systematic review was undertaken of the major databases: Medline, Scopus, Web of Science, Rural and Remote Health, Embase and PEDro to April 2020 with no restrictions on language or publication date. Odds Ratios were calculated to report differences between intervention and control groups. Risk of bias was assessed using the PEDro scale. Meta-analysis was not conducted, given the high heterogeneity among studies. From a total of 3,219 articles identified from the title search, five studies were eligible, with a total of 2,831 participants. Interventions evaluated included education alone, exercise with education and ergonomic modifications. Community-based education and exercise led to significantly reduced chronic musculoskeletal pain [OR = 1.85 (95% CI 1.22, 2.82)] compared with controls. Ergonomic stove installation significantly reduced average prevalence of back pain (0.25% reduction in pain prevalence; p < .05); however, no significant effect [OR = 1.02 (0.63, 1.65)] was found when transformed to Odds Ratio. There were divergent findings for education programmes alone: one study reported a positive effect [OR = 1.78 (1.27, 2.49)], while another reported no significant effect [delivered either in home [OR: 1.21 (0.78, 1.86)] or in small groups [OR = 0.95 (0.60, 1.51)]. A significant improvement in knowledge was found with community-based education delivered in participants' homes [SMD: 1.27 (1.01, 1.54)], in small groups [SMD: 0.79 (0.53, 1.06)], using traditional puppetry [SMD: 4.79 (4.51, 5.06)], and with education and exercise [SMD: 0.29 (0.06, 0.52)]. There is low quality evidence that education and/or exercise improves knowledge of arthritis, and the effectiveness of ergonomic interventions on pain was unclear.

Necessary components of psychological treatment in pain management programs: A Delphi study.

BACKGROUND: There are various approaches to the psychological management of chronic pain and it is difficult to know which components of psychological therapies are necessary or desirable for the effective management of chronic pain. METHODS: We conducted a Delphi study to develop a consensus on the necessary and desirable psychological intervention strategies for chronic pain management. First, we identified 49 components of treatments that had been used in a treatment evaluated in a randomized controlled trial (RCT) through a systematic review. In the first round of the Delphi process, 23 (32% of 72) authors who had completed RCTs in chronic pain took part. In round 2, these experts plus clinicians working at pain management programs around Australia were invited to take part, and 44 experts completed the study. RESULTS: The panel agreed that it was necessary to include psycho-education, particularly about pain mechanisms and the role of thoughts in maintaining pain. Cognitive approaches were deemed necessary, although the panel did not specify one particular strategy. Finally, approaches to increase activity were deemed necessary, including the strategies of pacing, goal setting and graded exposure. Relaxation training and relapse prevention were also deemed necessary. CONCLUSIONS: There was a consensus that there were many desirable strategies to include in psychological chronic pain management approaches, but that treatments should include psycho-education, approaches to increase activity and cognitive approaches as a first line of intervention. Where patients fail to benefit from these approaches, experts identified other desirable strategies that could be utilized. SIGNIFICANCE: The expert consensus indicated that psycho-education, strategies to increase activity and cognitive therapy strategies were necessary for effective psychological treatment of patients with chronic pain. While other strategies were deemed desirable, psychological treatments should include at least those three components.

Activity-Based Therapy in a Community Setting for Independence, Mobility, and Sitting Balance for People With Spinal Cord Injuries.

INTRODUCTION: Activity-based therapy (ABT) aims to activate the neuromuscular system below the level of the spinal cord lesion and promote recovery of motor tasks through spinal reorganisation, motor learning and changes to muscles and sensory system. We investigated the effects of a multimodal ABT program on mobility, independence and sitting balance in individuals with spinal cord injury (SCI). METHODS: Retrospective clinical data from 91 adults who independently enrolled in four community-based ABT centres in Australia were analysed. The multimodal ABT program was delivered for 3 to 12 months, one to four times per week. Assessments were undertaken every 3 months and included the Modified Rivermead Mobility Index (MRMI), Spinal Cord Independence Measure (SCIM) and seated reach distance (SRD). A linear mixed model analysis was used to determine time-based and other predictors of change. RESULTS: There was a significant improvement after 12 months for all outcome measures, with a mean change score of 4 points in the SCIM (95% confidence interval [CI]: 2.7-5.3, d = 0.19), 2 points in the MRMI (95% CI: 1-2.3, d = 0.19) and 0.2 in the SRD (95% CI: 0.1-2.2, d = 0.52). Greater improvements occurred in the first 3 months of intervention. There were no interaction effects between time and the neurological level of injury, American Spinal Injury Association Impairment Scale classification, or duration post-injury for most outcomes. CONCLUSIONS: A community-based ABT exercise program for people with SCI can lead to small improvements in mobility, independence and balance in sitting, with greater improvements occurring early during intervention.

Combined education and patient-led goal setting intervention reduced chronic low back pain disability and intensity at 12 months: a randomised controlled trial.

BACKGROUND: One model of care that has not been tested for chronic low back pain (LBP) is patient-led goal setting. We aimed to compare the clinical effectiveness and healthcare use of a patient-led goal setting approach (intervention) with simple advice to exercise (control) over 12 months. METHODS: An assessor-blinded randomised controlled trial. Intervention was education combined with patient-led goal setting compared with a control group receiving a standardised exercise programme. The primary outcomes were back pain disability and pain intensity. Secondary outcomes were quality of life, kinesiophobia, self-efficacy, depression, anxiety and stress. Outcomes and healthcare use were assessed immediately post-treatment (2 months) and after 4 and 12 months. Analysis was by intention to treat. RESULTS: Seventy-five patients were randomly assigned to either the intervention (n=37) or the control (n=38) group. Using linear mixed model analyses, adjusted mean changes in primary outcomes of disability and pain intensity were greater in the intervention group than in the control group (disability post-treatment: p<0.05). These differences were clinically meaningful. Mean differences in all secondary measures were greater in the intervention group than in the control group (p<0.05). There was no difference in healthcare use between groups over 12 months. CONCLUSION: A patient-led goal setting intervention was significantly more effective than advice to exercise for improving outcomes in disability, pain intensity, quality of life, self-efficacy and kinesiophobia in chronic LBP. These improvements were maintained at 12 months. Smaller effects were seen in measures of depression, anxiety and stress. TRIAL REGISTRATION NUMBER: ACTRN12614000830695.

An economic evaluation of the SUNBEAM programme: a falls-prevention randomized controlled trial in residential aged care.

OBJECTIVE:: To estimate the cost-effectiveness of a strength and balance exercise programme (SUNBEAM) which has been shown to be clinically effective in reducing the rate of falls in residents of aged care facilities. DESIGN:: An economic evaluation was conducted alongside a pragmatic cluster randomized controlled trial that included 16 residential care facilities and 221 participants. Mean participant age was 86 years, 65% were female and 78% relied on a mobility aide. A cost-effectiveness analysis examined the costs of providing the exercise programme and costs of health service use arising from falls in each arm (intervention and usual care) over 12 months. MAIN MEASURES:: Incremental cost-effectiveness ratios were calculated for the cost per fall avoided. Costs were bootstrapped to obtain adjusted confidence intervals for the incremental cost-effectiveness ratios. RESULTS:: Of 63 facilities contacted, 16 met the eligibility criteria and were randomized to the intervention or usual care (1:1). There were 142 falls in the intervention group and 277 in the usual care group. 72 injurious falls occurred in the intervention group versus 157 with usual care. Delivery of the SUNBEAM programme cost $463 per participant. The mean total cost of each fall (regardless of group) was $400.09 and the mean cost of each injurious fall was $708.27. The incremental cost-effectiveness ratio was $22 per fall per person avoided with the mean bootstrapped incremental cost-effectiveness ratio $18 per fall avoided (95% CI: -$380.34 to $417.85). CONCLUSION:: The SUNBEAM programme can be considered cost-effective, relative to other fall-prevention interventions in older adults.